How to Manage Ankle Trauma without Evident X-ray Signs

Numa Mercier, Dominique Saragaglia
European Musculoskeletal Review, 2011;6(3):195-200
pdf icon download pdf ejournal view ejournal

Abstract

The ankle is one of the most common sites of acute musculoskeletal injuries, and sprains account for 75 % of ankle injuries. The lateral stabilising ligaments are most often damaged. However, other ligamentous lesions of the polyarticular complex of the ankle should not be ignored. One should not forget misdiagnosed fractures that can mimic ankle sprains. The aim of this article is to provide a medical procedure for the best management of ankle trauma without evident X-ray signs and to present all the diagnoses that can be ignored if the practitioner is not aware of their existence.
Keywords
Ankle sprain, syndesmotic sprain, deltoid ligament, mid-foot sprain, talus fracture, calcaneus fracture, ankle radiography
Disclosure The authors have no conflicts of interest to declare.
Received: May 30, 2011 Accepted August 03, 2011
Correspondence: Dominique Saragaglia, Department of Orthopaedic Surgery and Sport Traumatology, Grenoble South Teaching Hospital, 38130 Échirolles, France. E: DSaragaglia@chu-grenoble.fr

The ankle is one of the most common sites of acute musculoskeletal injuries, and sprains account for 75 % of ankle injuries.1 Ankle injuries are among the most common injuries that occur in athletes. The severity and degree of these injuries vary greatly owing to the complexity of the ankle and surrounding structures.

Some authors use the Ottawa rules2 in order to determine when radiographic studies are indicated. But we do not agree for many reasons: firstly, physical examination is not thorough in accident and emergency departments; secondly, pain is subjective and very difficult to quantify; thirdly, the cost of ankle X-rays is very low compared with the cost due to a mistake; lastly, X-rays have a legal validity in some pathologies, such as osteochondral defect and posterior ankle impingement syndrome.

Physical examination is a key element of the diagnosis. However, clinical evaluation of the ankle is not easy. Fortunately, the more practical experience one has, the more one finds injuries. Capsuloligamentous damage of the lateral compartment is one of the determining elements in ankle sprains. In addition, other ligamentous lesions of the polyarticular complex of the ankle should not be ignored. Obviously, one should not forget misdiagnosed fractures that can mimic ankle sprains.

The aim of this article is to provide a medical procedure for the best management of ankle trauma without evident X-ray signs and to present all the diagnoses which can be ignored if the practitioner is not aware of their existence.3

Clinical Practice

Are X-rays Really Negative?

As in most acute injuries, plain radiographs are important to obtain different planes of the ankle. The first step, in accident and emergency, is to pay attention to X-ray quality. Some X-rays are too ‘black’ or too ‘white’. Good contrast may help the practitioner detect some fractures. Second, one should be careful about ‘too perfect’ anteroposterior (AP) and lateral X-rays. Third, even if the X-rays are badly realised, like a lateral view, this may reveal a fracture of the posterior or lateral malleolus. Finally, the most important thing is to turn the ankle round in order to make the exact diagnosis, and to look at the X-rays one more time if necessary.

Precise Clinical Examination

Questioning

Ankle trauma is the result of a traumatic event that is important to detail: direct trauma, equinovalgus, valgus force, equinus force, talus or valgus on the ankle. Some of the most common symptoms of ankle trauma include sudden pain in the heel and inability to bear weight on that foot.

Observation

Observation of the entire foot is crucial to look for deformity, oedema and ecchymosis.

References:
  1. Barker HB, Beynnon BD, Renstron PA, Ankle injury risk factors in sports, Sports Med, 1997;23:69–74.
  2. Stiell IG, Implementation of the Ottawa ankle rules, JAMA, 1994;271:827–32.
  3. Saragaglia D, Traumatologie à l’usage de l’urgentiste, Montpellier: Sauramps Medical, 2004.
  4. Besse JL, Traitement des entorses graves et des instabilités chroniques de la cheville. In: Cartier P, Epinette JA, Deschamps G, Hernigou P (eds), Cahiers d’enseignement de la SOFCOT, Paris: Expansion scientifique française, 1997;187–217.
  5. Frost SC, Amendola A, Is stress radiography necessary in the diagnosis of acute or chronic ankle instability?, Clin J Sport Med, 1999;9:40–5.
  6. Tourné Y, Corral L, Fornasieri C, et al., [Orthopedic treatment of severe ankle sprains: A continuous series of 90 cases], Journal de Traumatologie du Sport, 1999;16:81–8.
  7. D’Erme M, Lesions of the collateral ligaments of the ankle: diagnosis and follow-up with magnetic resonance and ultrasonography, Radiol Med, 1996;91:705–9.
  8. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH, Syndesmosis sprains of the ankle, Foot Ankle, 1990;10:325–30.
  9. Katznelson A, Lin E, Militiano J, Ruptures of the ligaments about the tibio-fibular syndesmosis, Injury, 1983;15:170–2.
  10. Dattani R, Patnaik S, Kantak A, et al., Injuries to the tibiofibular syndesmosis, J Bone Joint Surg Br, 2008;90:405–10.
  11. Horisberger M, Valderrabano V, Hintermann B, Posttraumatic ankle osteoarthritis after ankle-related fractures, J Orthop Trauma, 2009;23(1):60–7.
  12. Thompson MC, Mormino MA, Injury to the Tarsometatarsal Joint Complex, J Am Acad Orthop Surg, 2003;11:260–7.
  13. Myerson MS, Cerrato RA, Current management of tarsometatarsal injuries in the athlete, J Bone Joint Surg Am, 2008;90(11):2522–33.
  14. Arrowsmith SR, Fleming LL, Allman FL, Traumatic dislocation of the peroneal tendons, Am J Sports Med, 1983;11:142–6.
  15. Tourné Y, Saragaglia D, De Souza B, et al., Traumatic dislocation of the peroneal tendons : A lesion in downhill skiers. A study of 36 cases, Foot Ankle Surg, 1996;2:243–53.
  16. Tourné Y, Saragaglia D, Chaussard C, et al., Surgical Techniques in Orthopaedics and Traumatology, Paris: Éditions Scientifiques et Médicales Elsevier, 2000;4.
  17. Gluck GS, Heckman DS, Parekh SG, Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon, Am J Sports Med, 2010;38(10):2133–44.
  18. Frenkel SR, Di Cesare PE, Degradation and repair of articular cartilage, Front Biosci, 1999;4:671–85.
  19. Berkowitz MJ, Kim DH, Process and tubercle fractures of the hindfoot, J Am Acad Orthop Surg, 2005;13(8):492–502.
  20. McCrory P, Bladin C, Fractures of the lateral process of the talus: a clinical review. “Snowboarder’s ankle”, Clin J Sport Med, 1996;6:124–8.
  21. Della Rocca GJ, Nork SE, Barei DP, et al., Fractures of the sustentaculum tali: injury characteristics and surgical technique for reduction, Foot Ankle Int, 2009;30(11):1037–41.
  22. Torg JS, Pavlov H, Cooley LH, et al., Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases, J Bone Joint Surg Am, 1982;64:700–12.
  23. Fitch KD, Blackwell JB, Gilmour WN, Operation for non-union of stress fracture of the tarsal navicular, J Bone Joint Surg Br, 1989;71:105–10.
  24. Ugolini PA, Raikin SM, The accessory navicular, Foot Ankle Clin, 2004;9(1):165–80.
close

This content is copyright protected

However, if you would like to share the information on this webpage, you may use the headline and link below:

How to Manage Ankle Trauma without Evident X-ray Signs

Read more: How to Manage Ankle Trauma without Evident X-ray Signs