Ankle Injuries

History

  • Mechanism of injury is important to establish
  • Weight bearing following incident

Physical

  • Inspection:
    • Swelling
    • Erythema/Ecchymosis
    • Atrophy
    • Deformity
    • Skin changes (abrasions, lacerations)
  • Palpation:
    • Tenderness: specifically lateral and medial malleoli, and proximal fibula (maisonneuve fracture)
    • Effusion, Swelling, Temperature, Crepitus, Atrophy
  • Neurovasular (dosalis pedis and posterior tibialis pulse, sensory exam, motor exam)
  • Weight bearing
  • ROM
  • Assessment of joints above and below, assessment of foot
  • Special rules: Ottawa ankle rules (to determine if X-rays are necessary)
    • X-ray if any pain in the malleolar or midfoot area, and one of the following:
      • Bone tenderness along the distal 6cm of the posterior part of the tibia or medial malleolus
      • Bone tenderness along the distal 6cm of the posterior edge of the fibula or lateral malleolus
      • Bone tenderness at the base of the fifth metatarsal (foot injuries)
      • Bone tenderness at the navicular bone (foot injuries)
      • An inability to bear weight immediately AND in the emergency department for four steps



 

Imaging

  • Xrays of ankle include: AP, lateral, mortice view
  • If proximal fibula tenderness include tib/fib

Dislocations

  • Reduction should be done in ER to prevent tenting of skin (skin is very thin around ankle area)

Sprains

  • Lateral ankle sprains are the most common (85%).  Of the lateral ligaments, the anterior talofibular ligament is the most commonly injured
  • Most ankle sprains are treated non-operatively
  • Acutely ankle sprains are treated with rest, ice, compression and elevation
  • The patient may protect the ankle with braces/splints and may require additional support such as taping when returning to activity

Fractures

  • Weber Classification
    • Type A: transverse fibular avulsion fracture (syndesmosis is intact, +/- medial malleolus)
    • Type B: oblique fracture of the lateral malleolus at level of syndesmosis(+/- rupture of the tibiofibular syndesmosis and medial injury)
    • Type C: fibular fracture above syndesmosis (+/- rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus)
  • Pilon: ankle fracture with distal tibial metaphyseal fracture
    • Mechanism: axial loading in which the talus drives into the tibial plafond)
    • Associated with spinal compression fractures
  • Maisonneuve: proximal fibular fracture with medial ankle injury (medial malleoli fracture or deltoid ligament disruption), syndesmosis is disrupted (completely or partially)
    • Mechanism: external rotation force to ankle with transmission thru the interosseous membrane exiting through a proximal fibular fracture
  • Trimalleolar fracture: medial and lateral malleoli, with fracture of the posterior lip of articular surface of tibia (posterior malleoli)
    • Unstable and require urgent orthopedic attention

Management

  • Reduction of displaced fractures!
  • Orthopedic consultation indications (from E-medicine):
    • Displaced medial, lateral, or posterior malleolar fracture
    • Medial malleolar fracture with lateral ligament damage
    • Lateral malleolar fracture with deltoid ligament damage
    • Fibula fracture at or proximal to the tibiotalar joint line (eg, Danis-Weber classification type C)
    • All bimalleolar fractures
    • All trimalleolar fractures
    • All intraarticular fractures
    • All open fractures
    • All pilon fractures
  • Stable injuries
    • Back slab splint acutely (keep ankle at 90O)
    • Once swelling has subsided may change to a cast that allows walking
  • Unstable
    • Require ORIF (plating, pinning)

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