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Ankle Injury: Can You Find the Twist?

July 16, 2015

Brady Pregerson, MD

Slideshow

Ankle injuries are extremely common but aren't always straightforward. Look at this patient's history and x-rays. What do you see?

Half of all ankle sprains occur during sports activity but debilitating ankle injuries can be sustained by stepping off a curb or crossing an uneven driveway. The patient in the case study above got tangled up in tree roots on the day he hurt his ankle, along with 24,999 others in the United States.Can you tell from the x-ray image what kind of injury he has? What treatment would you recommend?Â When you're finished with the case, use the table below to brush up on your ankle injuries.Â ANKLE INJURIES from Quick Essentials Emergency Medicine 1-minute Consult pocketbook Ankle Fx:Stable: nondisplaced fibula. Treatment: cam walker or short leg cast Unstable: 2 bones or ligaments. Treatment: long leg cast, may need surgeryMisses:Talus, Maisonnueve (see below), calcaneus, effusion may mean an occult fractureAnkle sprain:Inversion most common mechanism.Exam:Check knee & foot, anterior drawer, squeeze test & external rotation for syndesmosis.Ottawa tool:No X-ray needed if malleoli, 5th metatarsal & navicular all non-tender and can walk 4 steps.Grades:1: pain w/o laxity.Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Rx: air splint, early range of motion2: laxity w/ good endpoint,limping.Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Rx: air splint, early range of motion3: laxity w/o endpoint,can’t walk, ecchymosis.Â Â Â Â Â Â Â Â Â Â Rx: NWB, posterior splint, cast Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â (surgery)Surgery:Indications: deltoid torn and intrarticular w/ wide mortise, syndesmosis tear w/ wide mortise.Maisonneuve:Medial ankle injury with proximal fibula fracture. Ankle film may show only wide mortise.Injury:External rotation mechanism; syndesmosis torn, peroneal nerve injury.Treatment:ORIF (open reduction with internal fixation)[[{"type":"media","view_mode":"media_crop","fid":"39667","attributes":{"alt":"","class":"media-image","id":"media_crop_250863670543","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3989","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 139px; height: 158px;","title":" ","typeof":"foaf:Image"}}]]Click image for details.