What's the Diagnosis? By Dr. Danielle Kovalsky

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