What is the most appropriate management for a patient with ankle pain and swelling after a traumatic injury, with tenderness over the lateral and medial malleoli, and intact pulses, skin, and sensation?

Management of Bimalleolar Ankle Fracture

This patient requires immediate orthopedic consultation for surgical evaluation and management. 1

Clinical Reasoning

The presentation of tenderness over both the lateral and medial malleoli following trauma strongly suggests a bimalleolar fracture pattern, which represents an unstable ankle injury requiring surgical fixation. 1

Key Decision Points

Stability Assessment:

• Bimalleolar fractures (involving both medial and lateral malleoli) are inherently unstable injuries that disrupt the ankle mortise 1
• A medial clear space >4 mm on radiographs indicates instability and confirms the need for surgical intervention 1
• Weight-bearing radiographs, if the patient can tolerate them, provide critical information about fracture stability 1

Why Orthopedic Consultation is Required:

• Displaced bimalleolar fractures require open reduction and internal fixation (ORIF) to restore anatomical alignment and prevent long-term complications including post-traumatic arthritis 1
• The American College of Radiology recommends standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) to evaluate fracture displacement and joint alignment 1
• Surgical fixation should address the lateral malleolus first to restore fibular length, followed by medial malleolar fixation 1

Why Other Options Are Inappropriate

Air cast or splinting with delayed follow-up (Options A and C):

• These conservative approaches are only appropriate for stable ankle injuries such as isolated lateral ankle sprains or small avulsion fractures 2, 3
• Functional treatment with early mobilization is superior for ligamentous injuries and small avulsion fractures, not displaced bimalleolar fractures 2
• Bimalleolar fractures require anatomical reduction that cannot be achieved with external immobilization alone 1

Stress views (Option D):

• Stress radiographs are used to evaluate ligamentous stability in ankle sprains, not for obvious fractures 4
• When both malleoli are tender following trauma, the diagnosis is already clear and stress views would cause unnecessary pain without changing management 4

Critical Pitfalls to Avoid

• Premature weight-bearing before adequate surgical fixation risks hardware failure, loss of reduction, and nonunion 1
• Failure to recognize the instability of bimalleolar fractures can lead to chronic pain, instability, and post-traumatic arthritis 3
• Delaying orthopedic consultation for unstable ankle fractures compromises outcomes and may allow soft tissue swelling to worsen, complicating surgical timing 1

Immediate Management Steps

While awaiting orthopedic consultation:

• Apply a well-padded posterior splint to immobilize the ankle and prevent further displacement 1
• Elevate the extremity to minimize swelling 4
• Ensure neurovascular status remains intact with serial examinations 5
• Provide adequate analgesia with NSAIDs or other appropriate pain management 4