Assessment and Treatment of Ankle Injuries. Introduction. Ankle Function and Injuries. Kevin T. Collopy AEMT-P, WEMT Greg Friese MS, NREMT-B

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1 Assessment and Treatment of Ankle Injuries Kevin T. Collopy AEMT-P, WEMT Greg Friese MS, NREMT-B Introduction Ankle Function and Injuries 14.2 million ankle injuries per year 15% of injuries include fracture

2 Objectives Discuss the anatomy and function of the ankle joint and foot Review the kinematics and types of mechanism of injury Learn to perform and in-depth examination for ankle injury Apply appropriate treatments for an injured ankle Topographic Anatomy

3 Objective 1: Anatomy and Function Ankle & Foot Bones Ankle & Foot Bones

4 Ankle & Foot Tendons Tendons connect muscle to bone Ankle & Foot Ligaments Ligaments connect bone to bone Ankle & Foot Arteries Locate arteries to assess circulation Nerves follow arteries

5 Ankle Joint(s) Talar joint joins tibia, fibula, and talus Subtalar joint includes talus and connecting inferior bones Ankle Movements Joints allow movement Dorsiflexion Plantar Flexion Eversion rotation Inversion rotation Objective 2: Mechanism of Injury Picture has been

6 Mechanisms of Injury Slips and falls Athletic rotational trauma Blunt trauma Fall from a height Front impact collisions Mechanisms of Injury Ankle fractures Open Closed Metatarsal fractures Crush injuries Ligament tear from hyperextension Severity of Injury Grade 1 No instability Minimal swelling Mild pain and tenderness Able to bear weight Grade 2 Moderate instability Significant pain and tenderness Swelling and ecchymosis Difficulty bearing weight Grade 3 Significant instability Severe pain and tenderness Swelling and ecchymosis Unable to bear weight

7 Sprains & Strains Sprains ligament injuries Strains tendon injuries Causes Hyperextension Twisting Falls Pulling Dislocations Joint separation Complete tearing of several ligaments Bone displacement May involve fractures Caused by pulling, trauma, hyperinversion, hypereversion Serious threat to distal circulation, sensation, and movement (CSM) Objective 3: Injury Assessment Complete a thorough exam before treating the injured ankle

8 Patient History Mechanism of injury how, when, where Pain location Pertinent history Underlying cause Expose both lower legs Communicate with patient Gross deformity Swelling Physical Exam O-P-Q-R-S-T Pain assessment Physical Exam Skin color and condition Temperature Assess distal circulation Dorsalis pedis Posterior tibial

9 Physical Exam Neurological Function Movement Sensation Physical Exam Palpate from proximal to distal Begin just below the knee Examine for crepitus, instability, deformity, and tenderness

10 Physical Exam Squeeze medial and lateral malleoli together Push on Navicular and cubiod bone Squeeze the 1 st and 5 th metatarsal together Drawer Test Pull foot anteriorly Compare injured to uninjured Invert and evert to test stability Weight Bearing Positive Exam Findings Yes Injury Likely Immobilize and Transport No Able to Bear Weight Unable Able Significant Injury Unlikely

11 Complete Assessment SAMPLE history Complete vital signs Objective 4: Treatment Treatment Goals Stabilization Proper Positioning Immobilization Manage pain and swelling Transport Hand Stabilization Position hands above and below ankle Minimizes movement to: Reduce pain Prevent further injury

12 Dislocation and Deformity Long bones Realign Joints Reposition Reduce Normal Anatomical Position Improves circulation Reduces stress on tendons Never force the ankle if you meet resistance Dislocation Intact CSM? Yes No Attempt Repositioning Splint ankle in position found Resistance or increase in pain Restore CSM Splint in New Position

13 Field Dislocation Reduction Follow local protocols Delayed care or prolonged transport If allowed: Reduce sooner than later better Decreased pain and swelling Improves circulation Medication Sedatives Benzodiazepines Analgesics Dilaudid Morphine Ketorolac Field Dislocation Reduction Explain process and gain consent Position supine Flex knee at 90 O Patient supports leg

14 Field Dislocation Reduction Firmly hold ankle Pull in-line traction Rotate to anatomical position Reassess CSM Open Fractures Assess distal CSM Reposition if necessary Control bleeding as needed Open Fractures DO NOT force bones into skin OK if bones slide in during realignment Dress and immobilize

15 Immobilization Maintains anatomical position Secures the foot and lower leg Immobilization of knee unnecessary Splinting Comfortable Well padded Complete Structural support Appropriately sized Immobilizes long bone above and below Compact Appropriate bulk Splints

16 Splints Allows excessive foot movement No structural support and inhibit reassessment Splinting Measure for proper size Look for voids Fill voids Splinting Secure straps distal to proximal Do not strap directly over injury Snug fit

17 Splinting Recheck CSM Readjust splint as needed Manage Pain and Swelling Rest Ice Compress Elevate Non-pharmacological Pain Treatment Recognition and Empathy Distraction Muscle relaxation Position of comfort Padding Ambient Temperature

18 Pain Medication Analgesics Morphine Dilaudid (hydromorphone) Demerol (meperidine) Nubain (nalbuphine) Antiemetics Phenergan (promethazine hydrochloride) Transport

19 Summary Bones, tendons, and ligaments combine to provide ankle movement and stability Sprains, strains, fractures, and dislocations may occur in isolation but are more likely in combination with one another Proper examination is essential to proper treatment Ideal immobilization occurs with the ankle in anatomical position Credits Greg Friese is an EMT-Basic, Wilderness EMT, and search dog handler in Wisconsin. He is a lead instructor for Wilderness Medical Associates. Kevin Collopy is a paramedic and Wilderness EMT in upstate New York with Kunkel Ambulance Service and he is training officer for Southern Madison County Ambulance, Hamilton, New York. Images and Photos Emergency Preparedness Systems LLC EMS and Rescue Photography Collection Kevin Collopy, personal collection LifeART images copyright 2004 Lippincott Williams & Wilkins. All rights reserved. Narration by John A. Chamberlain, Jr. References Collopy, Michael M.D. Personal correspondence regarding ankle anatomy and physiology, and reduction of ankle dislocations. American Academy of Orthopedic surgeons. The Foot and Ankle. O Keefe, D., Nicholson, D.A., Driscoll, P.A., and Marsh, D. The Ankle. British Medical Journal. Jan 29, Vol 308 pp Ganley, Theodore J. M.D. Ankle injury in the young athlete: Fracture or sprain? The Journal of Musculoskeletal Medicine. June Vol 17 pp Larsen, Dorthe RGN. Assessment and management of foot and ankle fractures. Continuing Professional Development, Orthopedics. September Vol 17, pp37-46.