History and exam
Key diagnostic factors
common
recent trauma
ankle pain and swelling
Pain is over the medial or lateral malleolus.[20]
inability to weight-bear
medial and/or lateral malleolus swollen and tender to palpation
Pain is bony and present over the medial or lateral malleolus.[19][20] May be associated with ecchymosis.[19][20] In the case of potential isolated lateral malleolar fractures, physical exam findings such as tenderness, ecchymosis, and swelling about the deltoid are poor predictors of deltoid integrity.[22]
Other diagnostic factors
common
ankle deformity
This is a common sign of dislocation.[19]
crepitus
There may be crepitus with range of motion.[21]
tenderness of the proximal fibula
Tenderness of the proximal fibula may signify fracture and possibly the Maisonneuve fracture pattern (disruption of the tibiofibular syndesmosis).[1]
tenting of the skin over the medial malleolus
If there is a dislocation there may be tenting of the skin over the medial malleolus.[23]
Ottawa ankle rules
Ottawa ankle rules have been developed to help decide when to order radiographs.[26][27] If there is posterior lateral or medial bony tenderness within 6 cm of the distal aspect of the fibula or tibia or an inability to weight-bear 4 steps at the scene or in the emergency department, then ankle radiographs should be ordered.
uncommon
history of osteoporosis
While ankle fractures are not classic osteoporotic fragility fractures, they are still common in postmenopausal women.[12][16][17] See Osteoporosis.
history of frequent falls
The relative risk of one or more falls in the year prior to injury is 1.2 (95% CI: 1.1 to 1.3).[17]
vascular compromise
Vascular compromise is rare and is usually the result of fracture-dislocations. Neurovascular status should be assessed using hard signs (lack of palpable pulse, continued blood loss, or expanding hematoma). Assessment should not rely on capillary return or Doppler signal to exclude vascular injury.[24]
Risk factors
strong
low-energy fall
The most common cause overall, accounting for up to 80% of ankle fractures.[4]
weak
osteoporosis
While ankle fractures are not classic osteoporotic fragility fractures, they are still common in postmenopausal women.[12][16][17] Studies of women with ankle fractures in this age group suggest that those at risk have a slightly higher BMI.[12] See Osteoporosis.
multiple falls
The relative risk of one or more falls in the year prior to injury is 1.2 (95% CI: 1.1 to 1.3).[17]
inversion injury to ankle
Second most common cause of ankle fractures (about 30%).[4]
playing sports
Sports injuries are the cause of about 10% of ankle fractures.[4]
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