Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Deformity, ischaemia and unstable syndesmosis need urgent orthopaedics
Gross deformity, threatened skin, absent pulse, progressive neurological loss, compartment features, open injury or suspected fracture-dislocation requires immediate reduction and trauma care; high ankle pain with proximal fibular tenderness may represent an unstable Maisonneuve-pattern injury.
Action: Use trauma ABCDE, document skin and complete neurovascular findings, urgently reduce a threatened dislocation with adequate analgesia, obtain orthogonal ankle and full-length tibia-fibula imaging as indicated, immobilise, keep weight-bearing restricted and involve orthopaedics immediately for instability or limb threat.
Synopsis
Assess ankle trauma without missing fracture, syndesmotic instability or proximal fibular injury, use Ottawa criteria and weight-bearing imaging appropriately, and deliver early functional rehabilitation with timely escalation of unstable patterns.
Do not begin with the label sprain: inspect deformity and skin, document pulses and nerves, palpate the entire fibula, malleoli, navicular, fifth-metatarsal base and Achilles, then test function.
Use the Ottawa ankle and foot rules to decide first-line radiography in alert adults: posterior malleolar, navicular or fifth-base tenderness or inability to take four steps warrants films.
Lateral sprain produces tenderness over the anterior talofibular and sometimes calcaneofibular ligaments; delayed anterior drawer or talar tilt may be more informative after acute guarding settles.
Key red flags
A deformed ankle, tented skin, open wound, cool foot, delayed refill or new sensory and motor loss requires immediate reduction and orthopaedic care.
Investigation priorities
01
First-line Ottawa-rule assessmentFirst stepFirst line
Select patients who need ankle or foot radiographs after acute injury while screening for rule exclusions.
02
First-line ankle and foot radiographs when indicatedFirst line
Detect malleolar, talar, fifth-metatarsal, navicular and alignment injury.
Management branches
First-lineExclude fracture and limb threat
An acute ankle injury presents without immediate need for trauma resuscitation.
Inspect skin and alignment and document pulses, refill, sensation and motor function before stress testing.
Apply Ottawa criteria, palpate the entire fibula and assess Achilles, midfoot and fifth-metatarsal base.
Lateral sprainMove early after brief protection
Fracture and unstable syndesmotic injury are unlikely and the pattern is an isolated stable lateral sprain.
Key medicines
Paracetamol for acute ankle painUse 500–1000 mg orally as required, leaving 4 hours or longer between doses and limiting the 24-hour total to 4 g; lower that ceiling for low body weight, frailty, malnutrition or liver risk.
Topical diclofenac gelSpread 2–4 g of diclofenac 1.16% gel over intact painful ankle skin per application, up to three or four times daily for a brief course within the licensed maximum.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.