A 25 year old male presents with right ankle pain. He was running from the police, jumped over a fence and suffered an eversion injury. He tried to get up and run but was unable to bear weight secondary to the pain. No pain or trauma anywhere else. Patient has a tender medial malleoli, neurovascularly intact, skin intact, compartments are soft. A right ankle X-Ray is pending. What is the next step in evaluation of this patient?

A. Perform a talar tilt and anterior drawer test of the right ankle.

B. Consult orthopedics.

C. Palpate the tibia and fibula.

D. Perform the Thompson's squeeze test.

E. Add a weight-bearing view.

Answer: C - palpate the tibia and fibula.

-This patient could have a medial malleolus fracture with fracture of the proximal third of the fibula (Maisonneuve) or middle third of fibula (Dupuytren's).

-These are some of the most commonly missed second fractures and why the ankle exam begins at the knee.

-Usually the result of an eversion injury such that force is transmitted through the interosseous membrane and exits through a fibula fracture.

-Medial ankle pain is always a red flag in ankle injuries; also consider syndesmosis injury, bi- or tri-malleolar fracture and deltoid ligament rupture.

-For all medial ankle injuries, consider tib-fib X-Ray as the fibula may NOT be tender!

-Ankle X-ray may reveal no medial malleoli fracture but instead show a medial clear space > 4 mm and/or a tibiofibular clear space widening.

-Can be complicated by peroneal nerve injury - loss of first web space sensation, loss of foot eversion and loss of foot dorsiflexion.

-Management - This is an unstable fracture and if you miss the second fracture, can lead to chronic disability secondary to talar shift.

-Orthopedic consult for surgical repair via ORIF with syndesmotic screws

-Strict non-weight bearing status and below the knee posterior knee slab splint.