However, immobilization is often indicated for more severe ankle injuries. These are usually accompanied by a large amount of edema, which precludes immediate casting. Examination of the Ankle With every ankle injury, it is critical to perform a thorough physical examination including radiographic studies, if warranted. Physical evaluation should include careful examination and palpation of the lateral and medial malleoli and palpation of the navicular and lateral collateral ligaments, deltoid ligament, syndesmosis, proximal end of the fifth metatarsal, and entire length of the fibula and tibia. In the case of a stable, nondisplaced distal fibular avulsion fracture, tenderness will be found over the lateral malleolus of the affected ankle, thereby mandating x-rays and precluding stress testing.
Trimalleolar fracture involves both malleoli and the posterior portion of the tibial plafond.
In a syndesmosis injury, the patient typically has tenderness over the anterior inferior tibiofibular ligament, often extending up the interosseous membrane, and pain with passive dorsiflexion and external ankle rotation. The three-way splint can be fabricated quickly and easily with a few orthopedic supplies. We use splint material that has seven layers of fiberglass with a layer of padding on each side to protect the skin from irritation. The bony prominences of both malleoli can lead to difficulty in minimizing the accumulation of edema. We have not found it necessary to taper the edges of the padding, but it is important to keep the padding smooth.