46 female slips and fall stairs
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ankle fracture classification management stair fall
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calcaneus fracture diagnosis imaging treatment
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ankle fracture X-ray AP lateral oblique
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Radiograph Analysis — Left Ankle (Sreeja Kumary, 46F, Stair Fall)
Image Findings
View 1 — AP (Mortise-type) view:
- The ankle mortise appears intact with no obvious talar shift
- The distal fibula and tibia cortices appear intact on this view
- The talus, subtalar region, and calcaneus are included
- No discrete fracture line is identified on the AP view
Views 2 & 3 — Lateral views:
- The distal tibia and fibula appear aligned
- The talus and calcaneus articulate normally; no step-off at the subtalar joint
- Bohler's angle (normally 20–40°) appears preserved — no calcaneal compression fracture
- No avulsion at the posterior calcaneus or base of 5th metatarsal visible
- Soft tissue density appears normal without gross swelling artifact on X-ray
Overall radiographic impression: No acute osseous fracture identified on these views. The ankle mortise is intact. Bohler's angle preserved.
Clinical Correlation Is Essential
A normal X-ray does not rule out significant injury in this mechanism. Key considerations:
| Injury | X-ray Visible? | Notes |
|---|---|---|
| Lateral ligament complex tear (ATFL/CFL) | ❌ No | Most common inversion injury |
| Maisonneuve fracture | ⚠️ Partial | Proximal fibula fracture — needs full leg X-ray |
| Base of 5th metatarsal avulsion | ✅ Sometimes | Check for Jones/pseudo-Jones fracture |
| Osteochondral talar dome lesion | ❌ No | Needs MRI |
| Syndesmotic injury | ❌ No | Needs stress views or MRI |
| Calcaneal stress fracture | ❌ No | Needs MRI |
Ottawa Ankle Rules (for clinical use)
An X-ray is indicated (and fracture likely) if there is:
- Bone tenderness at the posterior edge or tip of lateral malleolus (distal 6 cm fibula)
- Bone tenderness at the posterior edge or tip of medial malleolus
- Inability to weight bear (4 steps) immediately after injury and in ED
Ottawa Foot Rules (for midfoot): tenderness at navicular or base of 5th metatarsal.
Recommended Next Steps
- Clinical examination — palpate lateral malleolus, medial malleolus, syndesmosis, base of 5th MT, proximal fibula (Maisonneuve), navicular
- If point tenderness over syndesmosis → stress X-ray or MRI
- If persistent pain despite normal X-ray → MRI left ankle (rules out ligamentous tear, osteochondral defect, bone bruise)
- If unable to bear weight → short leg splint/back-slab, crutches, orthopedic review within 1 week
- At age 46 — consider DEXA scan if risk factors for osteoporosis present (perimenopausal women have accelerating bone loss)
Immediate Management
- RICE: Rest, Ice (20 min on/off), Compression bandage, Elevation
- Analgesia: NSAIDs (ibuprofen/diclofenac) ± paracetamol if no contraindications
- Non-weight bearing until fracture excluded clinically or by MRI
- Physiotherapy referral if ligamentous sprain confirmed
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