Written by: Eric Power, MD (NUEM ‘24) Edited by: Brett Cohen, MD (NUEM ‘21)
Expert Commentary by: Jake Stelter, MD (NUEM ‘19)
Stepwise Approach to Management of Ankle Injuries in the Emergency Department
Introduction
Ankle injuries are a common presentation to the emergency department. This group of injuries varies in severity with different treatments, discharge instructions, and follow up plans based on the injury classification.. Ankle fractures also have a large degree of variability in severity and require different initial management. In this post, we will focus on the most common types of ankle injuries and discuss the most important steps for initial assessment, management, and discharge instructions ED clinicians should be giving to their patients.
Ankle Sprains
A very common presentation of ankle injuries, especially for young athletes, is a patient coming in saying they “rolled” their ankle. This most often infers a mechanism of an inversion injury to the ankle, often after making a cut or sudden change in direction in a sporting event or landing on another competitor’s foot. In fact, it is estimated that 25% of all musculoskeletal injuries are inversion ankle injuries, and that half of all these injuries occur during sporting events. Sudden, forced inversion of the ankle, often while in slight plantar flexion, may result in injury to one or more ligaments of the lateral ankle ligament complex. The anatomy of this complex, from anterior to posterior, consists of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL) [1].
Isolated damage to the ATFL is by far the most frequent injury after “rolling an ankle”, making up two-thirds of all cases. With increased amounts of inversion force there is injury to the CFL followed by the PTFL, which are involved in about 20% of cases [2]. However, as with almost all complaints that come into the ED, a focused history and physical exam is the most important initial step to assess and correctly diagnose an ankle injury. The exam should start with assessments of neurovascular status with pulses, sensation, and capillary refill. The ankle should also be examined for gross deformity, tenderness, swelling, range of motion (ROM), strength, and associated injuries of the foot or knee.
Assessing for other Injuries
It is also important to recognize that ligamentous injuries often do not happen in isolation. Studies have found the prevalence of concurrent bony injuries in patients with ankle sprains to be 15-21%, with an anterior talofibular avulsion injury being the most common type [3,4]. When trying to decide whether to image these patients with ankle pain and likely sprains to assess for bony injury, many EM physicians may be familiar with the Ottawa rules. The rules and several interactive clinical decision-making tools are available online. For review, if the patient meets any of the following criteria, they require imaging of the ankle to assess for bony injuries.
Tenderness at the distal 6cm of the posterior edge of the fibula or tibia
Tenderness at the tip of either malleolus
Tenderness at the base of the fifth metatarsal or navicular
Inability to take four steps immediately after injury and on initial evaluation in the Emergency Department
A recently conducted review by Beckenkamp et al. revealed these rules to be highly sensitive (99.4%), but poorly specific (35.3%) to rule out visible fractures on plain films [6].
If x-rays are negative for fracture, the patient still may require orthopedic follow-up, surgery, and have a longer recovery if there is concern for a syndesmotic injury, or “high-ankle sprain”. This is the result of an injury to the tibiofibular ligament and is further discussed in a post by Ford et al [7]. Important considerations when there is clinical concern for this injury include looking for bony overlap on the malleolar films and performing specific exam maneuvers such as a “squeeze test”.
Symptom Management
When deciding what analgesic to use, providers should use clinical gestalt. In order to limit the use of opioid pain medications to prevent dependence and other associated side effects, we recommend they are only used in severe injuries where the patient is in obvious, uncontrolled pain or after a trial of non-opioid pain medications has failed. It is also our recommendation that physicians should not hesitate to use NSAIDs for pain management in fractures without other contraindications, as overall there is limited evidence to suggest it impairs bone healing [8,9]. These medications also provide the benefit of reducing inflammation in patients with swelling and/or joint effusion.
Generally accepted principles to promote healing, decrease swelling, and reduce pain are frequently referred to as the acronym “RICE” or “PRICE”. PRICE is now preferred because it includes protection of the affected structures, along with the other classic teachings. The remainder of the useful acronym includes rest of the injured joint, using ice for 20 minutes on, followed by at least one hour off while there is still pain and effusion, wearing a compression sock or stocking to decrease swelling, and elevating the affected joint above the level of the heart when possible [10]. These strategies should be used in conjunction with anti-inflammatory medications as previously mentioned to provide symptomatic relief while the injury is healing, followed by a focused home exercise program or physical therapy, often after an evaluation and referral from their primary care physician.
For a mild ankle sprain, PRICE with encouragement of early weight bearing is the ideal management. Semi-rigid braces such as an ankle stirrup brace may be superior to an ace wrap [11]. For moderate ankle sprains, give the patient crutches and have them avoid weight bearing for 2-3 days after injury, with encouragement to begin crutch walking when they are able to tolerate it [12]. A common error in treatment of mild and moderate sprains is prolonged immobilization which may delay recovery, these patients should be encouraged to perform range of motion exercises at home. For severe ankle sprains, immobilize the patient in a splint and refer them to follow-up closely with Orthopedic surgery [13].
Summary and Recommendation of Steps in Evaluation of Ankle Injuries for the ED Physician:
Expose the joint
Focused history: mechanism, ability to ambulate immediately after injury, co-injuries
Physical examination of the ankle: with a focus on neurovascular status, gross deformity, swelling, point tenderness, ability to ambulate or bear weight, strength, and ROM of the joint
Physical examination of the rest of the extremity: Evaluate the foot, knee and tibia/fibula for associated injuries.
Analgesia: NSAIDs and acetaminophen, adjuncts if needed based on severity of injury and initial pain control
Imaging, if appropriate: recommendation to use tools such as the Ottawa Ankle Rule and Ottawa Foot Rule
Protection: ace wrap, air cast, walking boot up to splint and crutches, if needed
Discharge instructions for acute recovery (“PRICE”) from injury and follow-up appointment
References:
van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1390-5. doi: 10.1007/s00167-012-2252-7. Epub 2012 Oct 30. PMID: 23108678.
Brostrom L (1966) Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand 132:537–550
Debieux P, Wajnsztejn A, Mansur NSB. Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room. Einstein (Sao Paulo). 2019 Sep 23;18:eAO4739. doi: 10.31744/einstein_journal/2020AO4739. PMID: 31553355; PMCID: PMC6905160.
Bachmann LM, Kolb E, Koller MT, Steurer J, Ter Riet G (2003) Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 326:417–423
Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-32.
Beckenkamp PR, Lin CC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. Br J Sports Med. 2017;51(6):504-10. Review.
[Peer-Reviewed, Web Publication] Ford W, Li-Sauerwine S. (2019, May 27). Not All Ankle Sprains are Created Equal. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/high-ankle-sprain.
1. Adolphson, P., Abbaszadegan, H., Jonsson, U., Dalen, N., Sjoberg, H.E., Kalen, S. No effects of piroxicam on osteopenia and recovery after Colles’ fracture: A randomized, double-blind, placebo-controlled prospective trial. Archives of Orthopaedic and Trauma Surgery, 1993; 112: 127-130.
[Peer-Reviewed, Web Publication] Farcas A, Bode, J. (2020, April 6). Clinical Question: are we impeding our patients’ fracture healing by giving them NSAIDs? [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/fx-nsaids
Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006 Nov 15;74(10):1714-20. PMID: 17137000.
Lardenoye S, Theunissen E, Cleffken B, Brink PR, de Bie RA, Poeze M. The effect of taping versus semi-rigid bracing on patient outcome and satisfaction in ankle sprains: a prospective, randomized controlled trial. BMC Musculoskelet Disord. 2012;13:81.
Birrer RB, Fani-Salek MH, Totten VY, Herman LM, Polit V. Managing ankle injuries in the emergency department. J Emerg Med. 1999;17(4):651-660.
Expert Commentary
This is a great review of ankle sprain injuries. Ankle sprains are one of the most common musculoskeletal injuries to present to the Emergency Department. From an emergency perspective, these injuries do not often require extensive intervention and are usually treated as discussed above with PRICE therapy. However, there are some important pitfalls to mention in regard to more serious injuries that can often be missed. The ankle joint is complex. It has multiple directions of motion and receives and distributes a lot of force and weight. It is the connection point between the lower leg and the foot, with multiple muscles and tendons originating in the lower leg, passing through the ankle and attaching to insertions on the foot. As a result of this anatomy, it is essential to not only evaluate the ankle, but to also pay attention to the foot and lower leg when evaluating an ankle sprain.
As pointed out, the most important first step in evaluating an ankle injury is to assess for neurovascular compromise and deformity. Dislocations or fractures causing neurovascular compromise require immediate reduction. Next, identifying the amount of swelling and ecchymosis is important. The more swollen and ecchymotic the ankle is, the more likely there is to be a severe injury. Palpation of the ankle is essential to guide further workup. Examining and palpating the base of the 5th metatarsal is important to evaluate for potential fractures to that bone. In addition, palpation of the entire fibula is important as well. External rotation injuries of the ankle can lead to syndesmotic sprains and a fracture of the proximal fibula called a Maisonneuve fracture. This will not be readily apparent on isolated ankle radiographs. In addition, I have a low threshold to image ankle injuries. Often when patients are in acute pain, it can be difficult to narrow down areas of tenderness. In addition, these patients will get x-rays if they follow up in an orthopedic clinic regardless.
My treatment of ankle sprains involves protecting the ankle, usually with an ace wrap and a stirrup ankle brace. I will provide crutches for non-weight bearing for the first 24 hours, after which I encourage patients to weight bear as tolerated. I also give instructions on ankle exercises to be done at home to prevent stiffness. For severe swelling or for high ankle sprains (discussed in a separate blog post), I will place the patient in a high rise controlled ankle movement (CAM) walking boot. Intermittent ice application for the first forty-eight hours definitely helps with swelling and pain, as does elevating the ankle when sitting. Compression stockings can be used, but are often painful. Hence, I prefer using an ace wrap for localized compression. Avoiding activities more intense than walking can worsen the injury and delay healing, so I typically tell patients to avoid running and returning to sports for a week or until reassessed, depending on the extent of injury. Reevaluation after a week with a sports medicine or orthopedic provider is beneficial to assess for healing, determine if further imaging, such as an MRI, is required, and begin rehab therapy.
Jacob Stelter, MD CAQ-SM
Division of Emergency Medicine
NorthShore Orthopaedic Institute
NorthShore University HealthSystem
How To Cite This Post:
[Peer-Reviewed, Web Publication] Power, E. Cohen, B. (2021, Nov 8). Ankle Injuries. [NUEM Blog. Expert Commentary by Stelter, J]. Retrieved from http://www.nuemblog.com/blog/ankle-injuries.
