Ankle Flashcards
What group of patients are predisposed to ankle injuries and why?
Ankle sprains are among the most common injuries managed in the emergency department. Lateral ankle sprains are most common, most injuries are sustained during sport. The incidence of ankle sprain is higher among adult females than males and higher among children than adults.
Intrinsic (patient related) risk factors for lateral ankle sprain include limited dorsiflexion, reduced proprioception and deficiencies in balance
The main extrinsic risk factors appear to be type of sports played with indoor court sports posing the highest risk.
What medications may predispose patients to fractures and why?
Osteoporosis is one of the most serious complications of oral corticosteriod treatment.
What medical conditions may predispose patients to present with ankle injuries?
Hypermobility syndrome
What is the importance of determining if there are an associated injuries?
Osteochondral lesions of the talar dome occur in 6-22% of ankle sprains are easily missed on the initial examination. This lesion should be suspected when tenderness is present along the anterior joint line with the ankle PF.
What are the most common mechanisms of injury for acute ankle injuries?
Inversion injuries leading to lateral ankle ligament sprains.
What is the relevance/importance of establishing of the mechanism of injury for acute ankle injuries?
Inversion stresses account for 85% of all ankle sprains and result in lateral ligamentous injury. As force increases, a predictable sequence of structures is injured.
The lateral joint capsule and the ATFL are the first structures to be injured following an inversion stress. Isolated injury to the ATFL is present in 6-70% of all ankle sprains. With greater forces, a tear of the CFL occurs, and finally, the PTFL is injured.
Eversion injuries to the ankle are much less likely to result in ankle sprains. When the medial structures are injured, avulsion of the medial malleolus occurs more frequently than rupture of the strong and elastic deltoid ligament. As the force increases, the AITFL and the interosseous ligament will tear.
Eversion of the ankle, IR of the tibia and excessive DF may result in tibiofibular syndesmotic ligament injury. This injury is termed high ankle sprain.
What is the relevance of establishing any sensations felt at the time of injury?
The presence of mechanical sensation such as popping or cracking suggests an avulsion fracture or tendon tear.
What is the relevance of determining the patient’s ability to weight bear at the time of injury?
Inability to weight bear or ambulate is associated with fractures, dislocations or a major disruption of the ligaments.
What is the relevance of determining type of activity which led to the ankle injury?
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what is the relevance of determining the neurovascular status of the ankle?
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What key information is important to assess for red flags?
Hematogenous osteomyelitis can occur in the distal tibia and is associated with fever, swelling, and tenderness at the site of infection. Although the clinical presentation of osteomyelitis can be nonspecific, signs of infection (fever, localised erythema, swelling and warmth and/or elevated erythrocyte sedimentation rate and C-reactive protein levels) may be present. Consultation with orthopaedic surgeon is warranted.
Infectious arthritis is less common in the ankle than at other sites but remains an important cause of ankle swelling and pain.
Physical examination demonstrated localised swelling, erythema, warmth and limited ROM. patients typically cannot ambulate.
Diagnosis of bacterial arthritis is suggested by elevation of white blood cell count, erythrocyte sedimentation rate and/or C-reactive protein.
Tumors, both benign and malignant are rare causes of poorly localised ankle pain. The classic presentation is of night pain that is chronic and responsive to NSAIDs.
What key information is important to determine in the setting of chronic ankle pain?
Did the patient have an acute injury prior to developing chronic pain?
What activity seems to worsen the problem?
How often and for how long does the patient engage in the activity? has there been a recent increase in the amount of duration of activity?
Is pain present during or after activity or both?
Is pain present when the patient first take step in the mornings?
Is there a problem with activities of daily living?
Is the problem only exacerbated by sports?
What key information is important to in the setting of atraumatic ankle pain?
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What key information in a patient’s past history is important for patients presenting with ankle pain/injury?
Considering systemic illness or conditions that may affect the foot is also important. eg: rheumatologic conditions may have early morning stiffness, involvement of multiple joints, back and/or hip pain and stiffness, skin rash or positive family history
What key information in a patient’s medication history is important for patients presenting with ankle pain?
There are several reasons for taking an accurate medication history
- a knowledge of the drugs a patient has taken in the past or is currently taking and of the responses to those drugs will help in planning future treatment
- Drug effects should always be on the list of differential diagnoses, since drug can cause illness or disease, either directly or as a result of an interaction
- Drugs can mask clinical signs
- To help avoid preventable errors in prescribing, since an inaccurate history on admission to hospital may lead to unwanted duplication of drugs, drug interactions, discontinuation of long-term medications and failure to detect drug-related problems.
The medication history should not simply be a list of a patient’s drugs and dosages. Other information, such as adherence to therapy, and previous hypersensitivity reactions and adverse effects, should be noted and should be compared with the patient’s GP records or previous prescription history in their hospital case notes.
Herbal remedies are infrequently recorded but may be important causes of morbidity.
What key areas of social history are important for patient’s presenting with ankle pain/injury?
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What is the relevance of determining any intervention to date?
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What is the relevance of determining the compensable status or health insurance status of the patient?
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What is the relevance of determining the last intake of food or fluids?
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Name the nerve supply of the ankle, foot and lower leg
Sciatic nerve bifurcates into the tibial and common peroneal nerve at the popliteal fossa. the common peroneal nerve follows the medial border of the biceps femoris, running in a lateral and inferior direction, over the lateral head of the gastrocnemius. The nerve warps around the neck of the fibula, passing between the attachments of the peroneus longus muscle. here the common peroneal nerve divides into superficial peroneal and deep peroneal nerves.
The common peroneal nerve innervates the short head of the biceps femoris muscle.
Superficial peroneal nerve innervates the muscles of the lateral compartment of the leg
Deep peroneal nerve innervates the muscles of the anterior compartment of the leg
The tibial nerve travels down the leg, posterior to the tibia. During its descent, it supplies the deep muscles of the posterior leg. As the foot, the nerve passes posteriorly and inferiorly to the medial malleolus, through a structure known as the tarsal tunnel. Immediately distal to the tarsal tunnel, the tibial nerve terminates by dividing into sensory branches, which innervates the sole of the foot.
the superficial peroneal nerve is a terminal branch of the common peroneal nerve. When the nerve reaches the lower third of the leg, it pierces the deep crural fascia and terminates by dividing into the medial and intermediate dorsal cutaneous nerves. These nerves enter the foot to innervate the majority of its dorsal surface.
The deep peroneal nerve travels underneath the extensor retinaculum and divides into lateral (innervates intrinsic muscles of the foot) and medial branch (innervates the skin).
