see also:

• orthopaedics in the ED
• the injured foot
• DVT, PE, VTE prophylaxis and risk assessment in patients with lower leg immobilization (eg BKPOP plaster for fracture ankle)
• WH guideline on ankle and foot fractures (pdf) - WH intranet only
• Phong Tran's - patient information website - sprained ankles
• Phong Tran's - patient information website - fractured ankles
• Phong Tran's - orthopaedics website - fracture neck of talus
• Phong Tran's - orthopaedics website - fracture calcaneum
• AO Foundation Surgery Reference website - free guidelines to fracture management via the AO system
• USC 2008 conference video - comprehensive review of the anatomy and patterns of ankle injuries - subscription required

• RCH - fractures (pdf)
• RCH - plaster care (pdf)
• Vic DHS - Fractures and plaster care (pdf)
• Western Health BKPOP DVT Patient Info Sheet (docx) - intranet only
• NHMRC NICS Stop The Clot patient information brochure (pdf) should be given to all patients who require lower limb immobilisation
• Vic DHS - ankle sprains (pdf)
• see patient information sheets for more

• consider the mechanism of injury
  • fall from a height suggests possible fractures of:
    • tibial plafond (pilon fracture)
    • talar neck fracture if in crouching position during fall
    • calcaneal fracture
    • Lisfrance fracture/dislocation tarso-metatarsal joints
    • thoraco-lumbar spine fracture
  • inversion injuries often fracture the base of 5th MT, or may cause a Jones fracture (location at the metadiaphyseal junction at proximal fifth metatarsal), thus if tender, Xray foot
  • palpate for tenderness over the proximal fibula to exclude potential Maisonneuve fracture (proximal fibular fracture associated with medial-sided and syndesmotic injury)
• examine closely to exclude possibility of open fracture (ie. breach of skin) which needs early orthopaedic Mx.
• osteochondral fractures of the talar dome are easily missed on routine Xrays, therefore, persistent ankle pain may require additional imaging studies

• lateral ankle sprains account for ~90% of adult ankle injuries
• ankle fractures occur in ~15% of those who present to doctors
• most unstable ankle fractures in adults are the result of excessive external rotation of the talus with respect to the tibia:
  • if the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues
  • if the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results

• in children, tenderness over the lateral malleolus suggest a type I Salter-Harris classification of epiphysial plate injury, even if radiographic findings are negative, although fortunately, most can be managed as for a severe sprain.
• SHII fractures of the distal tibia are common and best seen on the lateral view as the distal tibia epiphysis displacing anterior to the tibial shaft - these usually require early (< 1 week) closed reduction.
• a Tillaux fracture is a SHIII fracture involving the anterolateral tibial epiphysis that is commonly seen in adolescents and may require early ORIF if remains displaced > 2mm.
• a longitudinal lucency at the base of the 5th metatarsal is the growth plate of the apophysis and NOT a fracture.
• a transverse lucency at the base of the 5th metatarsal suggests a fracture NOT a growth plate.
• children also not uncommonly have fractures across the necks or the bases of the 2nd-4th MT's - have a lower threshold for Xray of painful feet after a fall.
• young children often present with a limp after a minor fall and there are no obvious areas of tenderness - these children should have a tibia and fibula Xray to exclude a toddler fracture of shaft of tibia.

• only ~15% of patients presenting with ankle injuries will have a fracture on Xray
• for the remainder, although there is some psychological reassurance from doing an Xray, it adds cost, time, contributes to ED overcrowding, and adds more radiation exposure unnecessarily.
• use of the Ottawa ankle rules to decide on who should have an Xray, can reduce the number of adult ankle Xrays required to ~35% of patients presenting, whilst still picking up nearly all significant fractures.
• the main barrier to their use is patient acceptance and physician awareness and preparedness to use them.

• see also Wikipedia
• DO NOT USE these rules if either patient is:
  • pregnant
  • has diminished ability to follow the test (for example due to head injury or intoxication)
  • child (under the age of 18) - although some evidence to support use in this age group, but not the foot rules
• X-rays are only required if there is bony pain in the malleolar zone and any one of the following:
  • bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
  • bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
  • an inability to bear weight both immediately and in the emergency department for four steps.
• in addition, foot Xray is required according to the Ottawa Foot Rules if either:
  • there is bony pain in the midfoot zone, and any one of the following:
    • bone tenderness at the base of the fifth metatarsal
    • bone tenderness at the navicular bone
    • an inability to bear weight both immediately and in the emergency department for four steps

• patients with severe sprains as evidenced by substantial swelling and/or bruising appear to gain earlier mobility if placed in a below knee plaster cast or backslab for the first 10 days¹⁾, followed by physiotherapy.
  • the early immobilised group had better results at 3 months but equal results at 12 months
• other patients are usually managed by a period of RICE - Rest, Ice, Compression with tubigrip bandage, and Elevation followed by physiotherapy.
• The goal of rehabilitation should be symmetric range of motion and 85% of contralateral strength prior to returning to sport.

• ankle fractures can be classified as single malleolar, bimalleolar, and trimalleolar if the posterior part of the tibial plafond is involved.
  • bimalleolar or trimalleolar injuries are always unstable and are treated with open reduction and internal fixation (ORIF).
• barely visible osseous chip fractures do not alter the routine active management of grade 1 and 2 ankle sprains.
• careful attention must be paid to all single malleolar fractures because ligament instability is frequently associated with the contralateral side.
  • in the presence of medial malleolar tenderness and more than 5 mm of medial clear space on the mortise view, make a presumptive diagnosis of deltoid ligament rupture if a displaced fibular fracture is present. Treat these injuries as unstable bimalleolar fracture warranting orthopaedic opinion +/- ORIF.
• distal fibula fractures are the most common fracture type to the ankle, and the Danis-Weber classification system is listed below.

• transverse fracture of fibula BELOW the level of the ankle joint
• stable and can be managed by closed reduction if needed
• may require ORIF if associated with a displaced medial malleolar fracture

• spiral fracture of fibula AT the level of the ankle joint
• occurs secondary to external rotational forces
• may require ORIF depending on ligamentous injury or associated fractures on the medial side

• fracture ABOVE the level of the ankle joint
• disrupts the ligamentous attachment between the fibula and the tibia distal to the fracture
• unstable - needs ORIF