Ligament Injury Management

Question 1

What are the Ottawa ankle rules

Answer 1

Ankle x-ray if there is pain in the malleolar zone and any of:

1. Tenderness over the posterior edge or tip of lateral malleolus
2. Tenderness over the posterior edge or tip of medial malleolus
3. inability to weight-bear both immediately and now

Foot x-ray if there is pain in the midfoot zone and any of:

1. Tenderness over navicular
2. Tenderness over base of 5th metatarsal
3. Inability to weight bear both immediately and now

Question 2

What other examinations can you do for ligaments

Answer 2

Palpate deltoid ligament and lateral ligament complex

Palpate fibula to knee (#head of fibula)

Squeeze test - squeeze mid calve - pain at syndesmosis +ve and requires urgent ortho assessment

Test weight-bearing

Anterior drawer test - hold foot still and push lower leg anteriorly and posteriorly - tests talofibular ligament

Tilt test - invert foot at ankle and compare to other side - tests lateral ligament complex, bias towards calcaneofibular ligament

Distal neuromuscular exam - check peroneal and sural nerves

Question 3

Generic management for ligament injuries

Answer 3

Acutely apply ice pack for 20 mins
Give patient crutches, analgesia and advice
- NSAIDs
- RICE
- Mobilise and weight-bear as able
- Try to fully weight bear for 2 mins every day for month
- Physio if not better 1-2 weeks

Question 4

What is the mechanism and symptoms of a damaged cruciate ligament

Answer 4

Anterior - forced flexion, hyperextension of knee (i.e. during tackle) or rotation injury to extended knee

Posterior - tibia forced backwards i.e. fall on object or hitting dashboard in RTA

Sx

• knee collapse when weight put on it
• immediate pain
• difficulty weight-bearing
• rapidly forming haemarthrosis

Question 5

What is the mechanism and symptoms of a damaged collateral ligament

Answer 5

Medial - blow to lateral side of knee
Lateral (uncommon) - blow to medial side of knee (check peroneal nerve)

Sx

• pain on inner/outer knee
• immediate pain
• difficulty weight bearing
• may have sx of instability (if high grade injury)

Question 6

What is the mechanism and symptoms of a damaged of a meniscal tear

Answer 6

Mechanism - rotational injury to flexed knee

Sx

• immediate pain
• difficulty weight-bearing
• slowly forming effusion
• clicking and locking (limiting extension)

Question 7

What are the ottowa knee rules

Answer 7

Age >55
Inability to weight bear both immediately and now
Isolated patella tenderness
Head of fibula tenderness
Inability to flex to 90 degrees