What is the next line of management for a patient with a road traffic accident (RTA) related left ankle injury, presenting with severe pain and swelling, unable to stand, and initial X-ray findings suggestive of no fracture, but with reports awaited?

Management of RTA Left Ankle Injury with Severe Pain, Swelling, Unable to Bear Weight, and Negative Initial X-ray

Immobilize the ankle immediately with a posterior splint or below-knee back slab, provide analgesia with NSAIDs (unless contraindicated), arrange urgent orthopedic referral within 1-2 weeks, and obtain MRI without IV contrast if pain persists beyond 1 week to evaluate for occult fractures, ligamentous injuries, or osteochondral lesions. 1, 2, 3

Immediate Management (First 24-48 Hours)

Immobilization and Pain Control

• Apply a posterior below-knee back slab or splint immediately to immobilize the ankle and prevent further soft tissue injury, even with negative radiographs 4
• Elevate the limb to reduce swelling 5
• Prescribe NSAIDs (ibuprofen 400-800mg every 6-8 hours) for pain control and inflammation, unless contraindicated by cardiovascular disease, GI bleeding history, or renal impairment 6
• Advise strict non-weight bearing with crutches given the inability to stand 1

Critical Assessment Points

• Reassess neurovascular status including dorsalis pedis and posterior tibial pulses, particularly important in trauma patients 5, 4
• Examine for signs suggesting instability: medial tenderness, bruising, or swelling which increase likelihood of occult injury 2
• Do not manipulate the ankle before adequate imaging unless there is neurovascular compromise or critical skin injury 2

Awaiting Final Radiology Report

What the Radiographs Should Evaluate

• The formal radiology report should specifically comment on: 1
  • Medial clear space (>4mm suggests instability)
  • Syndesmotic widening
  • Subtle avulsion fractures (particularly lateral talar process, anterior talofibular ligament avulsions)
  • Osteochondral lesions
  • Soft tissue swelling patterns

Common Pitfalls in Initial X-ray Interpretation

• Early acute injuries (<14 days) may show only soft tissue swelling on radiographs with fractures becoming apparent later 1
• Lateral talar process fractures (snowboarder's fracture) are missed 40-50% of the time on routine radiographs 1
• Osteochondral lesions and ligamentous avulsions may not be visible on standard views 1
• A missed tibial plateau or talar fracture can lead to significant long-term disability if not properly immobilized initially 7

Next Steps Based on Clinical Course

If Pain Persists Beyond 1 Week (Most Likely Scenario)

Order MRI ankle without IV contrast as the next imaging study 1, 3

The American College of Radiology designates MRI as "usually appropriate" for persistent ankle pain (>1 week but <3 weeks) with negative initial radiographs because: 1

• MRI detects occult fractures including talar dome, tibial plafond, and calcaneal injuries not visible on radiographs
• MRI identifies ligamentous injuries including anterior talofibular, calcaneofibular, deltoid, and syndesmotic ligament tears
• MRI reveals osteochondral lesions and bone marrow contusions that explain persistent symptoms
• MRI provides prognostic information about healing potential and guides definitive treatment 1

Alternative: CT Ankle Without IV Contrast

• CT is an acceptable alternative but less sensitive for soft tissue injuries including ligamentous tears 1
• CT is superior for detecting subtle cortical fractures and planning surgical fixation if fracture is found 1
• Consider CT if MRI is contraindicated or unavailable 1

Urgent Orthopedic Referral Criteria

Refer Within 1-2 Weeks for Specialist Evaluation 2

This patient meets criteria for urgent (not emergent) orthopedic referral given:

• Severe pain and swelling
• Complete inability to bear weight
• High suspicion for significant soft tissue or occult bony injury

Immediate Orthopedic Consultation Required If: 2

• Neurovascular compromise develops
• Obvious deformity suggesting dislocation (even if reduced)
• Skin compromise or impending skin breakdown
• Final radiology report reveals fracture requiring operative fixation

Follow-Up Protocol

Within 5-7 Days

• Clinical reassessment of pain, swelling, and ability to bear weight 5
• If symptoms improving: continue immobilization and non-weight bearing for total 2-3 weeks
• If symptoms unchanged or worsening: proceed directly to MRI without waiting the full week 1, 3

At 2 Weeks

• Convert posterior slab to circumferential below-knee cast once soft tissue swelling subsides (if significant injury confirmed) 4
• Begin early range-of-motion exercises if only soft tissue injury and pain allows 2

At 6 Weeks

• Remove immobilization and initiate supervised physiotherapy 8
• Supervised rehabilitation reduces residual symptoms and re-injuries compared to unsupervised home exercises 8

Critical Warnings

Do Not Miss These Injuries

• Pure ankle dislocation (0.46% of ankle dislocations) can occur without fracture and requires urgent reduction 4
• Syndesmotic injuries present with inability to bear weight and may have normal standard radiographs; require squeeze test, crossed-leg test, or external rotation test 1
• Talar dome osteochondral lesions cause chronic pain if missed and may require surgical intervention 1, 3

Avoid These Common Errors

• Failing to immobilize adequately leads to displacement of occult fractures and worsening soft tissue injury 7, 4
• Applying tight circumferential casts in the acute phase (first 48-72 hours) can compromise circulation due to ongoing swelling 2
• Delaying advanced imaging beyond 2-3 weeks in patients with persistent severe symptoms 1, 3
• Assuming all negative X-rays mean "just a sprain" when patient cannot bear weight 1