Rosen & Barkin's 5-Minute Emergency Medicine Consult (57 page)

• Closed fractures:
  
  • Primarily analgesics (opioids)
    
• Dislocations or displaced fractures requiring closed reduction consider:
  
  • Short-acting benzodiazepine (midazolam 0.05–0.1 mg/kg IV) or barbiturate (methohexital 1–1.5 mg/kg IV) with opioid analgesic
    
• Open fractures:
  
  • Cefazolin: 2 g loading dose (peds: 50 mg/kg) IV
    
  • Gentamicin: 5–7 mg/kg q24h (peds: 2.5 mg/kg q8h) IV
    
  • Vancomycin: 1 g loading dose (10 mg/kg in children) if penicillin allergic
    
  • Tetanus toxoid if indicated
    

FOLLOW-UP

• Unstable ankle fractures require urgent orthopedic consultation and may require admission
  
• Open ankle fractures and dislocations should be admitted for debridement, irrigation, and IV antibiotics
  
• Ankle dislocations that are treated with either open or closed reduction
  
• Concern for compartment syndrome or neurovascular injury
  

Simple nondisplaced stable ankle fractures without neurovascular compromise may be splinted for immobilization and discharged

• Splinting
  
• Elevation of affected lower extremity
  
• Fitted for crutches and shown how to use them
  
• Placed on nonweight-bearing status of affected joint, until seen by orthopedist
  

• To reduce a dislocated ankle, partial flexion of knee of affected limb will decrease tension on Achilles tendon and ankle
  
• Differentiate between ankle fracture and subtalar fracture on physical exam: While the latter is rare, it is also rarely reducible
  
• Remember to look for other injuries including lumbar spine, hip, tibia, fibula, especially the proximal fibular neck, and foot
  

• Bachmann LM. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.
  Br Med J
  . 2003;326:417.
  
• Blackburn, EW, Aronsson DD, Rubright JH, et al. Ankle fractures in Children.
  J Bone Joint Surg Am
  . 2012;94(13):1234–1244.
  
• Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: A meta-analysis.
  Acad Emerg Med
  . 2009;16:277–287.
  
• Koehler SM, Eiff P, et al. Overview of ankle fractures in adults.
  UpToDate.com
  . 2012 Oct.
  
• Slimmon D, Brukner P. Sports ankle injuries: Assessment and management.
  Aust Fam Physician
  . 2010;39(1–2):18–22.
  

See Also (Topic, Algorithm, Electronic Media Element)

Ottawa Ankle Rules Figure

CODES

• 824.0 Fracture of medial malleolus, closed
  
• 824.8 Unspecified fracture of ankle, closed
  
• 824.9 Unspecified fracture of ankle, open
  

BASICS

• Injuries to ligamentous supports of the ankle
  
• Ankle joint is a hinge joint composed of the tibia, fibula, and talus.
  
• Injuries may range from stretching with microscopic damage (grade I) to partial disruption (grade II) to complete disruption (grade III).
  

• Forced inversion or eversion of the ankle
  
• Forceful collisions
  
• 85–90% of ankle sprains involve lateral ligaments:
  
  • Anterior talofibular (ATFL)
    
  • Posterior talofibular (PTFL)
    
  • Calcaneofibular (CFL)
    
  • Usually the result of an inversion injury
    
  • The ATFL is the most commonly injured.
    
  • If the ankle is injured in a neutral position, the CFL is often injured.
    
  • The PTFL is rarely injured alone.
    
• Injury to the deltoid ligament (connecting the medial malleolus to the talus and navicular bones) is usually the result of an eversion injury:
  
  • Often associated with avulsion at the medial malleolus or talar insertion
    
  • Rarely found as an isolated injury
    
  • Suspect associated lateral malleolus fracture or fracture of the proximal fibula (Maisonneuve fracture).
    
• Syndesmosis sprains (injury to the tibiofibular ligaments or the interosseous ligament of the leg):
  
  • Occur most commonly in collision sports
    
  • Syndesmosis injuries (“high ankle sprains”) have a higher morbidity and potential for long-term complications.
    

• Children <10 yr with traumatic ankle pain and no radiologic evidence of fracture most likely have a Salter–Harris I fracture.
  
• The ligaments are actually stronger than the open epiphysis.
  

DIAGNOSIS

History may predict the type of injury found and should include:

• Time of injury
  
• Mechanism
  
• The presence of a “pop” or “crack”
  
• History of previous trauma
  
• Relevant medical conditions (e.g., bone or joint disease)
  
• Treatments attempted prior to arrival
  
• Ability to bear weight subsequent to the injury at scene and ED
  

• Aimed at detecting joint instability and any associated injuries:
  
  • Note the presence or absence of bony tenderness at posterior edge of medial and lateral malleoli as well as at the base of the 5th metatarsal.
    
• Document neurovascular status distal to the injury.
  
• Assess range of motion and compare it with the uninjured side.
  
• Stress testing in the ED is often limited by pain and may impair detection of ligament injury.
  
• The squeeze test helps identify syndesmosis injuries:
  
  • Squeeze tibia and fibula together at the midcalf; pain felt in the ankle indicates a positive test.
    

• The Ottawa Ankle Rules
  ,
  a selective strategy for obtaining ankle radiographs in adults, suggest that foot or ankle radiographs are unnecessary except when any of the following are present:
  
  • Bony tenderness at the posterior edge of the distal 6 cm or tip of either malleolus
    
  • Bony tenderness along the base of the 5th metatarsal or navicular bone
    
  • Inability to take 4 unassisted steps both immediately after the injury and in the ED
    
• The rules have been prospectively validated by the original authors as well as independently by groups in the US, the UK, France, and other countries.
  

• Ankle injuries should be radiographed if there is concern for fracture.
  
• Stress radiographs are rarely useful in the ED and should not be routinely ordered unless requested by a consultant.
  

• Ankle fracture (lateral, medial, or posterior malleolus) or dislocation
  
• Achilles tendon injury
  
• Maisonneuve fracture
  
• Os trigonum fracture
  
• 5th metatarsal fracture (Jones fracture)
  
• Transchondral talar dome fracture
  
• Peroneal tendon dislocation or injury
  

TREATMENT