Ep 105 Commonly Missed Ankle Injuries

This is EM Cases Episode 105 Commonly Missed Ankle Injuries. You probably can't remember the last time you worked a shift in the ED and didn’t see at least one patient with an ankle injury. While almost all of these patients are relatively straightforward to diagnose and manage a small but significant minority of these patients will have a more elusive diagnosis, that if not identified early, could lead to significant morbidity. On the flip side, if we’re super conservative and defensive and we immobilize everyone with an ankle injury no matter how minor we’re not doing our patients or our consultants any favors either. With the help of Canada’s leading ED-ortho educator Arun Sayal, the brains behind The CASTED Course, and Hossein Mehdian, an Orthopedic surgeon at North York General, we cover a general way of thinking about ankle injuries, the limitations of the Ottawa Ankle Rules, a simplified approach to the ankle x-ray, the importance of identifying an external rotation mechanism of injury and much more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Shaun Mehta, edited by Anton Helman January, 2018 Cite this podcast as: Helman, A, Sayal, A, Mehdian, H. Commonly Missed Ankle Injuries. Emergency Medicine Cases. January, 2018. https://emergencymedicinecases.com/commonly-missed-ankle-injuries/. Accessed [date]. Don't short change the history and physical for ankle injuries! We would not short change a patient with chest pain by taking a poor history. The same should apply to ankle injuries. It is best that we see and examine our patients first and then look for pathology on the x-ray, rather than the other way round, as often happens on busy shifts. Here are some useful pearls for the H&P to help distinguish the simple lateral ankle sprain or fracture from a more sinister injury. History The key here is mechanism, mechanism, mechanism. * What was the direction of force applied? * What was the height of the fall? * What was the direction the foot turned? * What happened afterward (i.e. weight bearing status)? There are also certain red flags for serious injuries not to be missed: * The patient reports an external rotation mechanism – consider this the “thunderclap headache" or “chest pain radiating to the back” of the ankle. * The patient is not weight bearing at all. Don’t forget the PMHx here. * Has the ankle been injured before? * What is the functional status of the unaffected limb? * Are there any sensory deficits from diabetes, recent back surgery or chronic alcoholism? External rotation mechanism of ankle injuries should be considered a red flag as the "thunderclap" headache is for subarachnoid hemorrhage.    Physical Do not limit your assessment to where the Ottawa Ankle rules guide you. Pitfall: Using the Ottawa Ankle Rules to guide your physical exam of a patient with an ankle injury. A few key physical exam maneuvers to do on all patients with ankle injuries: * Remember the ankle exam starts at the knee. Work your way down the entire fibula looking for tenderness. However, don’t be satisfied that the absence of tenderness there rules a Maisonneuve or Dupuytren's fracture. * Palpate the anterior aspect of ankle joint for clues of a syndesmosis injury or talus fracture * Squeeze proximal to the ankle joint looking for pain at the syndesmosis indicative of a syndesmosis injury Pearl: Ischemia as a result of an isolated ankle fracture is very rare.