Ankle Injuries

Anatomy

Hinge/saddle joint; wider anteriorly than posteriorly; thin capsule; curved surface of talus locks into place in dorsiflexion; lateral weaker than medial, especially anterior talofibularSubtalar joint: inferior talus + calcaneus; inversion and eversionMidtarsal joint: talonavicular, calcaneo-cuboid; abduction, adduction of forefootTarso-metatarsal: Lisfranc

Anatomy

Ottawa Ankle Rules

Pain near malleoli AND inability to weight bear (4 steps) immediately and in ED OR tender posterior / inferolateral / medial malleolus100% sensitivity; 41% specificity for clinically relevant fractures (98% sensitivity, 50% specificity if 1-15yrs); reduces XR’s by 30%

X-Ray Interpretation

On AP: distance between tibia and fibula 1cm proximal to tibial plafond should be <6mm; if not, rupture of distal tibiofibular ligament95% sensitivity overall

Ankle Sprain

Epidemiology

Pathology

Classification

Management

75% ankle injuries are sprains

Medial = deltoid ligament (10%): usually associated with fracture (Maissoneuve), rarely damaged aloneLateral (90%): Anterior talo-fibular ligament most common (90% of laterals), test with ant drawer test Posterior talo-fibular, test with post drawer test Calcaneo-fibular, test with talar tilt test

Rest; Ice (10mins per 2hrs for 48hrs) Compression, Elevation (to prevent swelling post-cooling); encourage early mobilisation with ankle strapping, motion and strength exercises at 48-72hrs; maybe OT for III

I Partial tear (usually anterior talo-fibular); little swelling, pain; no altered ROM; can weight bear

IIPartial tear (anterior talo-fibular + calcaneofibular); pain at rest; limited weight bearing; moderate-severe pain+swelling; tender inferior to lateral malleolus; mild-moderate instability

IIIComplete tear of 2+ parts of lateral ligament; severe pain; decreased weight bearing; joint movement with AP stressing; needs POP for 6-8/52 and maybe OT

Ankle Fractures

60% open fractures are caused by MVA, 10% from GSWUnstable fracture: suggested by swelling of both sides of ankle, deformityStable fracture: suggested by no deformity, minor swelling, unilateral symptoms

Classification

Pott’s Uni / bi / trimalleolar; bi and tri and unstable, uni depends of extent of damage

Weber

Supination adduction injury; fibula fracture below syndesmosis 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus (bi) 3 Above + posteromedial tibial fracture (tri)

A

Classification Weber

Supination extension rotation injury; fibula fracture at level of syndesmosis; most common 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus fracture / medial ligament injury (bi) 3 Above + posterolateral tibial fracture (tri)

B

Fibula fracture above syndesmosis 1 Fibula only (stable; all involve a tibfib ligament injury; manage closed if stable but careful as posterior ligaments may also be involved) 2 Complex fracture of fibula 3 Proximal fracture of fibula

C

Ankle Fractures

Management

Conservative: minimally displaced (<3mm) avulsion fractures of distal fibula without deltoid ligament injury (ie. Weber A1) = treat as sprainPOP: non-displaced fractures with intact mortice joint without deltoid ligament injury = below knee POPOT: displaced / unstable / mortice incongruity / bi/tri malleolar / contralateral ligament damage

Maisonneuve Fracture

Proximal fibula fracutre (within 6cm of top)AND

Medial malleolus (or deltoid ligament rupture)

Unstable; needs OT; due to external rotational force

Dupuytren’s Fracture

High fibular fractureAND

Disruption of ankle syndesmosis

Ankle Dislocation

Anterior: force on dorsiflexed foot; associated anterior tibial fracturePosterior: most common; usually associated with ruptured tibiofibular ligament or lateral malleolus fracture; posterior force on plantarflexed foot Lateral: results in malleolus fractureSuperiorManagement: relocate ASAP (by ED doc if dusky foot, absent pulse, tenting of skin); hang leg over edge of stretcher with flexed knee grasp toes and calcaneum plantar flex and invert traction moving whole foot in direction oppostite to deformity (usually anterolaterally) OT

Achille’s Tendon Rupture

Epidemiology

MOI

Assessment

Management

40-50yrs; associated with rheumatoid arthritis, SLE, chronic renal failure, long term steroids, gout, quinolones

Forceful dorsiflexion of foot; blood supply weakest 2-6cm above calcaneus hence most common site of rupture

Unable to walk / stand on toes; defect 2-6cm proximal to calcaneum; can still plantar flex without resistance; Thompson-Doherty-Simmons squeeze test

OT if: young and detected <6hrs (lower rates of muscle atrophy, re- rupture; earlier return of activity; risk of infection, skin necrosis, fistula formationEquinus cast otherwise with delayed surgical repair at 2-3/52 if no sign of repair