Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right ankle pain and inability to bear weight following a high-energy trauma. Mechanism of injury involves axial loading. Patient reports significant swelling, deformity, and localized tenderness over the distal tibia. No open wounds or skin tenting noted. Neurovascular status intact distally.
Clinical Examination Findings
Right lower extremity examination reveals significant edema and ecchymosis around the distal tibia and ankle mortise. Palpation demonstrates point tenderness over the distal tibial metaphysis and intra-articular involvement. Skin is intact with no signs of compartment syndrome. Distal pulses (dorsalis pedis and posterior tibial) are palpable and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes.
Treatment Protocol
Immediate immobilization with a posterior splint applied to the right lower extremity. Strict non-weight bearing status initiated. Elevation of the limb above the level of the heart to reduce edema. Pain management via analgesics. Orthopedic surgery consultation requested for definitive fixation planning. Serial neurovascular checks performed.