OR2.13 | Ankle Fracture Management — Summary & Reflection

KEY TAKEAWAYS

Ankle fractures are the most common operatively managed fractures. The Ottawa Ankle Rules determine when X-rays are needed: bony tenderness at the posterior 6 cm of either malleolus, or at the navicular or fifth metatarsal base, or inability to weight-bear, trigger radiographs. The Weber classification describes fibular fracture level relative to the syndesmosis (A = below, B = at, C = above); Weber C and bimalleolar/trimalleolar fractures are unstable. The Lauge-Hansen classification (SAD, SER, PAB, PER) describes sequential ligamentous and bony injury based on foot position and deforming force; SER is the most common pattern. Syndesmotic disruption is assessed clinically (squeeze test, external rotation stress) and radiographically (TFCS <5 mm, TFO >1 mm, MCS <4 mm); frank disruption requires fixation (screw or suture-button). Stable isolated lateral malleolus fractures are managed non-operatively; unstable bimalleolar/trimalleolar fractures and those with mortise widening require ORIF of fibula first, then medial malleolus, then posterior malleolus (if >25% of articular surface), followed by syndesmotic fixation if needed.

REFLECT

A 45-year-old man comes to the casualty after stepping into a pothole and 'twisting his ankle'. He has mild swelling over the lateral ankle, is able to limp in, and has no bony tenderness over the posterior malleoli, navicular, or base of fifth metatarsal. You do not order an X-ray, citing the Ottawa Ankle Rules. You diagnose a lateral ligament sprain and advise rest, ice, compression, and elevation. Two weeks later, he returns still unable to weight-bear normally. On re-examination, there is significant swelling of the entire ankle and you palpate a vague bony tenderness well above the lateral malleolus. Consider: what should your differential diagnosis now include? What examination and imaging step was missed at the initial visit that would have changed the outcome? What is the consequence of a missed Maisonneuve fracture treated as a sprain?