What's the next step in managing a patient who fell from a height, is stable, but complains of ankle pain with normal initial labs and imaging?

Management of a Patient with Fall from Height and Ankle Pain

For a patient who fell from the 4th floor and presents with ankle pain but normal initial labs and imaging, the next step should be a complete head-to-toe evaluation to assess for occult injuries, despite seemingly isolated ankle complaints. 1

Initial Assessment

• Begin with the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) as the systematic framework for evaluating this trauma patient 2, 3
• Check pulse as part of the circulation assessment in the ABCDE approach, which is critical in trauma patients to identify potential vascular compromise 2
• Perform a complete head-to-toe evaluation for ALL patients with trauma, even those presenting with seemingly isolated injuries 1
• Falls from heights greater than 6 meters (20 feet) are associated with major injuries including occult hemorrhage, making thorough assessment critical 1

Specific Evaluations Needed

• Assess vital signs including orthostatic blood pressure measurements to evaluate for occult blood loss 1
• Perform a thorough neurological assessment with special attention to peripheral neuropathies and proximal motor strength 1
• Evaluate the patient's ability to bear weight with a "get up and go test" - patients unable to rise, turn, and steadily ambulate should be reassessed 1
• Consider chest X-ray and head/neck CT if mechanism of injury suggests potential for additional injuries, despite normal initial imaging 1

Key Historical Elements to Obtain

• Location and cause of fall (mechanism of injury) 1
• Time spent on floor or ground 1
• Presence of loss of consciousness or altered mental status during or after the fall 1
• Medication assessment, particularly vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1
• Alcohol use which may mask symptoms of serious injury 1

Additional Imaging Considerations

• For ankle evaluation, if Ottawa or Pittsburgh criteria are met, anteroposterior and lateral radiographs should be obtained 1
• If ankle radiographs are negative but clinical suspicion remains high for occult fracture, CT may be the appropriate next imaging study 1
• Consider cross-table lateral view with horizontal beam to visualize lipohemarthrosis, which is frequently seen with intra-articular fractures 1

Management Approach

• For patients with high-energy trauma mechanisms (fall from 4th floor), maintain a high index of suspicion for occult injuries despite normal initial imaging 1
• If shock index (ratio of heart rate to systolic blood pressure) is ≥0.9, consider more comprehensive evaluation for occult hemorrhage 1
• Patients not able to bear weight should be reassessed thoroughly, as this is a significant indicator of potential serious injury 1
• Consider admission for observation if patient safety cannot be ensured or if high-energy mechanism suggests risk of delayed presentation of injuries 1

Common Pitfalls to Avoid

• Do not focus exclusively on the chief complaint (ankle pain) when the mechanism of injury suggests potential for multisystem trauma 1
• Avoid premature discharge based solely on normal initial imaging; high-energy falls require thorough assessment and possibly observation 1
• Do not overlook the need for a complete head-to-toe evaluation in all trauma patients, even those with seemingly isolated injuries 1
• Remember that the absence of pain does not rule out significant injury, especially in patients with altered sensation or distracting injuries 1