What is the initial management and evaluation for a patient presenting with an ankle fracture?

Initial Management and Evaluation of Ankle Fracture

For a patient presenting with an ankle fracture, immediate radiographic evaluation is warranted if there is point tenderness over the lateral malleolus, inability to bear weight, or presence of swelling, followed by appropriate immobilization and pain management. 1

Initial Assessment

Physical Examination

• Assess for:
  • Point tenderness over the malleoli (lateral, medial, posterior)
  • Tenderness over the talus or calcaneus
  • Ability to bear weight immediately after injury
  • Ability to ambulate for 4 steps in the emergency department
  • Swelling and ecchymosis around the ankle
  • Neurovascular status (pulses, sensation, capillary refill)

Ottawa Ankle Rules

Apply the Ottawa Ankle Rules to determine need for imaging:

• Radiographs indicated if:
  1. Pain in the malleolar zone AND bone tenderness at the posterior edge or tip of either malleolus
  2. Inability to bear weight both immediately and in the emergency department
  3. Point tenderness over the malleoli, talus, or calcaneus 2

Imaging

• First-line imaging: Three-view ankle radiographs (anteroposterior, lateral, and mortise views) 2, 1
• Weight-bearing radiographs are preferred when possible to detect dynamic abnormalities 1

Additional Imaging Based on Clinical Scenario:

• CT scan: For complex fracture patterns, posterior malleolar fractures, or when radiographs are inconclusive 2, 1
• MRI: When osteochondral injury is suspected or for persistent pain with negative radiographs 2, 1
• Stress views: May be needed to assess syndesmotic injuries or instability 2

Initial Treatment

Immediate Management:

1. Immobilization: Apply a removable splint for stable fractures 1
2. Pain control: Implement multimodal analgesia:
   • NSAIDs as first-line treatment
   • Acetaminophen
   • Consider peripheral nerve blocks for severe pain (especially in elderly patients) 2, 1
   • Reserve opioids for breakthrough pain only 1

Treatment Based on Fracture Classification:

• Stable, non-displaced fractures:

  • Removable ankle support
  • Early controlled weight-bearing as tolerated
  • Early mobilization exercises to prevent stiffness 1

• Displaced or unstable fractures:

  • Immediate orthopedic referral for potential surgical management
  • Proper immobilization until definitive treatment 1

Special Considerations

Elderly Patients

• Higher risk of wound complications, infection, and fixation failure, especially with diabetes and osteoporosis 3
• Consider peripheral nerve blocks for pain management:
  • Fascia iliaca compartment block has been shown to decrease opioid consumption and improve patient satisfaction 2
  • Ultrasound-guided popliteal sciatic and saphenous blocks may be beneficial for ankle fractures 2

Young, Active Patients

• At risk for post-traumatic osteoarthritis
• May require more aggressive management to restore anatomic alignment 3

Follow-up and Rehabilitation

Follow-up Timeline:

• 1 week for non-displaced fractures managed non-operatively
• 2 weeks and 4-6 weeks for clinical and radiographic assessment 1

Rehabilitation Protocol:

• Early mobilization is preferred over prolonged immobilization
• Early weight-bearing likely improves ankle function without increasing complication rates 4
• Removable ankle supports may lead to better outcomes than non-removable casts following surgical fixation 4

Common Pitfalls to Avoid

• Failing to identify syndesmotic injuries (responsible for 54% of early surgical failures) 5
• Inadequate fixation in osteopenic bone 5
• Not restoring fibular length in displaced fractures 5
• Missing posterior malleolar fractures (found in 50% of cases, more common in older females and diabetic patients) 2

By following this structured approach to ankle fracture management, you can ensure appropriate evaluation, treatment, and follow-up to optimize patient outcomes and minimize complications.