Synopsis
Apply the Ottawa ankle rules correctly, recognise unstable or skin-threatening injury, reduce urgent deformity without imaging delay, define malleolar and syndesmotic patterns, and prescribe safe fixation, mobilisation and follow-up.
- Inspect before palpation: gross deformity, threatened medial skin, open wound or neurovascular compromise takes priority over applying a decision rule or obtaining ideal radiographs.
- In people older than 5 years with traumatic ankle or midfoot pain, NICE recommends the Ottawa ankle and foot rules to decide whether radiographs are needed.
- Request ankle radiographs for posterior-edge or tip tenderness over the distal 6 cm of either malleolus, or inability to take four steps both immediately after injury and during assessment.
- Request foot radiographs for navicular or base-of-fifth-metatarsal tenderness, or the same inability to take four steps, when pain lies in the midfoot zone.
- The Ottawa rules decide imaging, not discharge, stability or treatment; they do not replace examination for wounds, proximal fibular pain, tendon rupture, neurovascular deficit or compartment syndrome.
- Obtain AP, mortise and lateral ankle radiographs when indicated; include the whole tibia and fibula for proximal tenderness, and use CT when posterior malleolar, plafond or complex fracture anatomy will change management.
- Urgently reduce a fracture-dislocation with threatened skin or circulation, then document neurovascular findings and obtain post-reduction films; do not wait for CT.
- Stable unimalleolar injuries may use a boot or cast with early loading and review, while talar shift, bimalleolar-equivalent, syndesmotic or displaced multi-malleolar patterns need urgent operative assessment.
Key red flags
A tented, blanched or insensate skin bridge over a displaced malleolus, absent pulses, cool foot or gross fracture-dislocation requires immediate reduction and reassessment before routine imaging.
Any wound near a fracture, exposed bone, contamination or gas in tissue is an open fracture until specialist assessment proves otherwise and needs the formal open-fracture pathway.
Pain escalating despite reduction, pain on passive toe movement, tense swelling or progressive sensory or motor loss raises acute compartment syndrome and requires emergency review.
Proximal fibular tenderness or common fibular nerve symptoms with ankle pain suggests a Maisonneuve pattern and unstable syndesmotic injury that a focal ankle film can miss.
Investigation priorities
Select patients with acute ankle or midfoot trauma who need radiography.
Define malleolar fracture and mortise alignment.
Management branches
The ankle is grossly deformed, open, neurovascularly compromised or tenting the skin.
- Perform trauma assessment, expose and photograph wounds once under policy, document pulses and named nerve function and give analgesia.
- Cover an open wound and give immediate network intravenous prophylaxis while preparing urgent reduction and orthopaedic escalation.
- Reduce the deformity without waiting for ideal films when skin or perfusion is threatened, then apply a well-padded splint.
- Repeat skin and neurovascular examination, obtain post-reduction imaging and escalate failed, unstable or deteriorating reduction immediately.
The mortise is congruent and the fracture or ligament injury is judged stable after adequate imaging.
- Provide a boot, cast or brace with explicit weight-bearing and ankle-movement instructions and ensure safe crutch use.
- Arrange timely fracture-clinic review and repeat weight-bearing or standard radiographs when stability remains uncertain.
- Use elevation, skin surveillance and progressive range and strengthening while avoiding prolonged unnecessary immobilisation.
- Assess VTE risk, falls and bone health and provide clear return advice for displacement, pressure damage or thrombotic symptoms.