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Emergency And Acute Medicine – Ankle Fracture/Dislocation
Basics – Description
Common mechanisms and injury patterns of the ankle include inversion, eversion, external rotation, combined mechanisms (e.g., Maisonneuve fracture), and inversion with dorsiflexion (snowboarder’s fracture). These mechanisms result in predictable patterns of malleolar, fibular, syndesmotic, or talar injuries. Most ankle fractures involve the malleoli and are common in young males and women aged 50–70 years. Risk factors include cigarette use and elevated BMI. Pediatric ankle fractures frequently involve the physis and may result in growth disturbances.
Diagnosis – Signs And Symptoms
Patients typically present with a history of trauma, ankle pain, swelling, deformity, and inability to bear weight. Soft tissue swelling, ecchymosis, skin tenting, or blanching may be present. Neurovascular compromise should be assessed carefully, including capillary refill and dorsalis pedis/posterior tibial pulses. A detailed history should determine the position of the ankle at injury, ability to bear weight afterward, and any audible “pop” or “snap.”
Physical Examination
The Ottawa Ankle Rules are highly sensitive for determining the need for imaging and are reliable in children older than 5 years. Examination should include inspection of the skin, assessment of distal neurovascular status, palpation of the proximal fibula when indicated, and evaluation of motor and sensory function.
Diagnosis – Tests And Interpretation
Radiographs should include AP, lateral, and mortise views, with additional tibia/fibula views if a Maisonneuve fracture is suspected. Post-reduction imaging is required for unstable fractures or dislocations. CT or MRI may be used to further evaluate tibial plafond or ligamentous injury
Treatment
Prehospital Care
Immobilize the ankle to limit pain, bleeding, and further injury. Avoid traction devices and do not attempt reduction of protruding bone.
Initial Stabilization And Therapy
Non–weight bearing, ice, compression, and elevation are essential.
ED Treatment And Procedures
All ankle fractures and dislocations require orthopedic referral. Open fractures require antibiotics, tetanus prophylaxis, and emergent consultation. Closed dislocations should be reduced promptly and immobilized with appropriate splinting. Stable injuries may be managed conservatively, while unstable injuries often require operative fixation.
Medications
Analgesics are the mainstay for closed fractures. Procedural sedation may be required for reductions. Open fractures require IV antibiotics and tetanus prophylaxis.
Follow-Up And Disposition
Unstable fractures, open injuries, dislocations, or neurovascular compromise require admission. Stable, nondisplaced fractures may be discharged with splinting and close orthopedic follow-up.
Key Clinical Insights And Common Errors
When reducing a dislocated ankle, partial flexion of the knee helps relax the Achilles tendon and decreases resistance during manipulation. Careful examination is necessary to differentiate ankle fractures from subtalar injuries, as subtalar dislocations are uncommon and often difficult to reduce. Clinicians should remain vigilant for associated injuries, including trauma to the lumbar spine, hip, tibia, fibula—especially the proximal fibular neck—and the foot, which may otherwise be overlooked.
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