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Management of ankle fractures

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5204 (Published 28 October 2011) Cite this as: BMJ 2011;343:d5204
  1. Simon Mordecai, senior house officer 1,
  2. Nawfal Al-Hadithy, senior house officer2
  1. 1Salisbury District Hospital, Salisbury SP2 8BJ, UK
  2. 2University College London, London, UK
  1. Correspondence to: S Mordecai simon_mordecai{at}yahoo.com

A 73 year old woman presented to the accident and emergency department after having fallen down a flight of stairs near her local shops. She had not injured her head; lost consciousness; or had a preceding event, such as chest pain, shortness of breath, or dizziness. After her fall she sustained a closed injury to her left ankle, which was swollen and painful to palpation over both malleoluses. She was also unable to bear weight on her left ankle. Her medical history included hypertension, hypercholesterolaemia, and osteoporosis. She had undergone hemiarthroplasty for a fracture to the neck of the right femur 10 years ago. She lived with her husband in a bungalow and was fully independent in activities of daily living, using a stick to mobilise. She was an ex-smoker and did not drink. The anterioposterior and lateral radiographs on admission are shown below (figs 1 and 2).

Fig 1 Anterioposterior radiograph on admission

Fig 2 Lateral radiograph on admission


  • 1 When should a radiograph be ordered after an ankle injury?

  • 2 From the radiographs how would you classify this type of injury?

  • 3 How would you manage this woman acutely?

  • 4 How would you definitively manage this injury?


1 When should a radiograph be ordered after an ankle injury?

Short answer

If there is bony tenderness over the medial malleolus or lateral malleolus and the patient cannot bear weight.

Long answer

The Ottawa ankle rules are a set of guidelines aimed at helping doctors in emergency medicine decide whether a patient with foot or ankle pain should be offered radiographic investigation.1 The guidelines were developed by a team of doctors working in the emergency department of the Ottawa Hospital, Canada, and have been adopted in emergency departments worldwide. Their main purpose is to limit the number of unnecessary radiographs, which are not only costly and time consuming but also expose …

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