Minor injuries – ankle injuries

This is part of a DFTB minor injuries series. Today’s post is about ankle injuries.

When should I x-ray an ankle?

The Ottawa ankle rules are a decision tool for x-ray in patients with an ankle injury.

If there is pain in either malleolar region, and one of the following then an x-ray is indicated:

  • Inability to bear weight (walk four steps) immediately after the injury and when examined.
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

The Ottawa ankle rules are very sensitive – so if your patient does not meet the criteria for x-ray, it is very unlikely that your patient has a fracture.

There is no evidence for CT or MRI in acute ankle sprain.

Can we use the Ottawa ankle rules in children?

The rules were originally validated in adults, but the analysis since shows that they can be used in children too. The introduction of the Ottawa ankle rules in one hospital in the UK reduced the number of x-rays ordered by 7% and showed no increase in the number of missed fractures.

It should be noted that these rules are meant to be applied to those patients who have the ability to walk prior to their injury, and can localise pain with verbal communication. For every 1000 patients that exhibit negative Ottawa ankle rules, 14 will actually have fractures.

What is a sprain?

A sprain is where you stretch or tear a ligament by applying abnormal force. Sprains usually occur in ankles, knees, wrists or thumbs.

Symptoms are usually pain, swelling, bruising, tenderness, difficulty using the joint functionally and even mechanical instability if severe.

Sprains can be classified according to severity:

  • Grade I – mild stretching of the ligament complex without joint instability.
  • Grade II – partial rupture of the ligament complex without joint instability.
  • Grade III – complete rupture of the ligament complex with instability of the joint.

How do we assess ankle stability?

There are two tests to assess this – the anterior drawer test and the talar tilt test.

Anterior drawer test: hold the leg with one hand and use the other hand on the back of the foot to gently pull it forward. If there is excessive forward movement of the foot then the test is positive.

Talar tilt test: hold the leg with one hand and use the other hand to hold the foot and gently invert it. If there is excessive tilting then the test is positive.

They are much more clearly explained in these videos:

How do we best manage a sprain?

Simple management includes analgesia, and PRICE (protect, rest, ice, compression, elevation).

  1. Protect from re-injury – this can include using a supportive shoe
  2. Rest the ankle for up to 72 hours
  3. Wrap some ice in a towel and hold it against the ankle for 15 mins every few hours for the first 72 hours
  4. Use a simple tubigrip or elasticated bandage (it helps with the swelling and offers support) but take it off at night
  5. Elevate the ankle on a pillow until the swelling settles

Do I immobilise it or encourage them to walk?

The patient should avoid heat, massage or running for the first 72 hours after the injury.

If the sprain is severe, then immobilising it for a short time can help their symptoms, but they need to be encouraged to begin mobilising after a day or two to avoid stiffness. If the sprain is mild then advise the patient not to immobilise the ankle. They should encourage gentle movement as soon as they can tolerate it.

What is the recovery time?

The usual recovery period, if the sprain is uncomplicated, is for the patient to be able to walk in 1-2 weeks, run in 6-8 weeks and return to their regular sporting activity in 8-12 weeks.

If in 7 days they still have difficulty walking or worsening symptoms, they should get a review.

CRACKCast E009 – Adult Resuscitation

This episode of CRACKCast cover’s Rosen’s Chapter 09, Adult Resuscitation. Here is some knowledge for the next time you are in the trauma bay with a patient with cardiac arrest. Shownotes – PDF Link Rosen’s in Perspective: Cardiac Arrest out of hospital cardiac arrests: 3-16% survival rates <1/3 are due to VF those who achieve ROSC have a 19-50% survival only 1/3 of those who survive to discharge return to near baseline pre-arrest ...

The post CRACKCast E009 – Adult Resuscitation appeared first on CanadiEM and was written by Chris Lipp.

Compartment Syndrome: UNDER PRESSURE

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Dr. David Forsh’s review yesterday of compartment syndrome made me realize how rarely we see this life-threatening diagnosis.

So what do we need to know?

What’s the etiology of compartment syndrome?

  • Majority cases 2/2 Fractures (75%); the rest are soft tissue injuries from causes such as: snake bites, seizures, burns, tourniquets,…
  • People with coagulopathy such as those on anticoagulation have a higher risk for compartment syndrome
  • The main fracture sites associated w/ compartment syndrome: (1) Tibia Fractures (diaphyseal region) (2) Distal Radius Fractures
  • May also see with open fractures!

Who/When do we usually see this in?

  • Young, Restless Men usually 2-4d after injury

How do patients present? Clinical diagnosis is hard because patients usually present with 1 of these signs and the rest when it is “too late”

  • 6ps: PAIN, Pallor, Pulselessness, Paresthesias, Paralysis, Perishingly cold/Pudgy calf
    • Pain is the earliest sign/ Pain w/ passive stretching/Pain out of proportion
    • Pudgy calf aka Swelling many patients will have swelling and a “tense” calf but this is not a very sensitive or specific clinical finding
    • Paresthesias in the legs may be seen initially around the 1st metatarsal dorsal webspace b/c that is where the deep peroneal n. ends and more susceptible to injury w/ swelling; 4hrs=damage; around 8-12hrs you see nerve damage
    • Pallor, Paralysis, Perishingly Cold, Pulselessness=BAD!

What ancillary tests do we use to diagnose this?

  • Stryker Needle to measure compartment pressure
  • Normal compartment pressure <10mmHg
  • >30-40mmHg may result in ischemic necrosis
  • Formula: ∆ pressure = diastolic blood pressure (DBP) — intracompartment pressure (ICP)
    • ∆P of ≤ 30 mmHg–>OR
  • You want to measure pressure in the anterior and posterior compartments (click link for Video)
  • Can also use A line setup, other methods…

Management

  • Remove all constrictive clothing or jewelry
  • elevate limb to level of heart
  • apply traction if indicated
  • Ideal time to fasciotomy: 6-12hrs approx 68% of patients will have good outcomes within this timeframe; outside this timeframe may not want to do fasciotomy based on risks/benefits (patient may have contracture w/o fasciotomy but they may have worse outcomes w/ fasciotomy)

Controversial Topics:

Do nerve blocks mask compartment syndrome? Dr. Forsh says “No!  Ischemic pain breaks through the nerve block and therefore you have a higher suspicion for compartment syndrome if patient is in pain. But don’t use dense blocks.”  What does the literature say? There is a mixed consensus with some studies finding possible delays in management of compartment syndrome 2/2 nerve block. Often these are nerve blocks that are too dense. Therefore if used there needs to be a thorough discussion with anesthesia about the type and amount of anesthetic used.

 

RECAP:

  • Look for compartment syndrome in patients with  fractures especially in the distal radius, diaphyseal of the tibia, or open fractures
  • Be weary of patients on anticoagulants as they are at increased risk for compartment syndrome 2/2 bleeding
  • Look for pain out of proportion, pain w/ passive stretching, parethesias in the 1st metatarsal dorsal webspace, all other signs late…
  •  Stryker measurement of pressure: DBP — ICP=∆ pressure <30mmHg–>Needs OR
  • Remove constrictive clothing/jewelry, elevate limb, GET PATIENT TO OR!

 

 

 

Sources:

  • Dr. David Forsh Orthopedic Emergencies Lecture at Sinai 10/12/2016.
  • McQueen, M. & Duckworth, AD. Diagnosis of Acute Compartment Syndrome. http://www.boneandjoint.org.uk/content/diagnosis-acute-compartment-syndrome
  • Compartment Syndrome. http://lifeinthefastlane.com/ortho-library/compartment-syndrome/
  • Inaba,K. & Swadron, S. Compartment Syndrome. Nov 2011. https://www.emrap.org/episode/november2011/compartment?link=episode-guide
  • Garner, M. R., Taylor, S. A., Gausden, E., & Lyden, J. P. (2014). Compartment syndrome: diagnosis, management, and unique concerns in the twenty-first century. HSS Journal®, 10(2), 143-152.

An NSAID for Your Broken Bone?

Case:  A 24 year old male with no past medical history presents with a closed distal radius and ulna fracture after a cycling accident.  After closed reduction and splinting, his pain is much improved.  You tell him that he will be discharged with oxycodone for pain as needed, but he asks if he can just take ibuprofen because oxycodone and other opioids make him sleepy, and he needs to return to work tomorrow.  

Clinical Question: Should patients with acute fractures avoid NSAIDs?

Extremity fractures are relatively common presentations in the ED. Recent literature from the orthopedic world has suggested that usage of NSAIDs (non-steroidal anti-inflammatory drugs) in the setting of acute fractures hinders the healing process and leads to worse outcomes.  Given that we often try to provide non-narcotic methods to control pain in the ED, removing a whole class of drugs like NSAIDs should not be done without strong evidence that they result in poorer outcomes for patients. 

A paper published in the Journal of Bone and Mineral Research in 2002 treated rats with a COX-2 (cyclo-oxygenase 2) selective NSAID, then studied signs of healing based on radiologic, histologic, and mechanical measures.  The authors showed that endochondral ossification was markedly deficient in both rats treated with a COX-2 inhibitor, suggesting that pro-inflammatory prostaglandins (suppressed by COX-2 inhibitors) are necessary for normal fracture healing.  Similarly, fracture healing is impaired in mice that have a mutation in the COX-2 gene [1].  A recent systematic review of the existing data published in the Journal of Bone and Joint Surgery in 2012 found similar results.  This review included 316 relevant papers, and concluded that the preponderance of evidence showed that inhibiting COX-2 disrupted early fracture healing in multiple animal models, although in vivo studies in humans have not yet substantiated this finding.  A limitation of the review was that the majority of the studies were small and of variable quality with numerous potentially confounding variables. Nevertheless, the authors concede that a short term course of NSAIDs in the setting of acute fracture is likely safe and may not impede healing to a significant degree [2]. Larger and more robust human studies are needed to better delineate the effects of NSAIDs on fracture healing and patient-oriented outcomes, but a single dose of NSAIDs may be acceptable in patients who should avoid opioid analgesics. 

Submitted by Jarrod Dornfeld, PGY-2

Edited by Phil Chan (@PhilChanEM), PGY-4

Faculty Reviewed by Albert Kim, MD, MACM

 

References

[1] Simon AM, Manigrasso MB, O'Connor JP. Cyclo-Oxygenase 2 Function Is Essential for Bone Fracture Healing. J Bone Mineral Research. 2002;17(6):963-976.

[2] Kurmis AP, Kurmis TP, O’Brien JX, Dalén T. The Effect of Nonsteroidal Anti-inflammatory Drug Administration on Acute-Phase Fracture Healing: A Review. J Bone Joint Surg. 2012;94(9): 815-823