Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left ankle pain and inability to bear weight following a [mechanism of injury, e.g., mechanical fall/twisting injury]. Reports immediate swelling, deformity, and severe pain. No numbness or tingling in the foot. No prior history of trauma to the left ankle.
Clinical Examination Findings
Left ankle: Significant edema and ecchymosis noted around the medial, lateral, and posterior malleoli. Obvious bony deformity present. Tenderness to palpation over all three malleoli. Distal neurovascular status intact: dorsalis pedis and posterior tibial pulses palpable, capillary refill < 2 seconds, sensation intact to light touch in all dermatomes.
Treatment Protocol
Immobilization in a posterior splint with stirrup applied to the left ankle. Strict non-weight bearing status initiated. Ice, elevation, and analgesics prescribed. Orthopedic surgery consultation requested for definitive management, likely ORIF (Open Reduction Internal Fixation).