Triage considerations Pain should be addressed as appropriate and a wheelchair provided for transport if the patient is having pain with weight-bearing Significant swelling and pain associated with an ankle injury should be quickly triaged for concern of possible compartment syndrome and/or complicated ankle fracture Clinical assessment Typically there is a history of a twisting mechanism to the lower leg with either eversion or inversion The ankle and foot should be examined closely for any skin defects, deformity, degree of swelling, neurologic deficits, and vascular injury Sensation should be evaluated on both the plantar and dorsal aspects of the foot Toe flexion and extension can be used to evaluate motor function The examination should include the function of the extensor hallucis longus muscle (great toe extension), ankle dorsiflexion, plantar flexion, inversion, and eversion In addition to the capillary refill of the toes, the dorsalis pedis and posterior tibialis pulses should be assessed, and if they cannot be palpated, must be evaluated by a Doppler probe to assess for any vascular compromise The ankle evaluation should include palpation superiorly of the tibia and fibula and inferiorly down to the proximal foot (including fifth metatarsal) Ankle sprains and fractures of the tibia may also be associated with proximal fibula fractures (Maisonneuve fracture); therefore, careful examination of the proximal fibula is important as part of the complete examination Management Radiographs should be obtained if there is concern for bony injury, and the Ottawa ankle rules may be considered for use in children older than years to guide the need for radiographic evaluation Anteroposterior, mortise, and lateral x-rays should be obtained to adequately evaluate the ankle The mortise view is especially important to evaluate fractures without obvious deformity as it may visualize a minimally displaced fracture that could be disguised by the tibiofibular overlap on the other views Foot films are recommended to evaluate tenderness over the fifth metatarsal that may represent a Jones or pseudo-Jones fracture Advanced imaging (CT) is recommended for the evaluation of intraarticular fractures for accurate diagnosis, preoperative planning, and assessment of reduction ANKLE SPRAINS The most common mechanism for ligamentous injuries is when the foot is adducted and inverted while held in plantar flexion Although common teaching has been that Salter-Harris type I distal fibular fractures are more likely than ankle sprains in children with open physes, a recent MRI-based study found that pediatric patients with fracture negative ankle x-rays ( Fig