Ankle Fracture Assessment & Management (Ottawa Rules)

Algorithm Steps

1. ▶

   Start

   Ankle Injury Presentation

   Traumatic ankle pain

   1. ●

      Action

      Initial Assessment

      History and examination

      • Mechanism of injury (inversion, eversion, rotation)
      • Ability to weight bear after injury
      • Swelling, ecchymosis
      • Deformity (obvious fracture-dislocation)
      • Neurovascular status
      • Skin integrity (open fracture)
      1. ◆

         Decision

         Obvious Deformity/Dislocation?

         Gross malalignment requiring urgent care

         1. ⚠

            Warning

            ⚠️ Urgent Reduction Needed

            Fracture-dislocation

            • Reduce immediately if skin tenting
            • Analgesia/sedation
            • Splint post-reduction
            • Check neurovascular post-reduction
            • X-ray after reduction
            1. ●

               Action

               X-ray Indicated

               AP, lateral, mortise views

               • AP view: Tibiofibular overlap, clear space
               • Lateral view: Posterior malleolus
               • Mortise view: Talar tilt, medial clear space
               • Check for Maisonneuve (proximal fibula)
               1. ◆

                  Decision

                  Fracture Present?

                  Classify if fracture found

                  1. ●

                     Action

                     No Fracture - Ankle Sprain

                     Treat conservatively

                     • Assess sprain grade (1-3)
                     • ATFL most commonly injured
                     • Grade 1-2: Functional treatment
                     • Grade 3: Consider immobilization
                     • Physiotherapy for proprioception
                     1. ✓

                        Outcome

                        Fracture Healed

                        Return to function

                  2. ◆

                     Decision

                     Weber Classification

                     Classify lateral malleolus fracture

                     • Weber A: Below syndesmosis (usually stable)
                     • Weber B: At level of syndesmosis (may be unstable)
                     • Weber C: Above syndesmosis (unstable)
                     1. ●

                        Action

                        Weber A (Infrasyndesmotic)

                        Usually stable

                        • Below level of ankle joint
                        • Syndesmosis intact
                        • Often isolated lateral malleolus
                        • Non-operative: Short leg cast/boot
                        • Weight bearing as tolerated
                        1. ◆

                           Decision

                           Operative vs Non-operative

                           Based on stability

                           1. ●

                              Action

                              Non-operative Treatment

                              Stable fractures

                              • Below-knee cast or CAM boot
                              • 6 weeks immobilization typical
                              • Weight bearing depends on fracture
                              • Serial X-rays to check alignment
                              • DVT prophylaxis consideration
                           2. ●

                              Action

                              ORIF (Open Reduction Internal Fixation)

                              Unstable fractures

                              • Lateral malleolus: Plate and screws
                              • Medial malleolus: Screws or tension band
                              • Posterior malleolus: If >25-33%
                              • Syndesmotic screw if disrupted
                              • Non-weight bearing initially
                     2. ●

                        Action

                        Weber B (Transsyndesmotic)

                        Stability assessment needed

                        • At level of syndesmosis
                        • Check medial clear space on mortise
                        • >4mm medial clear space = unstable
                        • Stress views or MRI if equivocal
                        • Stable: Non-operative treatment
                        • Unstable: ORIF indicated
                     3. ●

                        Action

                        Weber C (Suprasyndesmotic)

                        Unstable - typically surgical

                        • Above syndesmosis
                        • Syndesmosis disrupted
                        • Often with medial injury (deltoid/med mal)
                        • ORIF with syndesmotic fixation
                        • Check for Maisonneuve fracture
                  3. ●

                     Action

                     Bimalleolar/Trimalleolar

                     Multiple malleoli involved

                     • Bimalleolar: Lateral + medial malleolus
                     • Trimalleolar: + posterior malleolus
                     • Inherently unstable
                     • Usually requires ORIF
                     • Posterior malleolus >25-33% = fixation
         2. ◆

            Decision

            Apply Ottawa Ankle Rules

            Determine need for X-ray

            • X-ray indicated if ANY of the following:
            • 1. Bone tenderness at posterior 6cm of lateral malleolus tip
            • 2. Bone tenderness at posterior 6cm of medial malleolus tip
            • 3. Unable to weight bear 4 steps immediately AND now
            • Also check Ottawa Foot Rules for midfoot
            1. ●

               Action

               Ottawa Rules Negative

               <1% fracture risk

               • No X-ray needed
               • Likely ankle sprain
               • PRICE: Protection, Rest, Ice, Compression, Elevation
               • Analgesia (NSAIDs/paracetamol)
               • Functional rehabilitation
               • Safety net: Return if not improving in 5-7 days