How should I manage a patient with a suspected ankle fracture, presenting with pain, swelling, and difficulty walking, pending X-ray results?

Management of Suspected Ankle Fracture Pending X-ray Results

For a patient with a suspected ankle fracture presenting with lateral malleolus pain, swelling, and difficulty walking, provide immediate immobilization with a removable splint and prescribe NSAIDs for pain management while awaiting X-ray results. 1, 2

Initial Assessment and Management

Immediate Care

• Apply a removable splint to immobilize the ankle and provide stability
• Provide crutches to allow non-weight bearing or partial weight bearing as tolerated
• Elevate the ankle to reduce swelling
• Apply ice for 15-20 minutes every 2-3 hours to reduce pain and swelling

Pain Management

• First-line: NSAIDs (e.g., ibuprofen 400-600mg every 6-8 hours) for pain control and anti-inflammatory effects 2
• Second-line: Acetaminophen 1000mg every 6 hours can be added for additional pain relief
• For breakthrough pain: Short-term opioids may be considered, but should be limited due to potential risks 2
• Consider topical NSAIDs with or without menthol gel as an adjunct treatment 2

Diagnostic Approach

The Ottawa Ankle Rules (OAR) should guide your decision-making while awaiting X-ray results:

Ottawa Ankle Rules Positive Findings (already present in this case)

• Point tenderness over the lateral malleolus
• Inability to bear weight or walk without significant pain
• Presence of swelling 1, 2

These findings warrant radiographic evaluation, which you have already ordered appropriately.

Management Plan Based on X-ray Results

If X-ray Shows No Fracture

• Continue with removable ankle support rather than rigid immobilization 3
• Encourage early controlled weight-bearing as tolerated
• Recommend early mobilization exercises to prevent stiffness
• Follow up in 1 week if symptoms persist
• Consider MRI or CT if clinical suspicion remains high despite negative X-rays 1

If X-ray Shows Fracture

• Non-displaced fracture: Continue immobilization with removable splint, refer to orthopedics for follow-up within 1 week
• Displaced fracture: Immediate orthopedic referral for potential surgical management
• Complex fracture patterns: CT may be needed for better evaluation 1

Rehabilitation Considerations

• Early mobilization is preferred over prolonged immobilization to prevent stiffness and promote healing 2, 3
• Physical therapy may be beneficial after the acute phase to restore range of motion and strength
• Monitor for complications such as delayed union, non-union, or post-traumatic arthritis 2, 4

Important Caveats and Pitfalls

• Do not manipulate the ankle before X-ray results: Manipulation before knowing the fracture pattern significantly increases the risk of requiring re-manipulation (44% vs 18%) 5
• Monitor for neurovascular compromise: Check distal pulses, capillary refill, and sensation
• Be aware of decreased physical activity: Patients with ankle injuries show significantly reduced activity levels for up to 6 months post-injury 6
• Consider comorbidities: Elderly patients and those with diabetes or osteoporosis have higher risks of complications 4
• Don't miss associated injuries: Talar, subtalar, or calcaneal injuries may coexist with ankle fractures 5

Following this approach will ensure appropriate care while awaiting definitive diagnosis and minimize the risk of complications.