What is the appropriate management for an 8-year-old child with left ankle pain after a fall?

Management of Left Ankle Pain in an 8-Year-Old After a Fall

Apply the Ottawa Ankle Rules to determine if radiographs are needed, and if positive, obtain three-view ankle radiographs (anteroposterior, lateral, and mortise) as the initial imaging study. 1

Initial Clinical Assessment

Evaluate the child for Ottawa Ankle Rules criteria, which are validated for children ≥5 years of age and demonstrate 92-99% sensitivity for detecting ankle fractures 1:

• Inability to bear weight immediately after injury OR for 4 steps in the clinical setting 1
• Point tenderness over the medial malleolus, posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus 1
• Bone tenderness over the base of the fifth metatarsal or navicular bone 2

Imaging Decision Algorithm

If Ottawa Ankle Rules are POSITIVE:

• Obtain three-view ankle radiographs (anteroposterior, lateral, and mortise views) including the base of the fifth metatarsal 1
• Weight-bearing radiographs provide important stability information if the child can tolerate them 1
• Do NOT manipulate the ankle prior to radiographs unless there is neurovascular deficit or critical skin injury 1

If Ottawa Ankle Rules are NEGATIVE:

• No imaging is routinely indicated 1
• Proceed directly to conservative management 3

Acute Management (First 3-7 Days)

Apply cold therapy (ice and water mixture surrounded by damp cloth) for 20-30 minutes per application, 3-4 times daily, avoiding direct skin contact to prevent cold injury 1

Immobilize with a semirigid ankle support or lace-up brace combined with elastic compression wrap to reduce swelling, speed recovery, and protect injured ligaments 2

Limit activities that cause pain and avoid weight-bearing if painful 1

Provide pain control with NSAIDs or acetaminophen 2

Common Pitfalls in Pediatric Ankle Injuries

Do not rely on clinical examination alone in the first 48 hours, as excessive swelling and pain limit accurate assessment of ligament integrity 3

Watch for special pediatric injury patterns:

• Distal fibular avulsion fractures may require an anterior talofibular ligament view if not seen on standard radiographs, as occult fractures are identified in 26% of lateral ankle sprains using this view 1
• Bicycle spoke injuries warrant lower leg imaging if ankle fracture is present to assess distal tibia and fibula 1

Follow-Up and Rehabilitation

If radiographs show NO fracture:

• Begin early mobilization after initial 3-7 day acute phase, as this speeds healing and reduces pain more effectively than prolonged rest 2
• Implement functional rehabilitation including graded exercise, proprioceptive training, and progressive weight-bearing as tolerated 3
• Continue semirigid ankle support during activity 2

If pain persists beyond 1 week despite negative radiographs:

• Consider delayed physical examination at 4-5 days post-injury to assess ligament severity (anterior drawer test has 84% sensitivity, 96% specificity) 3
• Obtain MRI without IV contrast if pain persists to evaluate for occult fractures, osteochondral injuries, or ligamentous damage 3

If radiographs show fracture:

• Management depends on fracture type and stability; medial clear space <4mm confirms stability 1
• Refer to orthopedics for displaced fractures, large fragments (>15mm), or unstable injuries 4

Red Flags Requiring Emergency Evaluation

Activate EMS if the child has:

• Loss of consciousness 1
• Severe or worsening headache 1
• Repeated vomiting 1
• Altered mental status or seizures 1
• Visual changes 1
• Obvious deformity or open injury 1

Prevention of Reinjury

Previous ankle sprain is the greatest risk factor for future ankle sprains 2

Once recovered, consider ankle braces, taping, or neuromuscular training programs before returning to sports or high-risk activities 2