Figure 50.1
Representative AP and lateral radiographic images of rotational ankle fractures
What to Ask
- 1.
Are there any open wounds (possible open fracture) or threatened skin?
- 2.
Is there any evidence of neurovascular injury or compartment syndrome?
What to Request
- 1.
The affected extremity should be iced and elevated immediately.
- 2.
X-rays of the foot, ankle, and tibia.
- 3.
Adjuncts for reduction (lidocaine for hematoma block and antispasmodic such as IV valium).
- 4.
An assistant is often required, particularly for large or poorly cooperative patients.
When to Escalate
- 1.
Open fractures: should be irrigated in ED and receive antibiotics (will require formal irrigation and debridement in OR).
- 2.
Fracture dislocations with skin tenting require emergent reduction to decrease risk of conversion to open injury.
- 3.
Non-reducible ankle fracture-dislocations are a surgical urgency and may require open reduction and fixation.
Imaging
- 1.
AP, lateral, and oblique ankle views.
- 2.
X-rays of the foot, tibia, and knee (helpful to rule out Maisonneuve fracture).
- 3.
Advanced imaging (CT) is often not required. The exception to this is supination-adduction injuries, which have significant injury to the distal tibial weight-bearing surface (the plafond).
- 4.
Stress views: an external rotation force applied in a mortise view can help identify syndesmotic injury.
- 5.
Careful review of imaging is important, particularly for “non-displaced lateral malleolus fractures” (Fig. 50.2).
