We dissect one of the most common injuries we see in the ER -- ankle sprains
Brian Gilberti, MD
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Tags: Orthopedics
Show Notes
Among most common injuries evaluated in EDA sprain is an injury to 1 or more ligaments about the ankle jointHighest rate among teenagers and young adultsHigher incidence among women than menAlmost a half are sustained during sportsGreatest risk factor is a history of prior ankle sprainBone: Distal tibia and fibula over the talus → constitutes the ankle mortiseAside from malleoli, ligament complexes hold joint togetherMedial deltoid ligamentLateral ligament complex Anterior talofibular ligamentMost commonly injuredWeakest85% of all ankle sprains Posterior talofibular ligament Calcaneofibular ligamentSyndesmosisLateral ankle sprains Most common among athletesATFL most commonly injured Combined with CFL in 20% of injuries2/2 inversion injuriesMedial ankle sprainsLess common than lateral because ligaments stronger and mechanism less frequent More likely to suffer avulsion fracture of medial malleolus than injure medial ligament2/2 eversion +/- forced external rotationTypically landing on pronated foot -> external rotationHigh Ankle sprainsSyndesmotic injuryMore common in collision sports (football, soccer, etc)Grade IMildStretch without “macroscopic” tearingMinimal swelling / tendernessNo instabilityNo disability associated with injury Grade IIModeratePartial tear of ligamentModerate swelling / tendernessSome instability and loss of ROMDifficulty ambulating / bearing weight Grade IIISevereComplete rupture of ligamentsExtensive swelling / ecchymosis / tendernessMechanical instability on examInability to bear weight Beyond visual inspection for swelling, ecchymoses, abrasions, or lacerationsPalpation Pain when palpating ligament is poorly specific but may indicate injury to structureCheck sites for Ottawa ankle rules to evaluate if there may be an associated fracture with injury Posterior edge or tip of lateral malleolus (6 cm) Posterior edger or tip of medial malleolus (6 cm) Base of fifth metatarsal Navicular boneAcute ATFL rupture / Grade III Sprain 90% chance of this injury if hematoma and localized tenderness with palpation present on exam over this ligament Anterior drawer testAssess for anterior subluxation of talus from the tibiaAnkle in relaxed position, distal extremity is stabilized with one hand while the other cups the heel to apply anterior forceCompare to contralateral sideDifficult to determine if there is an acute rupture at this point and may be more easily diagnosed in subacute phase (4-5 days after injury)Ability to perform exam adequately limited by pain, swelling and potential muscle spasm Talar tilt testIf applying inversion force to ankle and there is excessive mobility → calcaneofibular ligament Thompson testCan be performed if there is concern for concomitant Achilles tendon injury Do not miss a Maisonneuve fracture by palpating proximally about the fibular ahead as forces may be transmitted through the syndesmosis Squeeze test – pressure just proximal to ankleIf elicits pain → concern for syndesmotic injury X-rays indicated if unable to rule out using Ottawa Ankle RulesSn (Up to 99.6) (one of the best validated tools we use in the ER)May have trouble applying rule if there is question of patients ability to sense pain (diabetic neuropathy), in which case obtain radiographs RICECrutch train so they can be weight bearing a toleratedIdeally initiate within first 24 hours of injuryIce 15-20 minutes q2-3h over the first 48 hours or until swelling improves NSAIDsTopical and PO are better than placebo We do not know if PO is superior to topical NSAIDs Early mobilization / Functional Rehab (sample patient instructions here)Work to restore range of motion, strength, proprioceptionFor Grade I and II, can begin as soon as the patient can tolerate and ideally within 1 week of the injuryPatients return to work sooner, decreased chronic instability, less recurrent injuriesDorsiflexion, plantarflexion, and perform foot circles as well as toe curls, inversion and eversion as toleratedProprioception Balancing on wobble boardContinue exercises until patient is able to return to activities at full capacity, without painImmobilizationHigh re-injury rates and important to protect against thisGrade I No immobilization required +/- Ace wrapGrade II Aircast brace Ensure patient understands that they should still partake in rehabilitation exercisesGrade III Data conflicts RCT, multicenter study comparing aircast brace, compression bandage, Bledsoe immobilization boot and below-knee cast for 10 daysAnkle function at 3 monthsCast group had most improvementNo difference at 9 months in function or complications May be institution-dependent and a cast can be offered initiallyAcute inflammation → reduction in swelling → development of new tissue → strengthening of tissue Return of basic function, though limited, occurs over 4-6 weeks depending on severity of sprainTry to limit strain put on joint (no heavy lifting, walking on uneven surfaces, try to limit standing while at work)Follow up:If pain or instability does not improve over 4-6 weeksGrade III sprainsMedial ankle sprains (may have underlying fracture that was undetected in ED on XR)Syndesmosis injuries (protracted recovery course)Injuries associated with fractures or dislocation / subluxation
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