Remember analgesia.Always assess and record the patients ability to bear weight
Ankle sprains - Ottawa Ankle Rules
Ankle x-rays are required if only if criteria below are fulfilled.
- With apparent ankle injuries, check other sites of trauma which are easily missed (i.e. tendo-achilles, os calcis, base of 5th metatarsal, whole of fibula (and tibia)
- Remember to x-ray the foot if there is bony tenderness over the navicular or base of 5th metatarsal.
- Check for AP instability.
- Treat by ice (if recent), elevation and active exercises when elevated.
- Encourage weight bearing, [BestBets] give stick/crutches if necessary
- Do not routinely refer to ED clinic
- In the case of a bad sprain, the above treatment is best supervised by direct referral to physiotherapy.
- If undisplaced, treat with below-knee POP and refer to the Fracture Clinic (CUH Fracture Clinic Referral form).
- Consider prophylactic anticoagulation (LMWH) if high risk of VTE or prior DVT.[BestBets]
- CUH EM and Orthpaedic divisions have (Feb 2013) reviewed the literature (including the 2012 Oct CEM guideline). Prophylactic anticoagualtion is not required those pateints discharged in a backslab.
- If displaced or tibio-fibular diastasis, refer to the on-call Orthopaedic Team
- If diastasis, obtain X-ray of whole leg.
Fracture calcaneum (os calcis)
- May occur from a fall onto the heels or with "simple" inversion ankle injuries.
- If in doubt - request axial X-ray.
- If the sub-talar articular surface is involved, refer to the on-call Orthopaedic Team for admission.
- Gross disruption of the subtalar joint is indicated by a flattening in Bohler's angle (should be 30° - 40°).
- If there is no sub-talar involvement apply a well padded POP backslab, advice, no weight bearing and provide crutches.
- Consider prophylactic anticoagulation (LMWH) particularly if high risk of VTE or prior DVT.[BestBets]
- Arrange a Fracture Clinic appointment.
- Warn patient to return immediately if pain increases
Rupture of the tendon-Achilles
- Steroid or Quinolone use
- Rheumatoid arthritis
- Renal failure
- Observe # foot may not rest in natural plantar-flexionflexion
- Palpable step in Achilles Tendon
- Thompson test - lie prone and calf squeeze produces plantar flexion in normal individuals).
- Matles test - lie prone, knees flexed 90°, gravity makes # side ankle more dorsiflexed
- Server's (calcaneal apophysitis) in teenagers
- Peroneal tendonopathy or dislocation
- Retrocalcaneal bursa, Os trigonum syndrome
- Ankle OA, Systemic arthritis (check other side)
- Sural neuroma (or referred pain from sacral roots)
Sub-talar and forefoot dislocation
- Reduce immediately under Entonox ± IV Morphine and Midazolam (sedation sheet)
- Urgency = prevent skin overlying head of talus becomes ischaemic
- Refer to the on-call Orthopaedic Team Referral form
- Suspect injury if point tenderness over midfoot, or laxity between 1st and 2nd MT’s
- > 1mm gap between adjacent bases of 1st and 2nd MT’s
- The six bone tarsometatarsal complex is known as the lis franc joint.
- Injuries uncommon, but up to 20% are missed.
- Force of injury variable and can be minor rotational to severe axial load.
- In most injuries involve disruption of the joint and associated fractures of metatarsals, cuneiforms and cuboids.
- A fracture at the base of the 2nd metatarsal is pathogmonic of disruption of the ligament complex.
Types of Lis-Franc fractures:
- Divergent: metatarsals splayed both medially and laterally - usually between 1st and 2nd MT's
- Isolated - one or more MT's are displaced from the rest
- Homolateral - all 5 MT's are displaced in the same direction either laterally or medially
Isolated fractures of the cuboid and cuneiform bones are rare and an associated injury to the lis franc joint should be sought
Management (thus why important to identify)
- Frequently require open reduction and internal fixation or Kirschner wires
- In interim, whilst waiting on orthopaedic opinion, should be immobilized in a below knee back slab and have hourly neurovascular obs due to the risk of swelling and compartment syndrome – (especially if crush type injury)
- Early can have dorsalis pedis artery injury therefore always double check pulse and perfusion
Avulsion Fracture of the base of the 5th metatarsal
- Tubigrip [Bestbets] rather than plaster
- Elevation when not walking on it, exercises.
- Stick or crutches.
- Review in clinic only if difficulty mobilising.
- POP only if patient unable to weight bear at all.
- Transverse fracture of shaft of little metatarsal.
- Very different to pull off fracture as above.
- Unstable as peroneus (brevis) tendons distract fracture and mal/non union likely.
- Treat in POP and refer fracture clinic (CUH Fracture Clinic Referral form)
Other metatarsal fractures
- Ice, elevation and exercises. POP may be helpful if multiple fractures.
- If compound treat as for compound fractures plus soft footwear.
- Fractures of the Hallux involving the articular surfaces require Fracture Clinic (CUH # Clinic Referral form)
- Otherwise follow-up in the ED clinic or by GP