What is the appropriate initial management for a post‑traumatic ankle hematoma, including conservative measures, signs of complications, and medication recommendations?

Management of Post-Traumatic Ankle Hematoma

For a post-traumatic ankle hematoma, begin with immediate clinical assessment using the Ottawa Ankle Rules to determine if radiography is needed, apply direct manual pressure with ice for bleeding control, elevate the limb, and initiate early thromboprophylaxis with low molecular weight heparin within 6-36 hours once hemostasis is achieved. 1, 2

Initial Assessment and Imaging

Determine fracture presence using Ottawa Ankle Rules 1:

• Obtain radiographs (AP, lateral, and mortise views) if the patient has:
  • Inability to bear weight immediately after injury 1
  • Point tenderness over the medial malleolus, posterior edge/inferior tip of lateral malleolus, talus, or calcaneus 1
  • Inability to ambulate 4 steps in the emergency department 1
• Ottawa Ankle Rules demonstrate 92-99% sensitivity for detecting ankle fractures 1
• Avoid manipulating the ankle before radiographs unless neurovascular deficit or critical skin injury is present 1

Immediate Hemorrhage Control

Apply direct manual pressure as first-line treatment 2:

• Use gauze or clean cloth directly on the bleeding site 2
• If bleeding continues, add more gauze on top without removing initial layers 2
• Apply local cold therapy (ice pack) to the wound area to help control bleeding 2
• Maintain pressure until bleeding stops completely 2

If direct pressure fails 2:

• Consider hemostatic dressing as adjunctive therapy 2
• Hemostatic dressings shorten time to hemostasis compared to standard dressings 2
• Once bleeding controlled, apply pressure dressing with elastic bandage wrapped firmly over gauze 2

Do NOT use pressure points or extremity elevation alone - these methods are ineffective and delay proper treatment 2

Conservative Management Measures

Implement RICE protocol modifications:

• Rest: Avoid weight-bearing initially, particularly if Ottawa Ankle Rules are positive 1
• Ice: Apply cold therapy as noted above for hemorrhage control 2
• Compression: Use pressure dressing once hemostasis achieved 2
• Elevation: Elevate the limb to reduce swelling (though not for bleeding control) 2

Monitoring for Complications

Assess for compartment syndrome risk factors 1:

• Monitor every 30 minutes to 1 hour during first 24 hours if patient has fracture, crush injury, hemorrhagic injury, or hypotension 1
• Clinical signs to assess repetitively: pain (spontaneous or with passive flexion/extension), tension, paresthesia, paresis 1
• Paleness, paralysis, and decreased pulse are late signs 1

Monitor for hematoma-related complications 3, 4:

• Persistent hematoma at 2 weeks post-injury correlates with inability to work and prolonged symptoms 3
• Large hematomas can cause tissue necrosis due to increased pressure or ischemia 4
• Pressure pain at the anterior talofibular ligament (ATFL) at 2 weeks predicts persistent instability at 9 months 3

Check for signs requiring operative evacuation 4:

• Skin necrosis overlying hematoma 4
• Increased tissue pressure 4
• Prompt recognition and evacuation prevents significant complications 4

Thromboprophylaxis

Initiate early pharmacological prophylaxis 1:

• Start low molecular weight heparin (LMWH) after hemorrhage control and hemostasis 1
• For isolated lower limb trauma without persisting bleeding, initiate within 6 hours following trauma or surgery 1
• For patients with solid organ damage or traumatic brain injury, introduction within first 36 hours appears safe (provided intracerebral bleeding stable on two successive CT scans) 1
• LMWH has been the reference standard for VTE prophylaxis for over 20 years 1
• Alternative: fondaparinux shows greater DVT reduction compared to nadroparin in lower limb trauma with added VTE risk factors 1

Pain Management Considerations

For fractures requiring manipulation 5, 6:

• Hematoma block is safe and effective for ankle fracture manipulation 5
• Intra-articular hematoma block (IAHB) results in shorter time to reduction compared to procedural sedation for ankle fractures with joint subluxation 6
• Pain differential with hematoma block averages 3.4 points less during reduction compared to time of injury 5
• No associated complications reported with hematoma block technique 5

Blood Pressure Management

Target systolic blood pressure 80-100 mmHg until major bleeding stopped in initial phase following trauma without brain injury 1:

• Permissive hypotension avoids adverse effects of aggressive resuscitation 1
• Aim for mean arterial pressure ≥65 mmHg 1
• Aggressive crystalloid resuscitation increases coagulopathy risk (>40% with >2000 mL pre-hospital fluids) 1

Common Pitfalls to Avoid

• Do not underestimate ankle sprains: Persistent hematoma, ATFL pressure pain, or instability at 2 weeks increases likelihood of symptoms persisting up to 9 months 3
• Do not delay imaging: Patients meeting Ottawa Ankle Rules criteria require radiographs as initial imaging study 1
• Do not use pressure points or elevation alone for bleeding control: These are ineffective 2
• Do not delay thromboprophylaxis excessively: Early initiation (within 6-36 hours depending on injury type) is safe and prevents VTE 1
• Do not ignore signs of compartment syndrome: Monitor repetitively during first 24 hours in high-risk patients 1