Malleolar fractures are typically low-energy rotational injuries.  These are commonly sports injuries in younger patients or from simple missteps in elderly or obese patients.  There is inability to bear weight and ankle pain and swelling. Gross deformity occurs with associated dislocation and some fractures, but may not be present in all unstable fractures.    

     The exam should focus on localizing tenderness, determining clinical stability of the ankle, and neurovascular assessment:

• Tenderness or swelling over the medial malleolus suggests medial injury even in the absence of fracture.
• The entire fibula should be palpated for tenderness so not to miss a proximal fibula fracture (seen in so-called “Maisonneuve fractures”)
• To assess ankle stability, make sure the talus is centered between the malleoli and does not displace with gentle rotation of the ankle (especially external) or when attempting to slide it anteriorly (an “anterior drawer test” of the ankle).