APCO

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• Evaluation of the Injured Ankle
• May 26, 2005

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Pretest of Ankle EvaluationWrite down your
answers.

• Medial ankle sprain can be associated with which
  worrisome diagnosis?
• What are the Ottawa Rules for the Ankle?
• What do you need to exclude when a pre-adolescent
  presents with an ankle sprain?

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Illustrative Case

• 36 year old health care provider
• Yoga class after long night of call
• Mild ankle pain the whole hour
• New pose Downward Dog

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• During her attempt at relaxation, someone kicks
  her in the right heelhard.
• Sharp pain in heel and leg
• Difficulty walking

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Yogic Pain

• W/U
• Dx
• Treatment..

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Most Common Diagnosis

• Sprain lateral, medial and syndesmosis.
• Malleolar fractures lateral and medial.
• 5th MT avulsion Fracture
• Achilles rupture

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Common Missed Diagnosis

• Achilles tendon rupture
• A Maisonneuve fracture--
• Posterior tibial tendon rupture or subluxation

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Red Flags

• High impact injuries require further workup.
• Neuro-vascular compromise with compartment
  syndromes
• sprain in pre-adolescent, whose physis are
  weaker than the ligaments.

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Basic Format for Joint Exam PORT

• Palpation tenderness
• Observation symmetry, deformity, swelling,
  alignment, gait, color
• ROM active and passive
• Tests specific provocative tests

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Palpation (PORT)

• Apply the Ottawa Rules
• Inspect for point of maximal tenderness
• palpate entire leg and foot

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Palpation (PORT)

• tenderness of medial or lateral ligaments
• tenderness of heel, bursa or Achilles tendon
• In kids, always touch the physis, rule out Salter
  I fractures.
• Check sensation and pulses.

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Observation (PORT)

• Look for symmetry
• standing examination
• look for effusion
• look for erythema
• walking normal gait, toe and heel walking.

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Range of Motion (PORT)

• Plantar flexion
• dorsiflexion
• inversion
• eversion
• active and passive ROM
• best before swelling
• exam limited by patients pain

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PORT TestsAnkle Ottawa STAT

• Ottawa rules rule in fractures -- x-ray
• S Squeeze test --syndesmosis injuries
• T Thompsons test -- Achilles rupture
• A Anterior Drawer -- anterior talofibular
• T Talar Tilt -- Deltoid ligament.

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Specific Tests and Diagnosis Ankle Ottawa
STAT

• Ottawa rules rule in fractures -- x-ray
• S Squeeze test --syndesmosis injuries
• T Thompsons test -- Achilles rupture
• A Anterior Drawer -- anterior talofibular
• T Talar Tilt -- Deltoid ligament.

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Specific Tests and Diagnosis Ankle Ottawa
STAT

• Ottawa rules rule in fractures -- x-ray
• S Squeeze test --syndesmosis injuries
• T Thompsons test -- Achilles rupture
• A Anterior Drawer -- anterior talofibular
• T Talar Tilt -- Deltoid ligament.

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Ottawa Rules

• ?

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Ottawa Rules

• Unable to bear weight (four steps)
• tenderness a distal tip or posterior aspect of
  medial malleolus
• tenderness a distal tip or posterior aspect of
  lateral malleolus
• Tenderness base of 5th MT
• Tenderness at the navicular

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Ottawa Rules
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Navicular
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5th metatarsal
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Ottawa Rules rule...

• Sensitivity 98
• Specificity varies, about 40
• Valid in children.
• Unclear in elders.

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Ottawa STAT Squeeze test syndesmosis injury

• Squeeze the tibia and fibula together gently
• Pain at the ankle or distal leg is test
• Pain with external rotation confirms injury
• Mechanism forced external rotation and hyper
  dorsiflexion

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Syndesmosis injury
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Ottawa STAT Squeeze test syndesmosis injury

• Treatment non weight bearing
• Graduate to a walking boot over two weeks
• Long recovery time 2 months
• If severe pain, check x-rays with external
  rotation stress 5mm ? complete rupture and
  needs referral

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Ottawa STAT Thompson test Achilles rupture

• Squeeze middle third of calf muscles
• Lack of plantar flexion ? complete rupture
• Hx Patient complains of loud noise and sudden
  pain
• Treatment not clear casting v. repair of
  professional athletes.

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Ottawa STAT Thompson test Achilles rupture

• Depression at site of rupture

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Ottawa STAT Anterior Drawer anterior
talofibular

• Ankle in neutral position
• One hand holds leg, the other holds heel
• Try to pull foot forward
• Positive test is a displacement 3mm

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FIGURE 2. Anterior drawer test to assess the
integrity of the anterior fibular ligament
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Ottawa STAT Anterior Drawer anterior
talofibular

• lateral ankle strain is most common sports
  injury.
• With forced inversion, anterior talofibular
  ligament is first to tear
• Lateral swelling, ecchymosis
• Difficult to assess after swelling starts

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Ottawa STAT Anterior Drawer anterior
talofibular

• (Ottawa Rules to decide on x-rays)
• Grade 1 tenderness without swelling
• Grade 2 tendernessswelling but minimal laxity
• Grade 3 tenderness swelling laxity

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Lateral ankle sprain treatment

• Crutches and splint until able to bear weight
  without pain.
• Grade 1 RICE, analgesics, return to activity in
  1 week
• Grade 2 RICE, consider brace or taping, and
  return to activity in 2-4 weeks
• Grade 3 Above, plus PT. Consider surgical
  consultation. Surgery rarely necessary.

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Ottawa STAT Talar tilt Deltoid ligament injury

• Hold lower leg with one hand
• Other hand cups ankle and everts the ankle
• Compare to normal side
• Excess eversion ? deltoid strain

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http//www.aafp.org/afp/20010101/93.html
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Ottawa STAT Talar tilt Deltoid ligament

• May be associated with other injuries
• Syndesmosis
• Maisonneuve Fracture
• If stable, treat like lateral ankle sprain

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Specific Tests and Diagnosis Ottawa STAT

• Ottawa rules rule in fractures -- x-ray
• S Squeeze test --syndesmosis injuries
• T Thompsons test -- Achilles rupture
• A Anterior Drawer -- anterior talofibular
• T Talar Tilt -- Deltoid ligament.

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Illustrative Case

• 36 year old medical provider
• Yoga class after call
• Downward Dog

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Yoga Student

• During attempt at relaxation, someone kicks her
  in the right heelhard.
• Sharp pain in heel and leg
• Difficulty walking

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What would you do?

• Hx?
• Red Flags?
• PORT approach to exam.
• Ottawa-STAT...