Learning objective no 1 and 4
Case History:
A 24 year-old female patient, felt from horse, sustained injury in her right ankle 3 hours before admission in A and E. Pain and swelling in her right ankle and unable to weight bearing.
No history of medical problem or previous medication.
Physical examination:
Generally well, normal hemodynamic.
Left lower limb: mild deformity of left ankle, oedema in medial and lateral ankle, pain in palpation in lateral and medial malleolus, pain in passive movement and decrease ROM in active movement. Skin and Neurovascular system intact.
Differential diagnosis:
- left lateral and medial ankle Ligament injuries
- Left Ankle fracture
- Left Ankle dislocation
- Left ankle fracture and dislocation
Plan of Diagnosis:
 Radiographs: Stress radiograph to assess competency of deltoid ligament
 a medial clear space of > 5 mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption
 more sensitive to injury than medial tenderness, ecchymosis, or edema
 gravity stress radiograph is equivalent to manual stress radiograph
AP and lateral Right ankle X-ray shows right bimaleolar ankle fracture

Treatment plan:
The management involves reduction (if displaced), and initial immobilisation in a splint or cast. Once the fracture has been immobilised the decision regarding definitive treatment depends on two key features: tibio-talar congruence and stability.
Operative management of the lateral malleolus most commonly involves open reduction and internal fixation following standard AO techniques.
Postoperative AP and lateral x-rays demonstrate fixation of bimalleolar Weber B supination/external rotation ankle fracture.
REFLECTION:
Complete history of the mechanism of injury in this case is crucial to establish differential diagnosis, as well as any possible injury outside the lower limb, such as head injury, chest or abdominal trauma. These concomitant injuries might influence overall diagnosis process, management of the patient or even post-operative outcomes.
A standard antero-posterior, lateral, and mortise views are generally sufficient to diagnose these injuries and plan the treatment. In case of tenderness over proximal fibula or medial clear space widening in mortise view, full-length the tibia and fibula radiograph should be obtained to rule out the presence of a Maisonneuve fracture. Complex axial imaging such as
CT scanning is rarely indicated except in triplane and pilon fractures.
Unstable injuries may be treated either surgical or nonsurgical treatment. However, nonoperative treatment requires close observation to evaluate any displacement that require further surgical approach. Many surgeons chose to manage unstable injuries operatively with anatomical reduction could be achieved with the talus sit properly within the mortise.
In general, the results following an anatomic reduction of displaced ankle fracture are sufficient. Long term outcome of posttraumatic arthritis has been found in 14% of patients although an anatomic reduction has been achieved, most likely as a result of chondral lesion that happened at the time of the injuries.