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 90^O)
  • Once swelling has subsided may change to a cast that allows walking
• Unstable
  • Require ORIF (plating, pinning)