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Ankle Fracture Workup

  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
Updated: Dec 08, 2014

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.[9] Diagnostic guidelines are available from the American College of Radiology Appropriateness Criteria for suspected ankle fractures.[10]

Indications for ankle radiographs in patients with acute ankle pain include pain in the ankle region plus one of the following[11] :

  • 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) underlying neurologic deficit affecting lower limb(s), (2) altered mental status, and (3) multisystem trauma.

Application of the Ottawa Ankle Rules to patients younger than 18 years is controversial. While some advocate the rules can be applied to children old enough to talk and walk, others use the ages 5 or 6 as a cut-off.[12]

Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral, and mortise views) of the ankle. 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.

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.

Radiographic examination of the foot is not required in patients with an isolated ankle complaint. Although there may be an occult fracture of the base of the fifth metatarsal, those should be found with adequately performed ankle radiographs.[13]

Externally rotated lateral radiographic projection can provide surgeons with additional information regarding the presence, size, and displacement of posterior malleolar ankle fractures, according to one study. In this study, posterior malleolar fractures were accurately identified on 86.67% (26 of 30) of standard lateral radiographs and on 100% (30 of 30) of externally rotated lateral radiographs. In addition, surgeons described the fracture with greater precision and had greater interclass correlation coefficient values regarding sagittal plane displacement (0.977 versus 0.939) and percentage of involvement of the tibial plafond (0.972 versus 0.775) with an externally rotated lateral projection, as compared with a standard lateral projection.[14]

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.

Contributor Information and Disclosures

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, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.


Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.

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Maisonneuve injury. Mortise view shows transverse fracture of the medial malleolus and widening of the tibiofibular syndesmosis without a fracture of the fibula. This injury is suggestive of a proximal fibula fracture (Maisonneuve fracture).
Pilon fracture in a 35-year-old man who fell 20 ft. Anteroposterior radiograph shows at least 2 fracture lines extending to the articular surface (plafond) of the tibia.
A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.
An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.
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