Lateral Malleolus Fracture and Sprain Management

Diagnostic Approach

The British Journal of Sports Medicine recommends using the Ottawa Ankle Rules as the primary decision tool to determine if radiographs are needed, with 86-99% sensitivity and 97-99% negative predictive value for excluding fractures 1, 3
Order radiographs if pain is present on palpation at the posterior edge or tip of the lateral malleolus, base of the fifth metatarsal, navicular bone, or if the patient is unable to bear weight immediately after injury and walk four steps 1

The British Journal of Sports Medicine suggests that functional treatment is superior to immobilization for reducing morbidity and improving quality of life, and recommends applying a lace-up ankle brace immediately and beginning early mobilization 2, 4
For stable fractures, follow the same functional treatment protocol as ankle sprains, and watch for signs of associated ligamentous injury, such as medial tenderness, bruising, or swelling 4

The British Journal of Sports Medicine recommends delaying ligament assessment until 4-5 days post-injury, as the anterior drawer test has optimal sensitivity and specificity at this time, allowing for a more accurate assessment of ligament integrity 3, 5, 6

The British Journal of Sports Medicine notes that 5-33% of patients will have persistent pain and instability at 1 year, and 3-34% will experience recurrent ankle sprains, and recommends addressing pain level, workload, and sports participation early to improve recovery outcomes 1, 2, 4