A 41 yo F presents to the ED with R ankle pain after a fall while playing outside in the snow. She has been unable to ambulate since the fall. Exam shows decreased ROM, swelling and a deformity of the R ankle. Tenderness is present over the medial malleolus and there is a decreased DP pulse on the R. Xrays are done and shown below. What's the diagnosis? (scroll down for answer)

Answer:  Closed R Trimalleolar Fracture with Posterior Dislocation

• Background
• Fracture of the lateral, medial and posterior malleolus (posterior aspect of distal tibia)
• Trimalleolar fractures make up 7-12% of all ankle fractures
• Presentation
• Pain, swelling, ecchymosis of ankle
• Typically occur with high force injuries
• Diagnosis
• Xrays: AP, lateral and mortise views of ankle
• Consider xrays of tibia/fibula to rule out proximal injury
• ED Management
• Evaluate for neurovascular compromise
• Can provide local anesthesia (intra-articular injection) or conscious sedation for reduction
• Clean/dress open wounds, prophylactic antibiotics and tetanus if indicated
• Immobilize, elevate
• Trimalleolar fractures are consided unstable- need orthopedic consultation, ORIF likely necessary