Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left ankle pain and inability to bear weight following a high-energy trauma. Mechanism of injury consistent with axial loading. No open wounds or neurovascular deficits noted at the scene. Pain is severe, exacerbated by movement.
Clinical Examination Findings
Left lower extremity: Significant edema and ecchymosis noted about the distal tibia and ankle joint. Tenderness to palpation over the distal tibial metaphysis and articular surface. Range of motion severely limited due to pain. Distal pulses (DP/PT) palpable and capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes.
Treatment Protocol
Immobilization with a posterior splint applied to the left lower extremity. Strict non-weight bearing status initiated. Pain management via analgesics. Radiographic imaging (AP/Lateral/Mortise views) and CT scan of the left ankle ordered to assess articular comminution. Orthopedic trauma consultation for definitive surgical fixation planning.