A patient falls from a step ladder and has point tenderness over the medial malleolus with swelling. What is the most appropriate initial step to manage this injury?

• A. ACE wrap and rest
• B. Rest, ice, compression, and elevation
• C. X-ray of the foot and ankle
• D. Nonweightbearing for 3-7 days

Answer: (C)

When there's focal bone tenderness over the medial malleolus after a fall, your priority is to determine whether a fracture is present before assuming a soft-tissue injury. This is why imaging is the appropriate initial step. An X-ray of the foot and ankle provides crucial information about whether there is a fracture that requires immobilization, weight-bearing restrictions, or surgical evaluation, or if the injury is purely a sprain. Relying on conservative measures without imaging could miss an occult fracture and lead to improper healing or complications. The exam finding of malleolar tenderness with swelling commonly triggers radiographs to rule out fracture, guiding proper management from the start.