What is the diagnosis?

Diaphyseal tibia fracture with callus formation on the medial and lateral sides, as highlighted in Image 2.

Image 2. XR of ankle with diaphyseal spiral fracture. There is callus formation on both the medial and lateral borders of the fracture (highlighted in red). Image courtesy of Dr. John Kiel, CAQ-SM, annotation by Author. 

What additional imaging modalities can help further characterize the injury?

Both CT (images found here) and Ultrasound (Image 3) can be helpful in better characterizing how much callus has been depositing. 

• Pearl: Both of these imaging modalities will pick up on the bony deposition prior to calcification that is required to be visible on x-ray

Image 3. Ultrasound image of the ankle fracture. Red circle overlying area of callus deposition. Image courtesy of Dr. John Kiel, CAQ-SM, annotations by Author. Dynamic ultrasound images can be found here. 

• Pearl:The bright white line on the bottom of Image 3 is the bony cortex. The fracture is the disrupted fragment. The half circle bright white density highlighted in red is the callus formation. If there is calcification of the callus it will cause shadowing below, limiting the view of the fracture pattern that would otherwise have been seen.

What is the management in the ED?

This case will require surgical management. However given that this fracture has callus formation there is typically not an urgent or emergent need to take to the OR. 

Splint the patient in their current positioning without any attempts at reduction given the subacute, healing fracture with bony callus. The patient should have urgent orthopedic follow up as they will likely require surgical management. 

When do you consult Orthopedics?

Orthopaedic consultation is not necessary on an emergent basis unless there is concern for a developing wound (threatened skin from pressure from malalignment) or neurovascular compromise.