01Approach to the Critical Patient/attcp41

Immediate priorities

›Stabilization priorities

›If hypotension tachycardia altered mental status, trauma resuscitation pathway

›Concomitant injuries screening

›Head injury

›Spine injury

›Pelvic injury

›If open fracture, immediate antibiotics and tetanus update

›Hemorrhage control

›Sterile saline dressing

›Gross contamination irrigation in ED

›If neurovascular compromise, immediate reduction and splinting

›Dorsalis pedis and posterior tibial pulses

›Capillary refill and skin temperature

›Paresthesia motor weakness progression

›If threatened skin over dislocation fracture dislocation, urgent reduction

›Medial skin tenting

›Lateral talar shift concern

Key decision points

›Time critical flags

›Open fracture

›Immediate orthopedic consultation

›Operating room timing planning

›Fracture dislocation

›Reduction under analgesia sedation

›Post reduction neurovascular reassessment

›Compartment syndrome concern

›Pain out of proportion

02History/hx41

Presentation and mechanism

›Core history elements

›Time of injury

›Immediate swelling

›Delayed swelling

›Mechanism classification

›Inversion

›Eversion

›High energy motor vehicle fall from height

›Weight bearing ability after injury and in ED

›Four steps ability

›Immediate inability

›Pain location mapping

›Lateral malleolus region

›Medial malleolus region

›Posterior malleolus region

›Prior ankle injury or surgery

›Chronic instability

›Hardware presence

Risk modifiers

›Patient factors

›Osteoporosis or low bone density risk

›Chronic steroid use

›Prior fragility fracture

›Diabetes with neuropathy

›Charcot risk

›Blunted pain perception

›Anticoagulation or bleeding risk

03Physical Exam/exam40

Inspection and palpation

›Local exam domains

›Deformity

›Obvious malalignment

›Talar shift appearance

›Swelling and ecchymosis pattern

›Medial bruising suggesting deltoid injury

›Posterior bruising suggesting posterior malleolus

›Skin integrity

›Open wound near malleoli

›Skin tenting

›Bony tenderness map

›Posterior edge or tip lateral malleolus

›Posterior edge or tip medial malleolus

›Navicular

›Base of fifth metatarsal

Neurovascular and tendon

›Distal status

›Pulses

›Dorsalis pedis

›Posterior tibial

›Perfusion

›Capillary refill

›Skin temperature and color

›Sensation

›Superficial peroneal distribution

›Deep peroneal first web space

›Tibial plantar surface

04Differential Diagnosis/ddx29

Traumatic

›Mimics and associated injuries

›Ankle sprain

›Lateral ligament injury

›Deltoid ligament injury

›Syndesmotic sprain

›High ankle sprain

›Maisonneuve fracture

›Talar dome osteochondral lesion

›Persistent deep ankle pain

›Locking or catching

›Fifth metatarsal fracture

›Tuberosity avulsion

›Jones fracture

›Calcaneus fracture

›Heel pain after fall

›Bohler angle change

Non traumatic and infection

›Non fracture causes

›Septic arthritis

›Fever

›Severe pain with minimal trauma

›Crystal arthritis

›Podagra history

›Sudden swelling

›Cellulitis

›Diffuse erythema warmth

›No bony tenderness focal

05Laboratory Tests/lt29

When labs add value

›Lab strategy

›No routine labs for isolated closed stable fracture

›Clinical course driven by imaging and stability

›Analgesia plan without labs

›If operative management likely, basic preop set

›Complete blood count for anemia infection concern

›Electrolytes including sodium potassium creatinine

›Glucose for diabetes control planning

›If open fracture or systemic infection concern

›Complete blood count for leukocytosis trend

›C reactive protein for inflammatory burden

›Blood cultures if febrile

›If anticoagulation bleeding concern

›INR if warfarin use

›Type and screen if large bleeding or surgery imminent

Point of care and special situations

›Focused testing

›Pregnancy test if pregnancy possible and imaging planned

›Urine beta hCG

›Serum beta hCG if uncertain

›If procedural sedation planned

›Glucose check if diabetes or altered mental status

›Targeted tests based on comorbidity

Pitfalls

›Limitations

›Normal inflammatory markers do not exclude early septic arthritis

›Clinical suspicion threshold

06Diagnostic Tests/dt54

Scoring Systems

›Ottawa ankle rules

›Ankle radiograph indications

›Pain in malleolar zone

›Bone tenderness posterior edge or tip lateral malleolus

›Bone tenderness posterior edge or tip medial malleolus

›Inability to bear weight immediately and in ED four steps

›Foot radiograph indications

›Pain in midfoot zone

›Bone tenderness at navicular

›Bone tenderness at base of fifth metatarsal

›Inability to bear weight immediately and in ED four steps

›Diagnostic performance

›Sensitivity approximately 99 percent for clinically significant ankle and midfoot fractures

›Reduced imaging utilization with low miss rate

›Use with appropriate application and exam quality

›Evidence and guideline notes

›Broad validation in emergency care populations

›ACEP Level B support for use of validated decision rules for imaging reduction

MRI

›MRI applications

›Occult fracture with persistent pain and negative radiographs

›Talar dome osteochondral lesion detection

›Ligament and tendon injury delineation

›When CT inadequate

›Cartilage injury concern

›Syndesmotic ligament complex detail

›Limitations

07Disposition/dispo30

Admission and consult criteria

›Higher level care triggers

›Open fracture

›Admit for operative irrigation debridement

›IV antibiotics continuation

›Fracture dislocation or unstable fracture requiring reduction

›Orthopedic consultation in ED

›Post reduction imaging confirmation

›Neurovascular compromise

›Immediate orthopedic involvement

›Frequent neurovascular reassessment

›Inability to ambulate safely

›PT OT needs

›Social support limitations

Discharge criteria and follow up

›Safe discharge pathway

›Closed stable fracture pattern

›Adequate pain control with oral regimen

›Intact neurovascular exam post immobilization

›Splint cast care understanding

›Elevation and swelling control plan

›Return precautions comprehension

›Orthopedic follow up timing

›Within 3 to 7 days for most fractures needing reassessment

›Within 24 to 72 hours for high swelling skin risk patterns

Transfer considerations

›Transfer triggers

›Need for urgent surgery not available onsite

08Treatment/t80

Analgesia and antiemesis

›Pain control framework

›Acetaminophen oral 1000 mg

›Maximum 4000 mg per 24 hours

›Lower maximum in liver disease

›Ibuprofen oral 400 to 600 mg

›Every 6 to 8 hours as needed

›Avoid in significant renal disease GI bleed risk

›Naproxen oral 250 to 500 mg

›Every 12 hours as needed

›Avoid in pregnancy third trimester

›Oxycodone oral 5 mg

›Every 4 to 6 hours as needed for severe pain

›Short course with bowel regimen

›Ondansetron oral disintegrating 4 mg

›Every 8 hours as needed

›QT risk consideration

Reduction and immobilization

›Reduction pathway

›If fracture dislocation or malalignment, initiate reduction

›Inline traction and reversal of deforming force

›Skin tenting relief goal

›Immediate post reduction pulses and sensation check

›Post reduction imaging

›Repeat ankle radiographs

›Mortise view alignment check

›Immobilization choices

›Posterior short leg splint

›Neutral ankle position

›Padding for swelling

›Crutch training before discharge

›Posterior splint plus stirrup

›Unstable malleolar fractures

›Syndesmotic injury suspicion

›Avoid circumferential cast in first 48 to 72 hours

Procedural sedation and regional options

›Analgesia sedation options

›Intra articular hematoma block

›Lidocaine 1 percent 10 to 20 mL

›Aspiration confirmation of intra articular placement

›Avoid if open fracture or infection concern

›Ketamine IV 1 mg per kg

›Additional 0.5 mg per kg as needed

›Emergence reaction mitigation plan

›Class IIa for ED procedural sedation in appropriate monitoring settings

›Propofol IV 0.5 to 1 mg per kg initial

›Additional 0.25 to 0.5 mg per kg as needed

›Apnea hypotension risk monitoring

›Class IIa for ED procedural sedation with trained staff

›Fentanyl IV 0.5 to 1 microgram per kg

›Titrate to effect

›Respiratory depression monitoring

›Naloxone availability

Antibiotics tetanus and wound care

›Open fracture bundle

›Cefazolin IV 2 g

›Every 8 hours

›Increase to 3 g if very high body mass

›Class I for early antibiotic administration in open fractures

›If severe cephalosporin allergy

›Clindamycin IV 900 mg

›Every 8 hours

›Add gram negative coverage for severe contamination per local protocol

›Irrigation and sterile dressing

›Remove gross debris

›Moist sterile dressing

›Splint after dressing

›Tetanus prophylaxis

›If unknown or incomplete immunization and dirty wound, tetanus vaccine plus immune globulin

›If immunized and last dose over 5 years for dirty wound, booster

Operative indications and stability

›Surgical consideration triggers

›Unstable ankle mortise

›Bimalleolar fracture

›Trimalleolar fracture

›Medial clear space widening on mortise view

›Syndesmotic instability

›Widened tibiofibular clear space

›Proximal fibula fracture pattern

›Posterior malleolus large fragment

›Articular incongruity

›Posterior instability

›Open fracture

›Irrigation debridement and fixation planning

›Compartment syndrome vigilance

09Special Populations/sp34

Pregnancy

›Pregnancy considerations

›Imaging safety

›Shielding when feasible

›Radiography dose generally low for extremity

›Shared decision discussion

›Analgesia modifications

›Acetaminophen preferred first line

›Avoid NSAIDs in third trimester

›Short course opioid if needed with obstetric awareness

›VTE risk awareness with immobilization

›Early mobilization when safe

›Obstetric guided prophylaxis if high risk

Geriatric

›Older adult considerations

›Low energy fractures as fragility signals

›Osteoporosis evaluation referral

›Fall risk assessment

›Skin breakdown risk with splints

›Extra padding and frequent checks

›Early follow up within 48 to 72 hours if swelling severe

›Delirium and sedation sensitivity

›Lower dosing titration

›Avoid polypharmacy when possible

Pediatrics

›Pediatric considerations

›Growth plate injury vigilance

›Salter Harris patterns in distal tibia fibula

10Background/b35

Epidemiology

›Epidemiology overview

›Common injury patterns

›Lateral malleolus fractures frequent

›Bimalleolar and trimalleolar patterns associated with instability

›Mechanism trends

›Low energy twisting in ambulatory adults

›High energy associated with plafond involvement

›Complication frequencies

›Post traumatic arthritis risk with intra articular step off

›DVT risk with immobilization and reduced mobility

Pathophysiology

›Injury mechanics

›Supination external rotation sequence

›Anterior inferior tibiofibular ligament injury

›Spiral distal fibula fracture

›Posterior malleolus involvement possible

›Pronation external rotation sequence

›Medial injury deltoid or medial malleolus

›Syndesmotic disruption risk

›Mortise stability concepts

›Talus requires congruent mortise for normal load transmission

›Medial clear space widening implies deltoid incompetence

Therapeutic Considerations

›Treatment rationale

›Early reduction prevents skin compromise and neurovascular injury

›Deformity tension relief

›Pain reduction after alignment

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Discharge instructions

›Splint care

›Keep clean and dry

›Do not insert objects into splint

›Swelling control

›Elevation above heart as much as possible for first 48 hours

›Ice 15 to 20 minutes at a time with skin protection

›Activity

›Non weight bearing unless explicitly instructed otherwise

›Crutches or walker use safety

›Medications

›Acetaminophen and NSAID schedule if appropriate

›Opioid only for severe pain and shortest duration

›Return to ED immediately

›Increasing pain not controlled by medication

›Numbness tingling new weakness in foot or toes

›Toes cold pale blue or capillary refill worsening

›Splint feels too tight or rapidly increasing swelling

›Wound concerns

›Any drainage foul smell or fever

›New redness streaking around any wound

›Follow up

›Orthopedic clinic appointment within recommended timeframe

›Repeat imaging expectations for alignment check

12References/r22

Guidelines and evidence sources

›Core references

›Ottawa ankle rules original derivation and validation studies

›Imaging reduction with high sensitivity for clinically significant fractures

›Implementation studies in emergency care

›Orthopedic trauma open fracture antibiotic timing recommendations

›Early first generation cephalosporin coverage

›Tetanus prophylaxis standards

›AAOS ankle fracture management guidance

›Stability based operative indications

›Post reduction immobilization principles

›BOAST guidance for management of ankle fractures and open fractures

›Early reduction and immobilization

›Follow up and operative timing principles

Coding and terminology

›Medical coding references

›ICD 10 CM closed fracture of medial malleolus S82 5

›ICD 10 CM closed fracture of lateral malleolus S82 6

›ICD 10 CM bimalleolar fracture S82 84

›ICD 10 CM trimalleolar fracture S82 85

›SNOMED CT concepts

›Ankle fracture disorder concept

›Fracture dislocation of ankle concept

›Open fracture of ankle concept

Evidence & Review

Evidence & Review