Orthopaedic Emergencies 311INJURIES TO THE LOWER TIBIA, ANKLE AND FOOTRequest an anteroposterior and lateral X-ray of the ankle based on these Ottawa
criteria, if there is pain in the malleolar area and any one of the following:
(i) Inability to bear weight (e.g. unable to take four steps without
assistance, regardless of limping) both within the first hour of
injury and in the ED.
(ii) Bone tenderness over the posterior edge or tip of the distal 6 cm
of the medial malleolus.
(iii) Bone tenderness over the posterior edge or tip of the distal 6 cm
of the lateral malleolus.5 Ottawa foot rules
Request an additional foot X-ray only when there is pain in the mid-foot and
any one of the following:
(i) Inability to bear weight both immediately and in the ED.
(ii) Bone tenderness over the base of the fifth metatarsal.
(iii) Bone tenderness over the navicular.
MANAGEMENT1 Refer the following injuries immediately to the orthopaedic team, after
giving analgesia and applying a below-knee plaster backslab (see below):
(i) Compound ankle injury.
(ii) Displaced lateral malleolar or medial malleolar fractures, with
widening or diastasis of the ankle mortice.
(iii) Bimalleolar and trimalleolar ankle fractures.
2 Treat conservatively in a below-knee plaster a stable ankle fracture such as an
undisplaced lateral malleolar fracture or a malleolar avulsion fracture.
(i) Below-knee plaster slab:
(a) Apply this from the metatarsal heads to below the tibial
tubercle, with the ankle at a right-angle (not in equinus)
(b) Repeat the ankle X-ray after application of the plaster
(c) Refer the patient to the next fracture clinic, with instructions
to keep the leg elevated as much as possible.
3 Patients able to bear weight, with minimal swelling and with no fracture
seen on X-ray:
(i) Apply a double-elasticated stockinet bandage, give the patient
crutches or a walking frame, and give an anti-inflammatory
analgesic such as ibuprofen 200–400 mg orally t.d.s. or naproxen
250 mg orally t.d.s.
(ii) Recommend initial elevation, no weight-bearing and a cold compress
(e.g. a bag of frozen peas) at home, followed by gradual mobilization.
(iii) Warn patients that they will not be fully fit for active sports for at
least 3–4 weeks, and recommend physiotherapy if available.
(iv) Review the patient after 5–10 days and refer to physiotherapy
when there is persisting disability, if not already attending.