Lecture 13: Tibia and Fibula fracture and high ankle sprains

Question 1

the fibula is the major – of the — side of the —

Answer 1

1. stabilizer
   2: medial
   3: ankle

Question 2

the fibula is a major factor in assisting the —-

Answer 2

deltoid ligament in preventing talar eversion
- you may have some stability with an injured deltoid ligament
- very poor stability with # fibula

Question 3

with an external/eversion rotation what parts of the body may you injure?

Answer 3

1: deltoid ligament
2: anterior inferior tib fib ligament
3: fibula
4: tibia

Question 4

with eversion you can have injuries to

Answer 4

1: deltoid
2: fracture
3” anterior - inferior tibial - fibula

Question 5

healthy ankle injury

Answer 5

MOI - usually in a skate or ski boot
- may have noticeable deformity
- no pain on palpation over deltoid ligament or malleoli
- if no deformity present, +ve squeeze and/or ER tests on lower leg

Question 6

what is the course of action for tibia and fibula fractures

Answer 6

1: stabilize joint (above and below the joint)
2: monitor for shock
3: transport to hospital

Question 7

The syndesmosis (high ankle) sprain

Answer 7

• approx 10% (1%-18%) of all ankle sprains involve injury to the inferior Tib/fib joint (syndesmosis)
• more common in sports where “boots” are work
  
  • ie. skiing or hockey
• difficult to diagnose
• considered one of the most difficult injuries to treat
• prolonged recovery
  
  • up to 55 days

Question 8

functional anatomy of the ankle syndesmosis

Answer 8

• when the ankle is in a neutral position the AITFL is oblique to both tibia and fibula
• interosseous membrane
  
  • fibers are also oblique to tibia and fibula
• with dorsiflexion
  
  • fibula externally rotates and it moves superiorly
  • external rotation of fibula increases the tension within these structures
  • interosseus and AITF ligament are now perpendicular vs. oblique

Question 9

functional anatomy of syndesmosis injuries

Answer 9

during dorsiflexion, the wider aspect of the talus is “jammed” between tibia and fibula
- this is what stops the dorsiflexion from going any further
- if the foot is forced into dorsiflexion and or talar eversion/external rotation, it will stress (and possibly injure) the structures holding the tibia and fibula together

Question 10

the bottom line for high ankle sprains

Answer 10

the mechanism of syndesmosis sprains is postulated to be eversion/external rotation of the foot and/or hyper-dorsiflexion

Question 11

assessment keys

Answer 11

• often a diagnosis of exclusion
  
  • rule everything else out (fracture, medial ankle injury, lateral ankle injury)
• no one test is definitive, therefore a combination of tests is warranted

Question 12

how can you rule out a fracture

Answer 12

• Ottawa ankle rules, if you think it is higher than Ottawa ankle rules then do external ankle test

Question 13

how can you rule out medial ankle injuries

Answer 13

talar tilt eversion

Question 14

how can you rule out lateral ankle injuries

Answer 14

anterior talar tilt to inversion

Question 15

what are the assessment/diagnosis for high ankle injuries

Answer 15

1: squeeze test
2: external rotation and dorsiflexion test
3: stabilization test

Question 16

a squeeze test

Answer 16

• done to indicate a high ankle sprain
• compress proximal tibia and fibual. positive test is pain at the level of the AITFL
• if the athlete feels pain then the structures must be severely compromised

Question 17

external rotation and dorsiflexion test

Answer 17

• stabilize the lower leg with one hand. passively dorsiflex and externally rotate the foot
• essentially putting stress through the ligament and seeing if it causes pain
• lowest false positive rate
• if you can only do one, this is the test to do

Question 18

how do you diagnose a high ankle sprain

Answer 18

tenderness over anterior inferior tibiofibular ligament (ATIFL)

Question 19

the stabilization test

Answer 19

• tightly apply a few layers of athletic tape just above the ankle joint to help stabilize the distal syndesmosis.
• called horse taping
• after the patient is taped, you test the patients function by asking them to stand, walk, toe raise, jump

Question 20

high end ankle sprains - subjective

Answer 20

• MOI = forced dorsiflexion and eversion
• pain just superior to the ankle joint and possibly up the leg
• did not hear/ feel a crack, but maybe a “pop
• didn’t notice much swelling
• pain 6/10
• 9/10 when walking but pain might slightly decrease to 7/10 if they are walking on their toes

Question 21

why does walking on your toes decrease pain from high ankle sprains?

Answer 21

because the narrow part of your talus is staying between the toes which holds the bones together reducing pain

Question 22

what are the results in special tests for high end ankle sprains?

Answer 22

• negative: Ottawa ankle rules prior to objective assessment
  
  • pain over the AITFL with external rotation test
• positive squeeze test-pain over AITFL
• positive external rotation and dorsiflexion - pain over AITFL
• positive stabilization test
  
  • standing and walking improved with tape. unable to hop
• tenderness 4 cm up the interosseous member
• negative talar tilt into eversion

Question 23

treatment for high end ankle sprains : phase.. acute (hot, painful, swelling (do not always swell) and red

Answer 23

plan: restricted ROM , ice , compression (do the horse taping), elevation
- foot exercises in plantar flexion
- protected gait (crutches)