Edited by Grace Xiong, Harry Lightsey, Brendan Striano - 7/1/2021
Descriptors
Malleolar: (isolated, bimalleolar, trimalleolar)
Relation to syndesmosis - Weber A (below), B (at syndesmosis), C (above syndesmosis)
Direction of dislocation
Exam Pearls
Lower Extremity Neurovascular Exam: DP and PT, if not palpable/perfused foot, need doppler and urgent reduction
Examine medial ankle for skin threatening and poke-hole open injuries
Assess for tenderness at the proximal Tib/Fib
Workup and Assessment of Injury Stability
Radiographs: AP/Lat/Mortise (Obl) Ankle; if pain proximally, Tib/Fib XRs
Two flavors:
Stable (isolated lateral malleolus fractures without medial clear space widening)
Unstable (lateral malleolus fractures with medial clear space widening, bimalleolar, trimalleolar fractures, or any fracture-dislocation, displaced isolated medial malleolus fracture)
Other imaging:
if stable appearing pattern with equivocal medial clear space widening, either bilateral gravity or external rotation stress views or no further imaging until follow-up
Post-reduction XR to ensure adequate reduction
if comminuted, trimalleolar, or with significant intraarticular involvement
Obtain post-reduction CT (only after seeing post-reduction XRs)
Labs: if admitting, pre-op labs, A1C if pt diabetic or if not known diabetic, but neuropathy on exam
Other: None
Management - Stable injury
Need for acute intervention: None
Weight-bearing and range of motion: WBAT in Tall air cast boot, ROMAT
Type of immobilization: Air cast boot, may come out of boot for hygiene
Admission or discharge status: Discharge with 1 week follow up in trauma clinic for repeat imaging to assess for interval medial widening that would indicate unstable pattern
Anticoagulation: ASA 81mg or 325mg PO daily x 4 weeks
Antibiotics: None
Management - Unstable injury
Need for acute intervention: Yes, immobilization and reduction
Weight-bearing and range of motion: NWB w/ UE crutches vs. wheelchair
Type of immobilization: Closed reduction and AO Short leg splint following hematoma block Ankle Hematoma Block
Admission or discharge status:
Two options based on patient choice and patient mobility/support at home:
Admission for trauma waitlist for surgical fixation
Discharge within 1 week in trauma clinic for surgical planning
Anticoagulation: ASA 81mg or 325 mg PO daily x 4wks
Antibiotics: Only if open fracture. Cefazolin 2g q8h for Gustillo Anderson I or II, Ceftriaxone 2g q24h for Gustillo Anderson III
Surgical Indications
Absolute: Open fracture, displaced medial malleolus, lateral malleolus with medial clear space widening (Bimal equivalent)
Relative: Posterior malleolus fractures >25% articular surface and >2mm articular gap