Ankle sprain: Difference between revisions
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==Background== | ==Background== | ||
===Ankle stabilization anatomy=== | ===Ankle stabilization anatomy=== | ||
[[File:Ankle anatomy.png|thumb|]] | |||
*Syndesmosis | *Syndesmosis | ||
*Ligaments | *Ligaments | ||
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===Medial Ankle Sprain=== | ===Medial Ankle Sprain=== | ||
*Isolated sprain is unusual; often associated | *Isolated sprain is unusual; often associated with fibular fracture or syndesmosis injury | ||
*Always rule-out [[Maisonneuve]] | *Always rule-out [[Maisonneuve]] fracture by evaluating proximal fibula | ||
===Syndesmotic Sprain ("High-ankle sprain")=== | ===Syndesmotic Sprain ("High-ankle sprain")=== | ||
* | *Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula | ||
*Pain just above talus | *Pain just above talus | ||
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{{Foot and toe fractures DDX}} | {{Foot and toe fractures DDX}} | ||
== | ==Evaluation== | ||
*Anterior drawer test | *Anterior drawer test | ||
**Tests anterior talofibular ligament | **Tests anterior talofibular ligament | ||
**Cup heel | **Cup heel with one hand and and pull anteriorly while pushing tibia posteriorly | ||
*Talar tilt test | *Talar tilt test | ||
**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 | ||
** | **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: (Likely Grade I) | ||
**NSAIDs, RICE (rest, ice, compression, elevation) | **[[NSAIDs]], RICE (rest, ice, compression, elevation) | ||
**1 week | **1 week follow up if no improvement | ||
*Stable joint but unable to bear weight: | *Stable joint but unable to bear weight or unstable joint (Grades II and III) : | ||
**Ankle | **Ankle cast immobilization or a removable walking boot for 7-10 days for grades II and III. Follow up at 5 days with ortho/podiatry. <ref>[https://www.podiatrytoday.com/guide-conservative-care-ankle-sprains Douglas Richie, A Guide To Conservative Care For Ankle Sprains. Podiatry Today Volume 29 - Issue 7 - July 2016]</ref> | ||
**[[Splinting#Lower Extremity|Posterior mold splint]] and ortho consult/referral | **[[Splinting#Lower Extremity|Posterior mold splint]] and ortho consult/referral | ||
==Disposition== | ==Disposition== | ||
* | *Discharge | ||
==See Also== | ==See Also== | ||
*[[Ankle (Main)]] | *[[Ankle (Main)]] | ||
*[[Ankle Fracture]] | *[[Ankle Fracture]] | ||
*[[ | *[[Ottawa Ankle Rules]] | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Orthopedics]] | [[Category:Orthopedics]] | ||
[[Category:Sports Medicine]] |
Revision as of 18:31, 31 December 2019
Background
Ankle stabilization anatomy
- 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
- Tibial plateau fracture
- Tibial shaft fracture
- Pilon fracture
- Maisonneuve fracture
- Tibia fracture (peds)
- Ankle fracture
- Foot and toe fractures
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
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
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: (Likely Grade I)
- NSAIDs, RICE (rest, ice, compression, elevation)
- 1 week follow up if no improvement
- Stable joint but unable to bear weight or unstable joint (Grades II and III) :
- Ankle cast immobilization or a removable walking boot for 7-10 days for grades II and III. Follow up at 5 days with ortho/podiatry. [1]
- Posterior mold splint and ortho consult/referral
Disposition
- Discharge