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Ankle Injuries

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by

Sukhbir Bhullar

on 8 April 2014

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Transcript of Ankle Injuries

Contents
Relevance
Anatomy Quiz
Assessment
Injuries
Relevance
Anatomy Quiz
Assessment
History:
MOI, Painful area, Continued activity, Weight bearing, Previous injuries, Prior treatment

Pointers:
Ankle fractures are more likely when the patient is unable to weight bear immediately after the injury. A crack or snap sound is not by itself indicative of a fracture. Ice, analgesia and elevation may influence the appearance of an injury.

Examination:
Look: Skin, soft tissues, muscle wasting.
Feel: Temperature, palpate for tenderness over: proximal fibula, lateral malleolus and ligaments, medial malleolus and ligaments, navicular, calcaneum, Achilles tendon, base of the 5th metatarsal.
Move: Passive and Active: Ankle dorsiflexion, plantarflexion, inversion, eversion.

Grasp heel and try moving tarsus up, down and side to side assessing the Midtarsal joints.

Neurovascular integrity, Measure calf swelling, Simmond’s test and gait assessment.
Ankle Injuries
Sukhbir Bhullar BSc MBChB MSc
Emergency Medicine CT3

The trainee will be able to
evaluate
the patient who presents with a traumatic limb or joint injury, to produce a valid
differential diagnosis
, appropriate
investigation
and implement a
management plan
.

Knowledge:
Fractures and ligamentous injuries of the ankle.

Skills:
Prescribe safely for traumatic limb pain. Demonstrate assessment of limb function. Detect neurovascular compromise. Demonstrate common techniques for reduction of dislocated or fractured ankle. Be able to splint and plaster injured limbs safely.

Behaviour:

Know when to seek advice and when to ensure appropriate follow up.
Mar 2013 - Mar 2014
Ankle Injuries: 3127

Fractures/ Dislocations/ Soft Tissue Injuries/ Others
True or False?
1) The ankle is a ball in socket joint?
2) The malleolar mortise is formed from distal tib-fib with inferior transverse part of posterior tibiofibular ligament?
3) The medial surface of the lateral malleolus articulates with the medial surface of the talus?
4) Tibia articulates with the talus in 2 places?
5) Inversion and Eversion occurs primarily at the subtlar and transverse tarsal joints?
6) Most injuries occur in dorsiflexion rather than plantarflexion?
7) Lateral ligament is formed by the anterior talofibular ligament, posterior talofibular ligament and the calcaneofibular ligament?
8) The medial ligament is made up of 4 parts?
9) Blood supply to the ankle is via the obtruator and internal pedundal arterty?
10) Nerve supply is via the Tibial and Deep Fibular nerves?
Anatomy Pointers
True or False?
1) The ankle is a ball in socket joint?
F
2) The malleolar mortise is formed from distal tib-fib with inferior transverse part of posterior tibiofibular ligament?
T
3) The medial surface of the lateral malleolus articulates with the medial surface of the talus?
F
4) Tibia articulates with the talus in 2 places?
T
5) Inversion and Eversion occurs primarily at the subtlar and transverse tarsal joints?
T
6) Most injuries occur in dorsiflexion rather than plantarflexion?
F
7) Lateral ligament is formed by the anterior talofibular ligament, posterior talofibular ligament and the calcaneofibular ligament?
T
8) The medial ligament is made up of 4 parts?
T

9) Blood supply to the ankle is via the obtruator and internal pedundal arterty?
F
10) Nerve supply is via the Tibial and Deep Fibular nerves?
T
Injuries
Sprains
Usually an inversion injury in plantarflexion affecting the lateral joint capsule and anterior talofibular ligament.

GRADE I: no ligament tear, minimal pain/swelling/ecchymosis
GRADE II: partial ligament tear, some loss of function, increased pain with weight bearing
GRADE III: complete tear, inability to bear weight, rule out fracture

Advise:
Rest, elevate ankle above hip level, consider ice intermittently for 10-15 mins during first 2 days. Begin to weight bear as soon as symptoms allow but elevate at other times. Gently exercise the ankle in all directions and use simple analgesics until symptoms improve. Resolution approximately at 4 weeks. Return to sport in 2 weeks, guided by recovery.

If non- WB- crutches, elevation and r/w in 2-4 days. Consider 10 day immobilisation in BKPOP if still no improvement with o/p follow up.
Dislocation
Orthopaedic Emergency! Orthopaedic Emergency! Orthopaedic Emergency!
Gross deformity
- Severe skin stretching (fracture blisters, skin necrosis, conversion of injury to compound fracture)
- Deficits in peripheral pulses or sensations

Treatment: Prompt reduction and immobilisation in POP usually has to precede x-ray. Analgesia or sedation is a must.

1) Entonox, IV analgesia or sedation as appropriate with full precautions.
2) Warn the patient about initial increase in pain.
3) With the knee flexed and supported genlty grasp the heel with hand and the calf with the other.
4) Pull smoothly on the heel, may need to exaggerate the deformity to obtain reduction.
- look for return of contours, relief of skin tension, and often dramatic pain relief.
5) Check pulses, sensation, immobilise in a POP and arrange in check x-rays
6) Orthopaedic referral immediately.
Fractures
Unimalleolar
Bimalleolar
Trimalleolar
Lauge-Hansen
supination-adduction
supination-ext rotation
pronation-abduction
pronation-eversion
pronation-dorsiflexion
Classification
Unimalleolar
Stability
Bimalleolar
Trimalleolar
Maisonneuve Fracture
-Spiral fracture of proximal fibula
-Tear of interosseous membrane
-Tear of syndesmosis
-Tear of deltoid ligament +/- medial
malleolus fracture
Pilon Fracture
- Ankle & distal tibial metaphyseal
fracture.
- Usually comminuted.
- Usually includes medial malleolus fracture,
anterior tibia margin fracture, transverse
fracture of posterior tibia
Management
- Small avulsion fractures: rest, elevation, analgesia
and early mobilisation
- Large avulsion fractures: may require intial
immobilisation with crutches and orthopaedic f/u
- Undisplaced isolated medial or lateral fractures:
analgesia, crutches, immobilise in well padded
BKPOP, limb elevation and othopaedic f/u
- Displaced fractures of medial or lateral malleolus:
require ORIF. Analgesia/ Sedation, reduction,
BKPOP, Orthopaedic referral.
- Bi/Tri-malleolar fractures: unstable. Reduce talar
shift, BKPOP, re-xray, Orthopaedic referral
Full transcript