Makindo Medical Notes"One small step for man, one large step for makindo" |
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Re-Xray all displaced # after POP to check position NICE advise fixation within 24-36 hours so discuss all ankle fractures with T&O for early admission if surgery needed
INJURY SITE | TYPICAL MECHANISM | PITFALLS/COMPLICATIONS | ED/ MIU/ UCC TREATMENT | FOLLOW-UP |
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Isolated lateral malleolar #: No talar shift and undisplaced |
Inversion (common) or eversion (less Common) injury |
Unstable if medial (deltoid) ligament complex disrupted. Document examination of medial malleolus and deltoid ligament. |
1. Avulsion of the tip of the lateral malleolus – treat as sprain. Can try an Orthopaedic boot if needed for comfort. 2. Proximal Weber A or Weber B without talar shift or deltoid ligament rupture - Orthopaedic boot 3. Weber B or C with suspicion of deltoid ligament rupture – ensure adequate position in below knee backslab |
1. Discharge with patient advice leaflet 2. Fracture clinic 3. Immediate referral to ortho |
Medial malleolar # or talar shift with no # seen |
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Check for fibula head tenderness: may indicate # at this site – Maisonneuve #. |
Reduce in ED as required, with adequate analgesia +/- sedation |
Immediate referral to ortho |
Isolated lateral malleolar # with talar shift
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Inversion (common) or eversion (less Common) injury |
Talar shift indicates medial (deltoid) ligament is torn. Accurate reduction essential to ensure joint congruity and avoid post traumatic OA |
Reduce in ED with adequate analgesia +/- sedation. BK slab POP and split the cast to ensure position maintained. Ensure ankle is at 90o flexion |
Immediate referral to ortho after reduction. Refer to ED if unable to reduce in MIU/UCC |
Bi/Tri malleolar # with displacement of talus.
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A more severe variation of above leads to the medial malleolus being avulsed rather than ligament rupture. |
May be difficult to reduce accurately by manipulation and usually require fixation
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Manipulate initially to achieve improved position and, therefore, reduce swelling that can lead to a delay in surgery. BK slab POP and split the cast to ensure position maintained. Ensure ankle is at 90o flexion |
Immediate referral to ortho after reduction. Senior review if reduction difficult. If fail to reduce despite good sedation & analgesia will need early operative reduction. Avoid repeated attempts in ED. |
Clinically dislocated ankle injury
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Rare but significant forces involved and clinically unstable |
May compromise neurovascular supply. Often tight white skin. |
Record neurovascular status pre and post reduction. Manipulate before X-Ray to reduce pressure on skin and vessels. Full Below Knee POP and split the cast to ensure position maintained. Ensure ankle is at 90o flexion |
Immediate referral to ortho |
Foot Talus |
Forced dorsiflexion. A, rare injury but most, often # is through the neck. Occ small flake # are seen without displacement |
BK backslab for analgesia Flake # may be managed conservatively. |
Treat talar dome # with BKPOP slab, crutches and Fracture clinic follow up. |
Refer ortho if any concern, particularly if intra articular bone fragments- CT early |
INJURY SITE | TYPICAL MECHANISM | PITFALLS/COMPLICATIONS | ED/ MIU/ UCC TREATMENT | FOLLOW-UP |
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Sprain or rupture of lateral ligament complex |
Severe adduction force causing inversion may sprain or, more rarely, completely rupture the lateral ligament complex. Pain and swelling are common with reduced ability to weight bear. |
Use Ottawa ankle rules to assess need for X-Ray. Greatest tenderness is often immediately below and anterior to the tip of the fibula. May be difficult to assess initially due to pain |
Consider Orthopaedic boot for 5/7 in severe sprains. Otherwise soft tissue management advice +/- crutches with appropriate advice sheet. |
Next available ED physio appointment or referral to local physio via patient’s own GP |
Rupture of Achilles tendon
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Abrupt onset of severe posterior ankle pain. No movement on squeezing the calf. May be a palpable defect
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May retain the ability to plantar flex foot but will have no movement on squeezing calf. Refer if in doubt May be missed if calf squeeze not performed. |
Below Knee POP in full equinus.
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In all patients under 55 years old and especially those active patients with physically demanding employment then discuss with on-call ortho team for consideration of percutaneous surgery. Otherwise Fracture clinic |
Strained calf muscle |
Similar to Achilles rupture –Achilles clinically intact |
Document that Achilles tested and intact clinically |
Rest, analgesia and advice that will take several weeks to heal and bruising may be significant. |
Discharge – consider ED physio clinic |