The cornerstones of the assessment are the mechanism plus the physical exam. A host of uncommon ankle injuries should be considered. The above three cases plus syndesmosis injury, Achilles tendon rupture, calcaneal fracture, and lateral process of the talus fracture are all diagnoses worthy of consideration. The list can be confidently narrowed by focusing on the mechanism of the injury (amount and direction of force) and the physical examination. When tenderness is found along the anterior joint line, consideration should be given to structures such as the syndesmosis, distal tibia, and talus. We can then interpret the X-rays within the proper clinical context and give proper attention to the areas of clinical concern.

Dr. Sayal is a staff physician in the emergency department and fracture clinic at North York General Hospital in Toronto, Ontario; creator and director of CASTED ‚Hands-On‘ Orthopedic Courses; and associate professor in the department of family and community medicine at the University of Toronto.

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