ROTATIONAL ANKLE ROTATIONAL ANKLE INJURIESINJURIES

CPT NATHAN T. BOYKIN

OPA-C

121ST GENERAL HOSPITAL

INTRODUCTIONINTRODUCTIONq Population based studies suggest that the

incidence of ankle injuries has increased dramatically from the 1960’s

q Patients with acute ankle injuries frequently present to primary care providers

q Accurate initial diagnosis and treatment of ankle injuries is instrumental in improving long term outcome

OBJECTIVES

q Review relevant ankle anatomyq Review pertinent history and physical

exam findings in ankle injuriesq Instruct on current treatment methods

and red flags associated with rotational ankle injuries

OUTLINEOUTLINE

q Anatomy reviewq Historyq Physical examq Sprainsq Fracturesq Conclusion

BONY ANATOMYBONY ANATOMYq Three bone joint

q Saddle shaped

q Talar dome wider anteriorly

LIGAMENTOUS ANATOMYLIGAMENTOUS ANATOMYq 3 Groups of ligaments

Syndesmotic

LIGAMENTOUS ANATOMYLIGAMENTOUS ANATOMY(LATERAL)(LATERAL)

Lateral Collateral Ligaments

LIGAMENTOUS ANATOMYLIGAMENTOUS ANATOMY(MEDIAL)(MEDIAL)

Medial Collateral Ligaments

THE HISTORYTHE HISTORY

q TimingqMOIq Able to W.B after

injuryq Location of painq History of

previous injury/surgery

OTTOWA ANKLE RULESOTTOWA ANKLE RULES

q States that ankle xrays are only needed if there is pain near either malleoli and one of the following is present:

qAge 55 years or olderq Inability to W.B. q Bone pain at the posterior tip of either

malleolus

PHYSICAL EXAM OF THE PHYSICAL EXAM OF THE INJURED ANKLEINJURED ANKLE

q Inspectionq Tenderness to

palpationq Special testsq Distal motor,

sensory and vascular exam

STANDARD STANDARD RADIOGRAPHIC VIEWSRADIOGRAPHIC VIEWS

AP MORTISE LATERAL

ANKLE SPRAINSANKLE SPRAINS

q Inversion and plantar flexion most common MOIq ATFL most frequently injuredq Grading of ligamentous injuryq Location of Tenderness

RADIOGRAPHIC FINDINGS RADIOGRAPHIC FINDINGS SPRAINS/TEARSSPRAINS/TEARS

q No Fractureq Effusion/Edemaq Symetrical Mortiseq Tib/fib Clear Space

TREATMENT TREATMENT SPRAINS/TEARSSPRAINS/TEARS

q Non-operative treatment is the mainstayq RICE principlesq Early motion (P.T.)q Short term immobilization and

progression of weight bearing may be in order

RED FLAGS/PEARLS RED FLAGS/PEARLS SPRAINS/TEARSSPRAINS/TEARS

q Syndesmosis injury (High Ankle Sprain)q TTP over navicularq TTP over lateral process of talusq TTP medial ankle and at proximal fibulaq TTP at 5th MT baseq TTP over talocrural joint

ANKLE FRACTURESANKLE FRACTURES

q Edema, may have obvious deformityq Ensure exam of knee and footq Ensure adequate N/V examq If obvious deformity with N/V

compromise reduce immediately

RADIOGRAPHIC FINDINGS RADIOGRAPHIC FINDINGS IN ANKLE FRACTURESIN ANKLE FRACTURES

q Ensure Adequate Viewsq As a General Rule: Joint Above and

Below q Entire Lower Leg if TTP over Deltoid

Ligament or Medial Maleolus fracture

CLASSIFICATION OF CLASSIFICATION OF ANKLE FRACTURESANKLE FRACTURES

qWeberq Lauge-Hansen

WEBER CLASSIFICATIONWEBER CLASSIFICATION

qWeber A

qWeber B

qWeber C

WEBER A WEBER A

WEBER BWEBER B

WEBER CWEBER C

LAUGELAUGE--HANSEN HANSEN CLASSIFICATIONCLASSIFICATION

TREATMENT OF ANKLE TREATMENT OF ANKLE FRACTURESFRACTURES

q If ankle fracture/dislocation, timely reduction and splinting essential

q Elevate

q Ice

q Post reduction N/V exam essential

q If closed injury and N/V intact may wait for surgical correction until swelling improves

REDUCTION OF ANKLE REDUCTION OF ANKLE FRACTURE/DISLOCATIONSFRACTURE/DISLOCATIONS

q BEND THE KNEE!!q Pull traction, accentuate, then reverse

the deformityq Quigley’s maneuverqMolded splint q Get adequate post-reduction

radiographs

IN THE EVALUATION OF IN THE EVALUATION OF ANKLE INJURIES BE ANKLE INJURIES BE THINKING ABOUTTHINKING ABOUT::

q OLT of talusq 5TH Metatarsal base fractureq Lateral process of talus fractureqMaissoneuve fractureq Subtalar dislocation

CASE #1CASE #1

CASE# 2CASE# 2

CASE# 3CASE# 3

CASE #4CASE #4

CASE #5CASE #5

CASE #6CASE #6

IN CLOSINGIN CLOSING

q Ankle injuries commonq Correct diagnosis and treatment

essential to reduce long term morbidity and mortalityq Remember the red flagsq If in doubt call the Orthopaedist on callq Access our website

REFERENCESREFERENCES1. Thompson, Jon C. Netter’s Concise Atlas of Orthopaedic

Anatomy. Icon Learning Systems. 2002. Pgs 243-2802. Koval, Kenneth J. Orthopaedic Knowledge Update #7. AAOS.

2002. Pgs 547-5503. Miller, Mark D. Review of Orthopaedics 3rd ed. W.B.

Saunders, 2000. Pgs 300-3014. LeBlanc, Kim E. Ankle Problems Masquerading as Sprains.

Primary Care: Clinics in Office Practice; 31 (2004) 1055-10675. Kaikkonen, Auvo. Surgery Versus Funtional Treatment in

Ankle Ligament Tears. Clinical Orthopaedics and Related Research; No. 326, pg 194-202, 1996

6. Tohyama, Harukazu. Anterior Drawer Test for Acute Anterior Talofibular Ligament Injuries of the Ankle. American Journal of Sports Medicince; Vol 31, No. 2; 2003

7. Weiss, Larry. Lauge-Hansen Classification: A Clockwork Injury; Journal of Foot Surgery; Vol 22, No. 3. 1983

REFERENCESREFERENCES8. Michelson, James. Ankle Fractures. Clinical Orthopaedics and

Related Research. No. 345. Pgs 198-205. 19979. Wolfe, Michael W. Management of Ankle Sprains. American

Family Physician. Vol 63, No 1. Jan 200110. Bucholz, Robert W. Rockwood and Green’s Fractures in

Adults Volume 2 5th ed. Lippncott Williams & Wilkins. 2001. Pgs 2001-2083

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