A 21-year-old female recreational player presented three weeks after a twisting injury to her right ankle. She describes experiencing an immediate onset of severe pain, being unable to continue and developing near immediate swelling. She was seen at a local A+E within hours of her injury and was diagnosed with an ‘ankle sprain’. She had x-rays at the time of injury and again ten days later. These were said to be normal. She has been unable to weight bear since the injury.
An initial x-ray (as well as a follow-up x-ray 10 days later) showed soft tissue swelling, an effusion but no bony injury. A subsequent MRI scan shows a non-displaced coronally orientated fracture of the posterior malleolus. There is a small volume of bone oedema associated with this. In association with the fracture there is thickening of the AITFL. The PITFL was radiologically normal and there was no evidence of widening of the syndesmosis. The ATFL was also thickened and attenuated.
Once the diagnosis of a fracture was made, this woman was managed with two weeks non-weight bearing in a walking boot. By this time, she was able to walk comfortably in her boot. She completed regular ROM exercises in a seated position during this period. She was able to progressively come out of the boot and was walking comfortably after five weeks of the diagnosis having been made. She was able to return to recreational football approximately four months after the injury.
The Ottawa rules were designed to determine when an x-ray was needed after acute ankle and mid-foot injuries. While these rules have almost 100% specificity, they have only modest specificity. The lack of specificity is highlighted in this case (where the x-rays did not clearly show the injury). If an initial x-ray is normal, but you suspect there may be a bony injury, one approach is to treat the patient and repeat the imaging in 7-10 days. By this time there is generally some fracture healing and the periosteal reaction is often evident. As this case illustrates though this is not always reliable. Another option is to arrange high-tech imaging with the aim of documenting a more significant injury. In most cases a CT or MRI would be the modalities of choice.
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