eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Ankle: Differential Diagnoses & Workup

Author: Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital
Coauthor(s): Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Jul 15, 2008

Differential Diagnoses

Ankle Injury, Soft Tissue
Dislocations, Ankle
Arthritis, Rheumatoid
Fractures, Foot
Compartment Syndrome, Extremity
Fractures, Tibia and Fibula
Deep Venous Thrombosis and Thrombophlebitis
Gout and Pseudogout

Other Problems to Be Considered

Tibia-fibular diastasis
Incisura fracture
Achilles tendon rupture
Achilles tendonitis
Charcot-Marie-Tooth disease

Workup

Laboratory Studies

  • No laboratory studies are necessary in patients with isolated ankle fracture when caused by a plausible mechanism. However, repeated ankle fracture or a fracture caused by simple, low force trauma can require investigation for osteoporosis, Charcot-Marie-Tooth disease, arthritis, connective tissue disease, or peripheral vascular disease.

Imaging Studies

  • Routinely obtaining radiographs following an ankle injury is not cost-effective because fewer than 15% of affected patients have fractures. Patients without fractures are identified reliably from the physical examination. Ottawa ankle rules provide practical guidelines to select patients for radiographic studies.
  • Indications for ankle radiographs in patients with acute ankle pain include pain in the ankle region plus one of the following:
    • Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus
    • Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus
    • Inability to bear weight both immediately and in the ED (defined as 4 steps)
    • Confounding variables to the Ottawa rules are (1) younger than 18 years, (2) underlying neurologic deficit affecting lower limb(s), (3) altered mental status, and (4) multisystem trauma.
  • Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral, and mortise views). In the mortise view, the foot is rotated approximately 15° internally, allowing better visualization of the ankle mortise. Check radiograph for headset sign (ie, tibia sits atop the talus resembling a headpiece on a receiver). Normally, the space between the cradle and the handle should be equal. Lack of symmetry suggests injury. Stress views help assess ankle joint stability but usually are deferred during the initial ED evaluation.
    • The ankle joint usually adheres to the ring axiom (eg, a fracture in one part of the ring often is associated with a second injury). Always look for an associated medial malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is seen. A vertical fracture of the medial malleolus is also associated with either a lateral malleolar fracture or rupture of the lateral ligaments.
    • Accessory ossicles appear frequently adjacent to the medial and lateral malleoli and may mimic fractures. Clinical correlation is important. Accessory ossicles demonstrate well-corticated margins, whereas fracture fragments exhibit less-defined borders.
  • CT scan and MRI
    • CT and MRI imaging studies may be part of outpatient management where imaging features by the other modalities are equivocal.
    • Advanced imaging is most useful to diagnose talar dome and triplane fractures, distinguish pilon from trimalleolar fractures, and differentiate an accessory ossicle from an avulsion fracture. Occasionally, these tests are used to assess the complexity of the fracture and any associated ligamentous and intra-articular injuries.
  • A bone scan rarely is indicated emergently. It may be useful for diagnosing and localizing stress fractures, infections, and neoplastic lesions.

Other Tests

  • Stress radiographs assess the ankle during stress testing; however, results of this test generally do not affect immediate ED management.

More on Fracture, Ankle

Overview: Fracture, Ankle
Differential Diagnoses & Workup: Fracture, Ankle
Treatment & Medication: Fracture, Ankle
Follow-up: Fracture, Ankle
References
[ CLOSE WINDOW ]

References

  1. Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. J Orthop Trauma. Apr 1995;9(2):113-6. [Medline].

  2. Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. J Orthop Trauma. Jan 1998;12(1):67-8. [Medline].

  3. Birrer R, Cartwright T, Denton J. Immediate diagnosis of ankle trauma. In: The Physician and Sports Medicine. Vol 22. McGraw Hill; 1994:95-103.

  4. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). Apr 2003;15(2):126-32. [Medline].

  5. Bucholz RW, Heckman JD. Fractures in adults. In: Rockwood and Green's Fractures in Adults. 5th ed. 2001.

  6. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?. Acta Orthop Scand. Feb 1998;69(1):43-7. [Medline].

  7. Cummings RJ, Hahn GA. The incisural fracture. Foot Ankle Int. Mar 2004;25(3):132-5. [Medline].

  8. Daffner RH. Ankle trauma. Radiol Clin North Am. Mar 1990;28(2):395-421. [Medline].

  9. Derksen RJ, Bakker FC, Geervliet PC, et al. Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankleand foot rules by specialized emergency nurses. Am J Emerg Med. Oct 2005;23(6):725-9. [Medline].

  10. Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg. Mar-Apr 1996;35(2):127-33; discussion 189. [Medline].

  11. Duke Orthopaedics. Ankle Fractures. Wheeless' Textbook of Orthopaedics online. 2005:[Full Text].

  12. Fox A, Wykes P, Eccles K, et al. Five years of ankle fractures grouped by stability. Injury. Jul 2005;36(7):836-41. [Medline].

  13. Funk JR, Srinivasan SC, Crandall JR. Snowboarder's talus fractures experimentally produced by eversion and dorsiflexion. Am J Sports Med. Nov-Dec 2003;31(6):921-8. [Medline].

  14. Greenfield DM, Eastell R. Risk factors for ankle fracture. Osteoporos Int. 2001;12(2):97-103. [Medline].

  15. Holroyd BR, Wilson D, Rowe BH, et al. Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules. Am J Emerg Med. May 2004;22(3):149-55. [Medline].

  16. Howard JL, Buckley R, McCormack R, et al. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma. Apr 2003;17(4):241-9. [Medline].

  17. Kannus P, Palvanen M, Niemi S, et al. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone. Sep 2002;31(3):430-3. [Medline].

  18. Kirkpatrick DP, Hunter RE, Janes PC, et al. The snowboarder's foot and ankle. Am J Sports Med. Mar-Apr 1998;26(2):271-7. [Medline].

  19. Koury SI, Stone CK, Harrell G, et al. Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care. Feb 1999;15(1):37-9. [Medline].

  20. Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. Oct 2005;19(9):635-9. [Medline].

  21. Koval KJ, Zhou W, Sparks MJ, et al. Complications after ankle fracture in elderly patients. Foot Ankle Int. Dec 2007;28(12):1249-55. [Medline].

  22. Leisey J. Prospective validation of the Ottawa Ankle Rules in a deployed military population. Mil Med. Oct 2004;169(10):804-6. [Medline].

  23. Martin AG. Weber B ankle fracture: an unnecessary fracture clinic burden. Injury. Aug 2004;35(8):805-8. [Medline].

  24. McCrory P, Bladin C. Fractures of the lateral process of the talus: a clinical review. "Snowboarder's ankle". Clin J Sport Med. Apr 1996;6(2):124-8. [Medline].

  25. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. May 2007;21(5):307-15. [Medline].

  26. Mora S, Zalavras CG, Wang L, et al. The role of pulsatile cold compression in edema resolution following ankle fractures: a randomized clinical trial. Foot Ankle Int. Nov 2002;23(11):999-1002. [Medline].

  27. Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR Imaging. Semin Musculoskelet Radiol. Sep 2005;9(3):210-26. [Medline].

  28. Myers A, Canty K, Nelson T. Are the Ottawa ankle rules helpful in ruling out the need for x ray examination in children?. Arch Dis Child. Dec 2005;90(12):1309-11. [Medline].

  29. Nugent PJ. Ottawa Ankle Rules accurately asses injuries and reduce reliance on radiographs. J Fam Pract. Oct 2004;53(10):785-8. [Medline].

  30. Okcu G, Yercan HS. Is it possible to decrease skin temperature with ice packs under casts and bandages? A cross-sectional, randomized trial on normal and swollen ankles. Arch Orthop Trauma Surg. Dec 2006;126(10):668-73. [Medline].

  31. Park JW, Kim SK, Hong JS, et al. Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma. Apr 2002;52(4):655-9. [Medline].

  32. Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury. Dec 2006;37(12):1157-65. [Medline].

  33. Port AM, McVie JL, Naylor G, et al. Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus. J Bone Joint Surg Br. Jul 1996;78(4):568-72. [Medline].

  34. Ruiz E, Cicero J. Emergency Management of Skeletal Injuries. ed. Mosby-Year Book, Incorporated; 1995:517-541.

  35. Schmittenbecher PP. What must we respect in articular fractures in childhood?. Injury. Feb 2005;36 Suppl 1:A35-43. [Medline].

  36. Shariff SS, Nathwani DK. Lauge-Hansen classification--a literature review. Injury. Sep 2006;37(9):888-90. [Medline].

  37. Sharma S, Fraser M, Lovell F, et al. Characteristics of males over 50 years who present with a fracture: epidemiology and underlying risk factors. J Bone Joint Surg Br. Jan 2008;90(1):72-7. [Medline].

  38. Stergioulas A. Low-level laser treatment can reduce edema in second degree ankle sprains. J Clin Laser Med Surg. Apr 2004;22(2):125-8. [Medline].

  39. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. Mar 16 1994;271(11):827-32. [Medline].

  40. Tang CW, Roidis N, Vaishnav S, et al. Position of the distal fibular fragment in pronation and supination ankle fractures: a CT evaluation. Foot Ankle Int. Jul 2003;24(7):561-6. [Medline].

  41. Thordarson DB. Detecting and treating common foot and ankle fractures: Part 1: The ankle and hindfoot. Phys Sportsmed. Sep 1996;24(9).

  42. Thordarson DB, Ghalambor N, Perlman M. Intermittent pneumatic pedal compression and edema resolution after acute ankle fracture: a prospective, randomized study. Foot Ankle Int. Jun 1997;18(6):347-50. [Medline].

  43. Thordarson DB, Greene N, Shepherd L, et al. Facilitating edema resolution with a foot pump after calcaneus fracture. J Orthop Trauma. Jan 1999;13(1):43-6. [Medline].

  44. Werner CM, Lorich DG, Gardner MJ, et al. Ankle fractures: it is not just a "simple" ankle fracture. Am J Orthop. Sep 2007;36(9):466-9. [Medline].

  45. Wexler RK. The injured ankle. Am Fam Physician. Feb 1 1998;57(3):474-80. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ankle fracture, broken ankle, ankle joint, ankle injury, Maisonneuve fracture, medial malleolus fractures, open ankle fractures, pilon fracture, pediatric ankle fractures, posterior malleolar fractures, ankle pronation-external (eversion) rotation injuries, ankle supination, adduction injuries, ankle supination external (eversion) rotation injury, ankle syndesmotic injury, ankle trimalleolar fracture, vertical loading of the ankle, pronation dorsiflexion injury, ankle trauma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital
Kara Iskyan, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.