Ankle sprain: Difference between revisions

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===Syndesmotic Sprain ("High-ankle sprain")===
===Syndesmotic Sprain ("High-ankle sprain")===
*Assoc with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
*Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
*Pain just above talus
*Pain just above talus


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**Tests for combined injury of anterior talofibular and calcaneofibular ligaments
**Tests for combined injury of anterior talofibular and calcaneofibular ligaments
**Inversion at the ankle causes tilting/lifting of the mortise joint
**Inversion at the ankle causes tilting/lifting of the mortise joint
===Imaging===
{{Ottawa Ankle Rules}}
{{Ottawa Foot Rules}}
====Exceptions====
*Age <6 or >55
*Only for blunt trauma mechanism
*Does not apply to subacute/chronic injuries
*Does not apply to injuries of the hindfoot or forefoot


===Classification===
===Classification===
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**Partial ligament tear; possible instability
**Partial ligament tear; possible instability
**Increased pain, swelling, ecchymosis; difficulty bearing weight
**Increased pain, swelling, ecchymosis; difficulty bearing weight
**Immoblize with air splint; PT with ROM/stretching/strengthening exercises
**Immobilize with air splint; PT with ROM/stretching/strengthening exercises
*Grade III
*Grade III
**Complete ligament tear; significant instability
**Complete ligament tear; significant instability
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==Management==
==Management==
*Stable joint and ability to bear weight:
*Stable joint and ability to bear weight:
**NSAIDs, RICE (rest, ice, compression, elevation)
**[[NSAIDs]], RICE (rest, ice, compression, elevation)
**1 week follow up if no improvement
**1 week follow up if no improvement
*Stable joint but unable to bear weight:
*Stable joint but unable to bear weight:
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*[[Ankle (Main)]]
*[[Ankle (Main)]]
*[[Ankle Fracture]]
*[[Ankle Fracture]]
*[[Ottowa Ankle Rules]]
*[[Ottawa Ankle Rules]]


==References==
==References==

Revision as of 16:10, 18 October 2019

Background

Ankle stabilization anatomy

Ankle anatomy.png
  • Syndesmosis
  • Ligaments
    • Medial: Medial collateral (deltoid) ligament (tibia to talus and calcaneus)
    • Lateral: Anterior/posterior talofibular, calcaneofibular ligaments

Clinical Features

Lateral Ankle Sprain

  • Most common
  • Due to inversion of plantarflexed ankle
  • Anterior talofibular ligament (ATFL) is most commonly injured ligament

Medial Ankle Sprain

  • Isolated sprain is unusual; often associated with fibular fracture or syndesmosis injury
  • Always rule-out Maisonneuve fracture by evaluating proximal fibula

Syndesmotic Sprain ("High-ankle sprain")

  • Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
  • Pain just above talus

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

  • Anterior drawer test
    • Tests anterior talofibular ligament
    • Cup heel with one hand and and pull anteriorly while pushing tibia posteriorly
  • Talar tilt test
    • Tests for combined injury of anterior talofibular and calcaneofibular ligaments
    • Inversion at the ankle causes tilting/lifting of the mortise joint

Imaging

Ottawa ankle rule

Ottawa ankle rule

Ankle x-ray needed if:

  • Pain near the maleoli AND
  • Inability to bear weight immediately and in the ED (4 steps) OR
  • Tenderness at posterior edge or tip of lateral malleolus OR
  • Tenderness at posterior edge or tip of medial malleolus

Ottawa foot rules

Ottawa foot rules

Foot x-ray series needed if:

  • Pain in the midfoot AND
  • Inability to bear weight both immediately and in the ED (4 steps) OR
  • Tenderness at the navicular OR
  • Tenderness at the base of the 5th metatarsal

Exceptions

  • Age <6 or >55
  • Only for blunt trauma mechanism
  • Does not apply to subacute/chronic injuries
  • Does not apply to injuries of the hindfoot or forefoot

Classification

  • Grade I
    • No tearing of ligaments
    • Minimal pain, swelling, ecchymosis; weightbearing is tolerable
    • No splinting/casting; weight bearing as tolerated, isometric exercises, full ROM and stretching/strengthening exercises
  • Grade II
    • Partial ligament tear; possible instability
    • Increased pain, swelling, ecchymosis; difficulty bearing weight
    • Immobilize with air splint; PT with ROM/stretching/strengthening exercises
  • Grade III
    • Complete ligament tear; significant instability
    • Severe pain, swelling, ecchymosis; inability to bear weight
    • Immobilization and possible surgery; PT same as grade 2 but longer time period

Management

  • Stable joint and ability to bear weight:
    • NSAIDs, RICE (rest, ice, compression, elevation)
    • 1 week follow up if no improvement
  • Stable joint but unable to bear weight:
    • Ankle brace with follow up in 1wk
  • Unstable joint

Disposition

  • Discharge

See Also

References