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Ligament and Tendon Injuries
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Tendon injuries typically result from either hyperdorsiflexion, when the peroneal tendon is injured, or sudden plantarflexion, which results in an Achilles tendon injury. Patients with an Achilles tendon rupture have severe pain and are unable to walk on their toes, run, or climb stairs. Ligamentous sprains tend to result from inversion and eversion injuries. The most common ankle sprain involves the anterior talofibular ligament. An isolated sprain of the medial deltoid ligament is rare, and an associated fibular fracture (Maisonneuve fracture) or syndesmotic ligament injury may be present. Any injury with signs of neurovascular compromise requires immediate attention.
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Diagnosis and Differential
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Evaluate the ankle along with the joints above and below the injury. A positive Thompson test (with the patient lying prone and knee flexed at 90°, the foot fails to plantarflex when the calf is squeezed) is diagnostic of Achilles tendon rupture. Palpate the proximal fibula for tenderness resulting from a fracture or fibulotibialis ligament tear. Squeeze the fibula toward the tibia to evaluate for syndesmotic ligament injury. If tenderness is isolated to the posterior aspect of the lateral malleolus, then a peroneal tendon subluxation may be present.
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The Ottawa Ankle Rules guide clinicians in determining when imaging studies are needed for suspected ankle injuries (Fig. 175-1).
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Joint stability is the primary determinant of a treatment plan for a sprain. Instability is suspected based on physical examination and radiography. The examiner may perform the anterior drawer and talar tilt tests to assess stability. If the examiner is unable to perform reliable stress testing, the injury is considered potentially unstable. Any asymmetry in the gap between the talar dome and the malleoli on the talus x-ray view suggests joint instability.
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Emergency Department Care and Disposition
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If the patient has a stable joint and is able to bear weight, then protection (with an elastic bandage or ankle brace), rest, ice, compression, and elevation (PRICE) for up to 72 hours is indicated. Prescribe analgesics, and add motion and strength exercises within 48 to 72 hours. The patient should follow-up in 1 week if the pain persists.
A patient with a stable joint who is unable to bear weight requires an ankle brace and orthopedic follow-up.
A patient with an unstable joint requires a posterior splint and referral to an orthopedist for definitive care.
Treatment of Achilles tendon rupture includes splinting in plantar flexion, nonweightbearing, and referral to an orthopedist for possible operative repair.
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Posterior dislocations are the most common ankle dislocation and occur with a backward force on the plantarflexed foot, usually resulting in rupture of the tibiofibular ligaments or a lateral malleolus fracture. Reduce ankle dislocations immediately if vascular compromise (absent pulses, a dusky foot, or skin tenting) is present. Grasp the heel and foot and apply downward traction, with analgesia and sedation as needed. Following successful reduction, apply a splint, assess postreduction neurovascular status, obtain postreduction radiographs, and consult orthopedics immediately.
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Ankle fractures are classified as unimalleolar, bimalleolar, and trimalleolar. Bi- and trimalleolar fractures require open reduction and internal fixation (ORIF) by the orthopedist. ED care includes posterior splinting, elevation, ice application, and orthopedic consultation. Treat unimalleolar fractures with nonweight bearing and posterior splinting. Manage minimally displaced avulsion factures of the fibula like ankle sprains. Ankle fractures can be occult and associated with other parts of the lower extremity (Table 175-1). Patients with open fractures require wet sterile dressing, splinting, tetanus toxoid as necessary, a first generation cephalosporin (eg, cefazolin 1 gram IV), and immediate orthopedic consultation.
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