Clinical CommunicationsManaging ankle injuries in the emergency department
Introduction
The ankle carries the body’s entire weight during standing, and is the focal point for dynamic vectors of stress during walking and running. It must be both strong and flexible. It is designed to meet the transmission of repetitive concentrated stresses. The ankle sustains the greatest loading force per surface area of any joint. During normal walking, the forces are equivalent to supporting five times body weight. It is no wonder the ankle is so frequently injured. Ankle injuries are common in the emergency department, accounting for up to 30% of visits (1) and 12% of traumatic injuries (2). The prevalence and severity of ankle injuries have been increasing in the United States since the 1950s; this has been attributed to increased recreational activity, particularly among older adults (3).
Section snippets
Epidemiology
Five to ten million ankle injuries occur each year in the United States. Adults 21–30 years old are at greatest risk (3). Collision sports such as hockey, football, and soccer, and cross-country running, lacrosse, and basketball account for the majority of ankle injuries, with half of all basketball injuries being ankle sprains (3). The yearly cost of ankle injuries exceeds $2 billion.
Five percent of sports injuries (at a rate of 6 per 100 participants) are to the ankle, and of these, 85% are
Biomechanics and pathomechanics
Low force injuries (<20 mph) usually involve only soft tissue elements, whereas high velocity injuries (>20 mph) tend to cause fractures (9). Injury to the lateral side is far more common than injury to the medial ankle. Injury during dorsiflexion is more likely to be bony, whereas injury during plantar flexion is more likely to be ligamentous. When the ankle is plantar flexed, it is less stable, and injuries tend to involve the lateral ankle. Anatomy explains these propensities.
When the foot
Evaluation of ankle injuries
After the absence of other, potentially life-threatening, injuries is established, evaluation of ankle injuries begins with history, frequently the only method available to determine the mechanism of injury.
The patient should be asked about the intensity of the force, field conditions, footwear, and disability immediately after the injury occurred. The report of a “snap,” “crack,” or “pop” at the time of injury may be described by the patient, but it does not reliably suggest a fracture (14).
Radiographic examination
Ankle films account for about 2% of all radiographic examinations and about 10% of emergency radiographs. They are of no diagnostic benefit in most ankle injuries, yet account for a substantial yearly cost. Clinical criteria have been shown to have a 99–100% specificity and better than 50% sensitivity. 27, 28, 29, 30, 31 (Table 1 ) .
Ottawa Foot and Ankle Low Risk Clinical Decision Rules (the Rule) were developed to prospectively predict fractures in patients with ankle and midfoot injuries. Dr.
Sprains
The severity of ligamentous injury is rated either by counting the number of injured ligaments or by the degree of disruption of a specific ligament. The severity of injury parallels the number of ligaments injured (2) (Table 2 ). Sprains are Grade 1 if <25% of the fibers are torn, Grade 2 if 25–75% are disrupted, and Grade 3 if >75% of the ligament is non-contiguous 2, 4, 37.
A number of other injures can masquerade as ankle sprains. Occult fracture is the most obvious of these. The most common
Treatment
After the diagnosis is made, treatment should aim to quickly restore stability and functional mobility. The traditional ED recommendation was rest, ice, compression, and elevation (RICE), perhaps with a nonsteroidal anti-inflammatory drug (NSAID) for 3–4 days to control edema and pain (38). Pain requiring a more potent analgesic should suggest a fracture, a compartment syndrome, or drug-seeking behavior. Traditional immobilization was primarily with elastic (“Ace”) wrap, athletic tape, or a
Consultation
Consultation is indicated acutely for complex injuries, unstable joints that may be Grade 3 sprains, diagnostic uncertainty, or when deltoid and syndesmotic sprains are suspected. Locking is an ominous sign and usually indicates a need for referral (55). Any talar or fibular avulsion fractures that may lead to peroneal instability or disability should be seen expeditiously by an orthopedist. Persons in whom risk of disability must be minimized, such as competitive athletes, should be seen early
Tendonitis
Any of the 11 tendons that transit the ankle joint are susceptible to inflammation. These tendons are the flexors digitorum longus and brevis, Achilles, flexor hallucis longus, tibialis anterior and posterior, and peroneal longus, brevis, and tertius (57). Technically, these inflammations are peritendinitis. When accompanied by degeneration, the condition is termed tendinosis. The cause of the inflammation may be acute trauma but most commonly is repetitive microtrauma from overuse. Microtrauma
Achilles tendon injury
The distal portion of the Achilles tendon, that is, the 2–6 cm above its calcaneal insertion, is relatively avascular. This is the zone where most problems occur (58). A sudden extreme contraction of the calf muscles, such as in jumping up or landing from a jump as occurs in basketball or tennis, stresses this tendon. When the tendon is not adequate to the stress, as may often be the case in a sedentary or middle-aged individual, the tendon may rupture with an audible “pop” and some degree of
Peroneal tendon subluxation/dislocation
Sudden, resisted dorsiflexion and eversion of the ankle can lead to tendonitis or tearing of the retinacular roof producing subluxation or dislocation. There is retro-malleolar or postero-lateral ecchymosis, tenderness, and swelling. Distinct from a lateral collateral sprain, the history is of eversion, weakness on resisted eversion and dorsiflexion, and apprehension with a painful sensation of popping or snapping when the examiner’s fingers cup the posterior lateral malleolus during resisted
Tarsal tunnel syndrome
The tarsal tunnel syndrome is somewhat analogous to the better known carpal tunnel syndrome. The posterior tibial nerve becomes entrapped behind the medial malleolus in the fibro-osseous tunnel created by the flexor retinaculum. Analogous to the carpal tunnel syndrome, a neuropathy is produced by repetitive stress. Tarsal tunnel syndrome is most often seen in sports that require much foot pounding such as running, racquet sports, basketball, soccer, etc. Additional risk factors include poorly
Synovial impingement
Persistent antero–lateral ankle pain following recurrent ankle sprains results from a chronically swollen, hypertrophied, synovial membrane that is pinched in the mortise. The patient complains of swelling and pain during activity; the pain is worsened by sudden starts and stops. Tenderness at the anterior aspect of the mortise and discomfort during passive forced dorsiflexion suggest synovial impingement. A magnetic resonance imaging scan may be necessary to confirm the diagnosis. Surgical
Os trigonum
An accessory sesamoid bone is located posterior to the posterior tubercle of the talus in 5–14% of the population. This sesamoid, the os trigonum, is frequently unilateral and may be overlooked as a cause of chronic ankle sprain. There is usually a history of a sprain weeks to months earlier, persistent posterior and postero-lateral ankle pain, with swelling and ankle instability, and normal ankle films. The physical examination is consistently diagnostic if it demonstrates a 25° decrease in
General follow-up
In all cases in which the ankle injury is at all significant, patients need to be cautioned about the resumption of athletic activities. Even when the ankle does not hurt during ordinary walking activities, it may take 4–6 months for complete healing. During this time, the ankle remains prone to re-injury. Support with athletic tape and cautious training under the direction of a knowledgeable coach are preferable.
Summary
Most ankle trauma is not limb-threatening. Most soft tissue injury is subsequent to plantar flexion, inversion, and internal rotation. Many ankle injuries do not require X-ray examinations. Stable injuries can be managed conservatively by an emergency physician; unstable ones should be managed in conjunction with an orthopedic surgeon. All ankle injuries require a comprehensive discharge plan including instructions about the expected course of healing, the resumption of activities, and an
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2017, Gait and PostureCitation Excerpt :Baseline characteristic and a flow diagram of the patients through the study have been published previously [17]. Eligible patients were all adults aged 18–64 and had a lateral ankle sprain grade I or II (mild to moderate) [19]. The ankle sprain was confirmed by a clinical examination by orthopaedic consultants at the emergency department (i.e. inspection, palpation and laxity testing in the frontal and sagittal plane) and a radiograph.
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2017, PM and RCitation Excerpt :This prospective study was a subproject of a larger randomized controlled trial registered at clinicaltrials.gov (NCT01449760) [23,24]. Fifteen patients with a grade I or II [25] subacute ankle sprain were included 4 weeks after the sprain. All included participants were between 18 and 40 years of age.
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