The approach (Fig 40.10 ) to the evaluation and diagnosis of traumatic ankle injuries relies primarily on physical findings and the results of radiographic evaluation Initially, pulses and sensation are assessed Loss of pulses and/or sensation suggests a fracture/dislocation and the need for a rapid reduction; when available without delay, orthopedic consultation is advisable After providing analgesia, immobilize the site to prevent further compromise, and obtain a radiograph If neurovascular status is adequate and the general inspection reveals no obvious abnormalities, proceed with the rest of the physical examination as described previously Next, examine the area for open wounds If present, apply a sterile saline dressing and immobilize the extremity before obtaining a radiograph Consider administering intravenous antibiotics and tetanus prophylaxis If radiographic studies indicate a fracture or dislocation, provide treatment of the specific injury (see Chapter 111 Musculoskeletal Trauma ) Administer analgesia as needed If no fracture is evident on the radiograph, but tenderness is elicited over a physis, the diagnosis of an S-H type I injury can be made clinically and appropriate immobilization is performed (see Chapter 111 Musculoskeletal Trauma ) One study demonstrated that approximately 18% of children with tenderness at the distal fibular physis and normal radiographs will develop new periosteal bone formation, thus implying the presence of an occult fracture A negative radiographic result with bony tenderness remote from a physis suggests the diagnosis of contusion while absence of focal bony tenderness often suggests a ligamentous injury A stable ankle in a patient who has pain with ligamentous stress or palpation characterizes a grade I sprain A grade II sprain is more severe; instability is insignificant Joint instability indicates a torn ligament and a grade III sprain