2.1 Literature search

A systematic search was conducted on PubMed in June 2025 using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA guidelines) to identify relevant studies published between 2000 and 2025. The search combined terms related to ankle injuries (including "ankle fracture," "ankle sprain," "lower limb fracture," and "ankle pain") with prehospital care terminology ("prehospital," "paramedic," and "EMS"). Only English-language publications were included. This comprehensive strategy ensured capture of all pertinent literature examining the assessment and management of ankle injuries in the prehospital setting, while maintaining focus on contemporary practice guidelines and evidence.

2.2 Study selection

The selection process employed a rigorous, two-phase approach to identify the most relevant and methodologically sound studies. In the first phase, two independent reviewers systematically screened all retrieved titles and abstracts against predefined eligibility criteria. We prioritized studies that specifically address prehospital or primary care management of acute ankle fractures, with particular attention to those reporting measurable orthopaedic outcomes such as fracture displacement rates, soft tissue complications, or time delays to definitive treatment. Comparative studies evaluating different immobilisation techniques (e.g. conventional splinting versus temporary external fixation) received highest consideration, as did investigations of standardized assessment protocols.

Throughout this process, any disagreements between reviewers were resolved through discussion and, when necessary, consultation with a third senior investigator to reach consensus. The final selection represented a balanced synthesis of high-quality evidence directly applicable to first-contact providers, intentionally favouring studies that bridged the gap between emergency medicine and orthopaedic priorities. This approach ensured our recommendations would be both evidence-based and pragmatically implementable across varied clinical settings. The complete selection methodology follows PRISMA guidelines, with the study flow diagram (Fig. 1) documenting the screening process and reasons for exclusion at each stage.

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Fig. 1 – Flow diagram of literature search.

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2.3 Quality of evidence assessment

Methodological quality of the included studies was assessed using the Scale for Assessment of Narrative Review Articles (SANRA) and Newcastle-Ottawa Scale (NOS) as seen in Table 1. The highest-quality evidence came from Borra et al.'s (2020) systematic review (NOS 8/9) and Siebenbürger et al.’s prospective study (NOS 8/9). Moderate-quality studies (NOS 6–7/9) and narrative reviews (SANRA 8–9/12) provided supporting clinical data, while case reports offered preliminary insights.^7,8 This spectrum informs our protocol while highlighting evidence gaps.

3.1 Assessment protocol

Table 2 summarizes the evidence-based steps for initial assessment of ankle fractures, emphasizing a systematic approach that prioritizes life-threatening conditions before focusing on the injured limb. It outlines key actions including Advanced Traumatic Life Support (ATLS) protocol adherence, early identification of fracture-dislocations, application of the Ottawa Ankle Rules, and mandatory serial neurovascular examinations, with supporting evidence from multiple studies.^5,9,14 The implementation column provides clinical guidance for each step, ensuring practical application in the prehospital setting.

3.2 Analgesia administration

Table 3 highlights critical gaps in prehospital analgesia administration, particularly for elderly patients, as demonstrated by White et al. and McEachin et al.^11,12 It advocates for standardized pain assessment as a "vital sign" and introduces innovative alternatives like nebulised ketamine¹³ for patients with difficult intravenous access, offering actionable strategies to address current disparities in pain relief provision.

3.3 Management protocol

Table 4 synthesizes best practices for fracture immobilisation, drawing on evidence from multiple studies.^3,5,7,14 It contrasts the benefits of padded splinting with stirrups against the risks of compression wraps alone, while emphasizing post-splinting elevation and serial neurovascular reassessment. The implementation column translates evidence into clear clinical actions, such as documentation protocols and intervention triggers for worsening vascular status.

4.1 Pillars of effective early management

4.2 Importance of early immobilisation

Early immobilisation of ankle fractures is crucial in reducing fracture displacement, minimising soft tissue trauma, and optimising conditions for surgical repair.^3,5,14 Splintage helps to reduce pain, haemorrhage and pressure on surrounding structures.⁵ It is important for healthcare providers to immobilize the joint above and below the fracture.^3,5 Ankle fractures are commonly immobilized in a short box splint or vacuum splint.⁵ The ankle should be elevated and ideally an icepack should be placed over a thin cloth on the medial or lateral side of the ankle, to reduce the amount of swelling and blistering.³ The icing should be done for 20 min every 2–3 h³

In more complex or unstable injuries, such as fracture-dislocations, the joint should be restored to a normal position as early as possible especially if there is any neurovascular compromise or open fractures, if the managing healthcare professional has received sufficient training.⁵ Current literature strongly favours temporary external fixation over simple splinting for ankle fracture stabilisation. In a retrospective study comparing splints and external fixation for ankle fracture-dislocations, Wawrose et al. found that splinted patients had a 50 % loss of reduction and 17.6 % skin necrosis, whereas none occurred in those treated with external fixators.⁴ While external fixation is often impractical in primary care settings, these findings emphasise the importance of accurate, well-padded splint application as the next best alternative.

4.3 Consequences of suboptimal prehospital management

The consequences of suboptimal early management in ankle fractures can profoundly influence orthopaedic outcomes across multiple domains as seen in Table 5 below. Improper splinting techniques and persistent fracture movement frequently precipitate soft tissue complications, including blistering, pressure necrosis, and excessive swelling, which often necessitate delayed definitive fixation to allow for tissue recovery.¹ A paediatric splint audit of 275 patients, though not exclusively focused on ankle fractures, revealed that 93 % of the splints were improperly applied.¹⁷ The splints were improperly positioned in 59 % of cases while 52 % were splints of an incorrect length.¹⁷ Concerningly, 77 % of these patients had an elastic bandage applied to the skin, resulting in excessive swelling.¹⁷ Skin and soft tissue complications such as bruising, abrasions, blistering and ulcerations eventually occurred in 40 % of patients.¹⁷ Targeted training interventions demonstrated the reversibility of these issues. After implementing a competency-based splinting program, Carino et al. later demonstrated that after focused education, correct application rates improved.¹⁸ These results underline the importance of practical splinting competency among first responders.

Even when initial reduction is successfully achieved, secondary displacement commonly occurs due to inadequate splint application, substantially increasing the complexity of subsequent surgical interventions.⁴ Comparative studies demonstrate this clinical impact quantitatively, with splinted patients experiencing significantly longer delays to surgery (mean 11 ± 5 days) versus those managed with external fixation (7 ± 4 days), a difference primarily attributable to the need for soft tissue stabilisation in sub optimally immobilized fractures.¹⁹ Critically, failure to perform and document serial neurovascular assessments following splint application may result in missed diagnoses of compartment syndrome or vascular compromise, complications that carry potentially limb-threatening consequences if not promptly identified and managed.⁵

4.4 Bridging the gaps in standardisation

Despite the frequency of ankle fractures, no unified protocol exists across EMS or family medicine networks for their prehospital management. National and regional guidelines provide general fracture principles but lack ankle-specific guidance, particularly regarding fracture-dislocations or vascular risk stratification. This results in wide variability in immobilisation quality, pain management, and triage decisions. Encouragingly, training programs have shown that targeted education on splinting techniques can increase correct application rates,¹⁸ underscoring the importance of structured instruction in early fracture care. To address these gaps, we propose a structured protocol tailored for EMS and primary care clinicians as seen in Fig. 2 below.

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Fig. 2 – Systematic protocol for prehospital ankle fracture assessment.

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We acknowledge certain limitations in our study. The heterogeneity of the included studies and data extracted precluded a meta-analysis. The majority of included studies were retrospective and extrapolated from small sample sizes or single-centre experiences. The proposed protocol, while grounded in evidence, requires validation through multicentre prospective trials. Further large-scale studies are required in the field of prehospital fracture management, extending beyond fractures of the ankle joint.