![]() You should consider full-length tib/fib films in all ankle injuries to rule out a more proximal fracture including a Maisonneuve fracture. While the Ottawa Ankle Rules are often referenced and tested on exams, these criteria can miss significant injuries. The vast majority of ankle injuries require at least basic radiographs for proper evaluation. In the setting of a more diffuse traumatic injury, always examine all other bones and joints even if the patient is only complaining of pain at the ankle (their ankle injury may be a distracting injury).Ĭonsider examination and diagnostic evaluation for any injuries that are likely to co-occur (e.g., pilons with fibular fractures, bilateral calcaneal fractures, and vertebral compression fractures ). If instability is suspected or apparent, avoid having the patient bear weight. Impaired ROM can be indicative of dislocation, ligamentous injury, or intra-articular pathology.Ĭertain provocative tests or inability to bear weight can be clues to instability. If active ROM is impaired, perform passive ROM. In general, consider imaging of joints adjacent to an area of bony tenderness and imaging of bones adjacent to areas of joint tenderness. Significant swelling over a fracture may produce bullae known as “fracture blisters” Skin tenting or other overlying skin changes are often indicative of impending open fracture or risk of skin necrosis. Obvious tendon or muscular deformity may be seen with Achilles tendon rupture. Gross deformities often suggest fracture or dislocation. Abnormal neurovascular findings suggest injury to nearby structures (nerves and blood vessels) from dislocations, bony trauma, or increased compartment pressures. ![]() ![]() Neurovascular assessment (perfusion, pulses, sensory function, motor function) should be prioritized, regardless of acuity. Use your exam to guide your initial management as well as your imaging decisions and differential diagnosis.Īny significant bleeding should first be controlled in the setting of an open injury ![]() The exam (along with the history) is critical for proper diagnostic evaluation. Respect, but do not rely upon, the mechanism. While knowing the mechanism can provide clues to potential injuries or increase your index of suspicion for certain injuries, mechanisms of injuries can be variable. Unstable injuries may be obvious at time of presentation, with the patient not being able to bear any weight.Ĭertain injuries are classically associated with certain mechanisms (e.g., traumatic axial loading with calcaneal fractures, pilons, and vertebral compression fractures). Ankle fractures may present similarly to an ankle sprain, but are also seen in higher mechanisms of trauma, including MVCs, falls from height, penetrating wounds including GSWs, or other types of direct force to the ankle. Ankle sprains are most commonly caused by ankle inversion. Injuries discussed are shown in Image 1.Īnkle injuries are most commonly caused by abrupt twisting of the ankle. This post will cover some of the most common and important injuries, but is not comprehensive. Certain injuries carry risks of further injury, injury-related complications, and poor outcomes which are exacerbated if they are inappropriately managed in the ED. Furthermore, a patient’s ability to work can be affected both by initial result of injury (e.g., weight bearing status, discomfort) or any sequelae (e.g., nonunion, post-traumatic arthritis or deformity).Īs an EM physician, it is important to have an understanding of the spectrum of ankle injuries and how these are appropriately evaluated. Within the Medicare population alone, foot and ankle surgeries are responsible for more than 11 billion dollars spent annually. Ankle injuries have financial implications for both the healthcare system and patients. Ankle fractures are the third most common fracture in the ED and more than 20,000 patients are seen in the ED for ankle sprains each day. ![]() Ankle injuries are among the most common reasons for ED visits. ![]()
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