Prior to their fusion, physeal injuries are more likely than ligamentous sprains in children Distal tibia/fibula and significant injuries to the foot are especially at risk for the development of compartment syndrome; therefore, the extremity should be closely monitored for increasing swelling and signs and symptoms associated with compartment syndrome Current Evidence As both bony and ligamentous ankle injuries present with pain and swelling, radiographs are often used for evaluation of ankle injuries in children The Ottawa ankle rules are a set of clinical decision rules for obtaining ankle and foot radiographs that can be useful for children over years old They recommend that an ankle radiograph is only required if the patient has any pain in the malleolar zone, and if the patient has any of these findings: bone tenderness at the posterior edge or tip of the lateral malleolus, bone tenderness at the posterior edge or tip of the medial malleolus, or inability to bear weight both immediately and in the ED The rules recommend a foot radiograph if there is pain in the midfoot zone and any of the following: bone tenderness at the base of the fifth metatarsal, bone tenderness over the navicular, or inability to bear weight both immediately and in the ED Adolescents are at risk for sustaining transitional fractures during the 18 months in which the physis begins to close (14 years in girls, 16 years in boys) While the physis is still open, the lateral aspect of the distal tibial physis is weaker and more prone to injury, leading to the specific injury patterns associated with the Tillaux fracture, involving the epiphysis only, or triplane fractures, with fracture extension into the distal tibial metaphysis In addition, fractures of the ankle can be associated with a syndesmosis injury, seen as medial joint space widening between the distal tibia and fibula on the radiograph, which may need surgical treatment Clinical Considerations Clinical recognition After ankle trauma, the patient commonly develops pain, swelling, and ecchymosis and may be unable to bear weight The differential diagnoses for ankle injuries include nondisplaced Salter–Harris type I fractures; ligamentous injuries; osteochondral fractures of the tibia/fibula or talus; and avulsion injuries