AdultPediatric
Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow — check first
Diagnostic flow — check first
- Ottawa rules: pain in malleolar zone + tenderness over posterior edge of either malleolus or inability to bear weight × 4 steps → XR.
- Medial ankle pain → palpate proximal fibula (Maisonneuve).
- Calf 'pop' → Thompson test for Achilles.
- Fall from height with heel pain → image L-spine + bilateral calcanei.
Differential diagnosis — checklist
0/15
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Traumatic0/9
Atraumatic0/6
Initial ED workup
Bedside0/6
- Vitals
- Inspect deformity, ecchymosis, skin tenting, open wounds
- Palpate per Ottawa: posterior edge of medial + lateral malleolus, navicular, base of 5th MT
- Squeeze + ER test for syndesmosis
- Thompson for Achilles
- NV exam (dorsalis pedis, posterior tibial, sural, peroneal)
Labs0/2
- CBC, CRP, urate if atraumatic effusion + fever
- Joint aspiration if septic suspected
Imaging0/4
- AP + lateral + mortise XR per Ottawa
- Tib-fib XR if Maisonneuve suspected (proximal fibula)
- CT for plafond, talus, calcaneus
- MRI (without contrast) for occult fracture / OCD
Initial management0/3
- Posterior splint or walking boot, ice, elevation, NSAID + acetaminophen
- Reduce dislocations / displaced fractures emergently
- Aspirate + ortho washout for septic ankle
Pearls / pitfalls
Pearls
- Maisonneuve is the classic miss — always palpate the proximal fibula in ankle injuries.
- Bohler angle <20° suggests calcaneus fracture even if subtle.
- Achilles rupture is often missed because patients can still plantarflex weakly via FHL/peroneals — use Thompson test.