Case 4: Female with Sports Injury Flashcards
Compartment syndrome
Complication of extremity trauma due to rising pressure in muscle compartment that impairs perfusion to that same muscle compartment
Causes of compartment syndrome
Fractures
Crush injuries
Burns
Arterial injuries
Treatment of compartment syndrome
Emergent decompression via fasciotomy
6 P’s of compartment syndrome
Pain - earliest sign Pallor Pulselessness Paresthesia (itching, tingling) - most reliable sign Perishing cold Paralysis
Significant ankle injury features
- immediate presentation
- unable to weight bear (bearing weight = able to take 4 steps independently)
- history of previous ankle sprain
Hearing a snap or a tear is diagnostic of
Knee injury (not ankle)
Characteristics considered when grading an ankle sprain
- presence/absence of ligament tear
- loss of functional ability
- severity of pain
- presence/severity of swelling
- presence of ecchymosis
- difficulty bearing weight (limited ability in taking 4 steps)
Grade 1 ankle sprain: stretching or small tear of ligament
- mild tenderness + swelling
- mild or no functional loss
- no mechanical instability
- no excessive stretching or opening of joint w stress
Grade 2 ankle sprain: incomplete tear
- tenderness
- mild/moderate pain, swelling, ecchymosis
- some loss of motor function
- mild/moderate instability
- stretching of joint w stress with definite stopping point
Grade 3 ankle sprain: complete tear + loss of integrity of ligament
- severe swelling (> 4 cm about the fibula)
- ecchymosis
- can’t bear weight
- mechanical instability
- stretching of joint w stress without definite stopping point
Mechanisms of injury of ankle sprains
a) plantar flexion and inversion (most common)
b) excessive eversion and dorsiflexion
Damaged structures in plantar flexion/inversion ankle sprain
Lateral stabilizing ligaments
- anterior talofibular (most easily injured)
- calcaneofibular (if injured = instability)
- posterior talofibular (rarely injured)
Ankle anterior drawer test
Used to assess integrity of anterior talofibular ligament
Ankle inversion stress test
Used to assess integrity of calcaneofibular ligament
- invert patient’s ankle and assess for laxity
Excessive eversion and dorsiflexion leads to damage of what structures?
Medial stabilizing ligaments (less common than lateral because of bony articulation b/w medial malleolus + talus)
- strong deltoid ligament
- anterior tibiofibular ligament
- bony martise
Examining injured lower extremities
- always examine uninjured extremity first for baseline and to establish relationship w patient
- excessive swelling/pain can limit exam up to 48 hrs after acute injury
Crossed leg test
Have patient cross legs w injured leg resting at midcalf on knee to detect high ankle sprains: syndesmotic injury between tibia and fibula
Differential for acute ankle pain following inversion injury (5 most likely)
- lateral ankle sprain
- peroneal tendon tear
- fibular fracture
- talar dome fracture
- subtalar dislocation
Less likely causes of acute ankle pain (4)
- medial ankle sprain
- syndesmotic sprain
- fracture of tibia
- arthritis of ankle
Lateral ankle sprain
Present post-trauma with pain, warmth, some swelling - do not create a deformity
Peroneal tendon tear
Due to inversion injury and may occur in conjunction with lateral ankle sprain
Main sx: persistent pain posterior to lateral malleolus
At risk with repetitive trauma
Fibular fracture
Due to fall, athletic injury, or high velocity injury
- severe pain, swelling, inability to ambulate, deformity
Talar dome fracture
Due to acute injury - can be missed on initial Xray
- biggest concern is avascular necrosis (due to interruption of blood supply)
Subtalar dislocation
In setting of high energy injury - involve taleocalcaneal and talonavicular joints
With pain, swelling, deformity
Medial ankle sprain
due to forced eversion
Injury to deltoid ligament
Syndesmotic sprain
Involves interosseus membrane + anterior inferior tibiofibular ligament
- positive ankle squeeze test
Fracture of tibia
After high velocity trauma
- severe pain
- cannot bear weight at all
- visible malformation of extremity
Arthritis of ankle
Less common than in other joints - chronic process in elderly - involves tibiotalar joint
Stiffness, swelling
Ottawa ankle rules
Clinical Dx tool to evaluate adults with acute ankle and midfoot injuries
Rules suggest Xray of ankle is needed if
a) pain in malleolar zone +
b) tenderness on posterior edge of medial or lateral malleolus OR inability to bear weight immediately after injury and in ED
Rules suggest Xray of midfoot is needed if
a) pain in midfoot zone +
b) tenderness at either navicular bone or base of 5th metatarsal OR inability bear weight immediately after injury and in ED
Cochrane review demonstrated….led to quicker return to sports, work in comparison to…
Semi rigid ankle support > simple wraps/bandages
RICE for MSK injuries
Rest for 72 hrs after ankle sprain (but then start to stretch to preserve range of motion and improve function of forming scar tissue)
Ice several times for 10 min
Compression
Elevation
Pain control for ankle sprain
Recommend 2-3 ibuprofen for pain up to 3x/day (after eating a snack) and no Hx of ulcers or problems w NSAIDs
Ankle re-injury prevention (3)
- daily ankle exercises
- no flip flops or sandals until ankle has healed
- protective device on ankle when returning to sports
Exercises to restore ankle strength
- ankle inversion, ankle eversion, ankle plantarflexion, ankle dorsiflexion, calf stretching
- single leg balancing
- proprioceptive exercises (best type of exercise)
Empiric Tx for uncomplicated UTI
3 days of trimethoprim/sulfamethoxazole (but only if there is <20% resistance)
