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
- X-ray if any pain in the malleolar or midfoot area, and one of the following:
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)