4: 19-year-old woman with sports injury Flashcards
Significance of Historical Features of Ankle Injury
A patient who seeks help immediately, and is non-weight bearing, is more likely to have a severe injury than one who presents a few days after an incident and is fully weight bearing (the ability to take four steps independently).
A history of previous ankle sprain is a common risk factor for ankle injury.
While hearing a snap or tear is diagnostically significant in an acute knee injury, it is not in an acute ankle injury.
Signs & Symptoms of Limb Threatening Injury - Compartment Syndrome
Compartment syndrome is a serious life- and limb-threatening complication of extremity trauma that occurs when rising pressure in a muscle compartment impairs perfusion to that same muscle compartment. Fractures, crush injuries, burns, and arterial injuries all can result in an acute compartment syndrome. You must have a high clinical suspicion for compartment syndrome, as delay in diagnosis or treatment can ultimately lead to compromised blood supply, nerve damage, and muscle death. Treatment is emergent decompression via fasciotomy.
The 6 P’s (Signs of limb threatening Injury)
- Pain
- Pallor
- Pulselessness
- Paresthesia (A skin sensation, such as burning, prickling, itching, or tingling.) 5. Perishing cold (The inability to regulate one’s body temperature.)
- Paralysis
Pain, especially disproportionate pain, is often the earliest sign and clinical hallmark of compartment syndrome.
However, the loss of normal neurologic sensation (paresthesia) is the most reliable sign.
Urgent evaluation is required for a patient you suspect of compartment syndrome.
Mechanism of Injury and Anatomy of Ankle Sprains
Plantar flexion and inversion:
The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, are most often damaged.
The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.
The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament,and the inversion stress test can be used to assess the integrity of the calcaneofibular ligament.
Excessive eversion and dorsiflexion:
In medial ankle sprains, the mechanism of injury is excessive eversion and dorsiflexion. Medial ankle stability is provided by the strong deltoid ligament, the anterior tibiofibular ligament, and the bony mortise. Because of the bony articulation between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains.
Grading Ankle Sprains
Grading of ankle sprains takes into consideration:
- -the presence/absence of a ligament tear
- loss of functional ability
- -severity of pain
- -presence and/or severity of swelling –presence of ecchymosis
- -difficulty bearing weight: the ability to take four steps independently
Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress.
Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point.
Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.
Pyelonephritis
Symptoms: Fever, chills, severe abdominal or back pain
Signs: Costovertebral angle tenderness
Risk Factors: Recent instrumentation or known anatomic abnormality of the urinary tract
Physical Exam Maneuvers for Diagnosing Ankle Injury
Negative inversion test:
Invert the patient’s ankle. Laxity indicates injury of the calcaneofibular ligament.
Crossed-leg test:
Have the patient cross their legs with the injured leg resting at midcalf on the knee to detect high ankle sprains (syndesmotic injury between the tibia and fibula).
Management of Ankle Sprain
RICE - Recommended for most musculoskeletal injuries Rest Ice Compression Elevation
Rest for the first 72 hours after an ankle sprain, as it may help with reduction of swelling and healing. Stretching is helpful after the first few days to improve range of motion and improve the function of forming scar tissue. Don’t rest the ankle for too long, as not moving the ankle for extended periods of time can actually cause more harm such as decreased range of motion, persistent pain and swelling, and chronic joint instability.
Ice the ankle several times throughout the day for 10 minutes or so at a time. And keep the ankle elevated.
Pain control
Studies have shown that compared to placebo, use of anti-inflammatory medications for sprains is associated with improvement in pain, function, and swelling.
First check for a history of problems with ulcers or anti-inflammatory drugs.
Instruct patients to take two or even three ibuprofen at a time for pain. But make sure to eat something like a snack or meal before taking them. Take them up to three times a day if needed.
Most Effective Compression For Ankle Injury
A Cochrane review demonstrated that semi-rigid ankle support led to quicker return to sports, work and less instability of the ankle compared to simple wraps and bandages. It also is more helpful with persistent swelling.
Ankle Re-Injury Prevention
- Daily ankle exercises.
- No flip-flops or sandals until the ankle has healed.
- Protective device on the ankle when returning to sports.
Ottawa Ankle Rules
The Ottawa ankle rules are a clinical decision tool designed to help in evaluation of adults (age 18 and up) with acute ankle and midfoot injuries. These have been reported to have a sensitivity of 97% to 100%. Recently the rules have also been used to exclude fractures in children greater than five years of age presenting with ankle and midfoot injuries.
–The rules suggest that radiographs of the ankle are needed if:
There is pain in the malleolar zone AND either bony tenderness along the distal 6 cm of the posterior edge of either malleolus OR inability to bear weight 4 steps both immediately after the injury and in the emergency department.
–Radiographs of the foot are needed if:
There is pain in the midfoot region AND one of the following: (a) bony tenderness at either the navicular bone or base of the fifth metatarsal OR (b) inability to bear weight four steps immediately after the injury and in the emergency department.
Differential of Acute Ankle Pain Following Inversion Injury
Acute ankle injury is one of the most common musculoskeletal injuries in athletes and sedentary persons, accounting for an estimated 2 million injuries per year and 20% of all sports injuries in the United States.
There are many potential reasons for ankle pain.
Lateral ankle sprains generally present acutely (after trauma) with pain, warmth, and some swelling. Ankle sprains do not create a deformity. If there is a large amount of swelling present, however, it may appear to be a deformity.
Peroneal tendon tear is typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain. Patient may complain of persistent pain posterior to the lateral malleolus. Swelling may or may not be present. Repetitive trauma may cause injury to the peroneal tendons.
Fibular fracture is usually due to a fall, an athletic injury, or a high velocity injury such as motor vehicle accident. Patient may have severe pain, swelling, inability to ambulate, and deformity.
Talar dome fracture is usually due to acute injury. Overall prognosis is related to potential for interruption of the blood supply. Talar dome fracture may occur in conjunction with an ankle sprain, and initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis after talar dome fracture.
Subtalar dislocation occurs in the setting of a high-energy injury involving the talocalcaneal and talonavicular joints. Pain, swelling, and deformity are present.
Medial ankle sprain
Somewhat rare and suggests that forced eversion has occurred. There is typically injury to the deltoid ligament.
Syndesmotic sprain
Generally involves the interosseus membrane and the anterior inferior tibiofibular ligament. Pain and disability are often out of proportion to the injury. One would expect a positive ankle squeeze test.
Fracture of tibia
Often follows a high velocity trauma. Often the patient experiences severe pain and is unable to bear weight at all. There may be visible malformation of the extremity.
Arthritis of the ankle
Less common than in some other joints. It is a chronic process, more commonly seen in older people. The tibiotalar joint is generally involved and the condition may occur as a result of prior injury, obesity, or history of rheumatoid disease. Symptoms may include stiffness, swelling, deformity, and a feeling of instability.
