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Ankle Injuries
Anatomy
Anatomy
Ottawa Ankle
Rules
Hinge/saddle joint; wider anteriorly than posteriorly; thin capsule; curved surface of talus
locks into place in dorsiflexion; lateral weaker than medial, especially anterior talofibular
Subtalar joint: inferior talus + calcaneus; inversion and eversion
Midtarsal joint: talonavicular, calcaneo-cuboid; abduction, adduction of forefoot
Tarso-metatarsal: Lisfranc
Pain near malleoli AND inability to weight bear (4 steps) immediately and in ED
OR
tender posterior / inferolateral / medial malleolus
100% sensitivity; 41% specificity for clinically relevant fractures (98% sensitivity, 50% specificity
if 1-15yrs); reduces XR’s by 30%
On AP: distance between tibia and fibula 1cm proximal
to tibial plafond should be <6mm; if not, rupture of
distal tibiofibular ligament
95% sensitivity overall
X-Ray
Interpretation
Epidemiology
Pathology
75% ankle injuries are sprains
Medial = deltoid ligament (10%): usually associated with fracture
(Maissoneuve), rarely damaged alone
Lateral (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
I
Partial tear (usually anterior talo-fibular); little swelling, pain; no
altered ROM; can weight bear
II
Partial tear (anterior talo-fibular + calcaneofibular); pain at rest;
limited weight bearing; moderate-severe pain+swelling; tender
inferior to lateral malleolus; mild-moderate instability
III
Complete 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 Sprain
Classification
Management
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
60% open fractures are caused by MVA, 10% from GSW
Unstable fracture: suggested by swelling of both sides of ankle, deformity
Stable fracture: suggested by no deformity, minor swelling, unilateral symptoms
Pott’s
Ankle Fractures
Uni / bi / trimalleolar; bi and tri and unstable, uni depends of
extent of damage
Classification
Weber
A
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)
B
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)
C
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
Classification
Weber
Management
Conservative: minimally displaced (<3mm) avulsion fractures of distal
fibula without deltoid ligament injury (ie. Weber A1) = treat as sprain
POP: non-displaced fractures with intact mortice joint without deltoid
ligament injury = below knee POP
OT: displaced / unstable / mortice incongruity / bi/tri malleolar /
contralateral ligament damage
Ankle Fractures
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 fracture
AND
Disruption of ankle syndesmosis
Anterior: force on dorsiflexed foot; associated anterior tibial
fracture
Posterior: most common; usually associated with ruptured
tibiofibular ligament or lateral malleolus fracture; posterior
force on plantarflexed foot
Lateral: results in malleolus fracture
Superior
Management: 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
Ankle
Dislocation
Epidemiology
MOI
Achille’s
Tendon Rupture
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
Assessment
Unable to walk / stand on toes; defect 2-6cm proximal to calcaneum; can
still plantar flex without resistance; Thompson-Doherty-Simmons
squeeze test
Management
OT if: young and detected <6hrs (lower rates of muscle atrophy, rerupture; earlier return of activity; risk of infection, skin necrosis, fistula
formation
Equinus cast otherwise with delayed surgical repair at 2-3/52 if no sign of
repair