How to manage a 3-day-old laceration on the back of the lateral (outer ankle bone) malleolus caused by a sharp object?

Management of Laceration on the Back of Lateral Malleolus

For a 3-day-old laceration on the back of the lateral malleolus caused by a sharp object, the most appropriate management includes wound cleaning, assessment for underlying injury, and appropriate wound closure techniques based on the wound characteristics.

Initial Assessment

• Evaluate the wound for:

  • Size and depth of the laceration
  • Signs of infection (redness, swelling, purulent discharge)
  • Involvement of underlying structures (tendons, ligaments, nerves)
  • Foreign body presence
  • Neurovascular status of the foot

• Consider radiographic imaging if:

  • Suspicion of underlying fracture based on mechanism of injury
  • Presence of point tenderness over the malleolus 1
  • Inability to bear weight
  • Foreign body suspected

Wound Management

1. Wound Cleaning:

   • Irrigate thoroughly with sterile saline
   • Remove any debris or foreign material
   • Consider local anesthesia for proper cleaning if painful

2. Wound Closure Options:

   • Since the wound is 3 days old, primary closure may not be appropriate
   • Consider secondary intention healing (leaving wound open) if:
     • Signs of infection are present
     • Wound appears contaminated
   • Delayed primary closure may be appropriate if wound is clean

3. Dressing:

   • Apply non-adherent dressing
   • Consider topical antimicrobial if indicated
   • Secure with appropriate bandaging

Special Considerations

• Anatomical Awareness: Be cautious of the sural nerve which overlaps or is tangent to the tip of the lateral malleolus in approximately 10% of cases 2

• Nerve Assessment: Perform a thorough neurological examination as variants of the superficial peroneal nerve may cross this area in more than 10% of cases 3

• Mobilization: Encourage early mobilization as tolerated to prevent stiffness and promote healing 1

Follow-up Care

• Regular wound checks until healing is complete
• Monitor for signs of infection
• Assess for proper healing and restoration of function

When to Consider Specialist Referral

• Deep lacerations with potential tendon, ligament, or nerve involvement
• Signs of infection not responding to initial treatment
• Evidence of underlying fracture or joint involvement
• Poor wound healing

Complications to Monitor

• Infection
• Nerve damage (particularly to the sural nerve)
• Scarring and contracture
• Delayed healing
• Underlying injury to ankle structures

Remember that proper management of lacerations in this area is crucial due to the proximity of important neurovascular structures and the relatively thin soft tissue coverage over the lateral malleolus.