Ankle Sprains and Their Imitators

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1 Ankle Sprains and Their Imitators Mark Halstead, MD Dr. Mark Halstead is the Associate Professor of the Departments of Orthopedics and Pediatrics at Washington University School of Medicine; Director of the Sports Concussion Clinic, and Medical Director at the. Dr. Halstead received his medical degree from the University of Wisconsin Medical School in After completing a residency and chief residency in pediatrics at the University of Wisconsin Children s Hospital, he completed a primary care adult and pediatric sports medicine fellowship at Vanderbilt University in Nashville, Tennessee. He currently serves as team physician for the St Louis Blues, Washington University and several local high schools and is a former team physician for the St Louis Rams. Dr. Halstead has been listed as Best Doctor in America since 2007 (Best Doctors, Inc.). Dr. Halstead has served as an elected member of the American Academy of Pediatrics (AAP) Executive Committee for the Council on Sports Medicine and Fitness as well as the Board of Directors of the American Medical Society for Sports Medicine (AMSSM). He also serves as a member of the advisory committee for the Missouri State High School Athletic Association (MSHSAA). Disclosures: None

2 Pediatric Ankle Sprains and its Imitators Mark Halstead, MD, FAAP Associate Professor, Depts. of Pediatrics and Orthopedics Washington University Sports Medicine --St Louis, MO Medical Director, Objectives Utilize objective criteria to determine the need for ankle imaging following an ankle injury Recognize common physeal ankle injuries unique to the adolescent athlete Select appropriate treatment options for pediatric ankle injuries 1

3 Epidemiology 50% of all ankle sprains are sports related Basketball 41% Football 9% Soccer 8% Peak age males females Anatomy Ankle is a hinge joint Primarily moves in dorsi- & plantar flexion Side to side movement is subtalar joint Bones : Tibia, Fibula, Talus Ligaments : ATFL, CFL, PTFL, AiTFL, Deltoid Syndesmosis Tendons: Peroneal, Posterior Tibialis and Achilles, FHL, FDL, Anterior Tibialis 2

4 Anatomy Anatomy 3

5 Anatomy Anatomy 4

6 Anatomy Physical Exam Inspection Weight bearing Swelling Bruising Crutches Braces Deformity 5

7 Physical Exam Range of Motion Dorsiflexion Plantarflexion Inversion Eversion Resisted Stength Same as ROM testing Physical Exam Palpation Bones (Ankle and Midfoot) Ligaments Tendons Ankle joint 6

8 Physical Exam Special Tests Anterior Drawer Physical Exam Special Tests Squeeze Test External Rotation Stress 7

9 Imaging Vast majority of ankle injuries will only need X- rays, at the most for evaluation. Standard Ankle series AP Lateral Mortise Imaging 8

$9-50% specifity Estimated missed fracture rate 1.22% 5.4-43.$

10 Imaging Ottawa Ankle Rules Originally validated in Adults Validated down to age % sensitivity % specifity Estimated missed fracture rate 1.22% % reduction in ankle radiographs if used Imaging 9

$Mechanisms Salter Harris I fractures Mistaken often for an ankle sprain Mechanism similar (inversion) Pain localized over lateral$

11 Mechanisms Salter Harris I fractures Mistaken often for an ankle sprain Mechanism similar (inversion) Pain localized over lateral malleolus Level of physis Majority of swelling concentrated over lateral malleolus Clinical exam is often key Xrays frequently read as normal 10

$I fractures$

12 Salter Harris Fractures Salter Harris I fractures 11

$Salter Harris I fractures Treatment Walking boot for 3 weeks If pain free at 3 weeks, transition to walking Return to sports at 4 weeks if does well Ice initially Work on range of motion exercises$

13 Salter Harris I fractures Treatment Walking boot for 3 weeks If pain free at 3 weeks, transition to walking Return to sports at 4 weeks if does well Ice initially Work on range of motion exercises Tylenol for pain Juvenille Tillaux fracture Unique fracture to adolescent population Often occurs age as one nears skeletal maturity Salter Harris III type fracture Occurs from eversion mechanism 12

$Juvenille Tillaux fracture Juvenille Tillaux fracture Typically will get$ Need for reduction Refer to Ortho Otherwise non weight bearing cast

Need for reduction Refer to Ortho Otherwise non weight bearing cast

14 Juvenille Tillaux fracture Juvenille Tillaux fracture Typically will get CT scan Looking for displacement in the joint. >2 mm displacement? Need for reduction Refer to Ortho Otherwise non weight bearing cast followed by boot Total immobilization for 6-8 weeks Probable need for physical therapy 13

$Triplane Fracture Salter Harris IV type fracture Also tend to occur age 12-15, when reaching skeletal maturity External$

15 Triplane Fracture Salter Harris IV type fracture Also tend to occur age 12-15, when reaching skeletal maturity External rotation force to foot Will look similar on AP but will note the SH IV component on lateral Refer to ortho Triplane Fracture 14

16 Triplane Fracture Triplane Fracture May need surgical reduction Often needs CT for extent of displacement If non surgical, will be 6 weeks non weight bearing and then transition to boot and physical therapy 15

$Lateral Ankle Sprain Most common injury in sports 85-90% of ankle injuries are inversion mechanism Greatest injury to ATFL May or may not felt/heard a pop May be associated with avulsion fracture of$

17 Lateral Ankle Sprain Most common injury in sports 85-90% of ankle injuries are inversion mechanism Greatest injury to ATFL May or may not felt/heard a pop May be associated with avulsion fracture of lateral malleolus or lateral talus Lateral Ankle Sprain Grading of sprains Grade I Ligament mildly stretched, no gross tearing, no laxity Grade II Partial tearing with some laxity Grade III -- completely torn, gross laxity 16

18 Lateral Ankle Sprain Treatment options Crutches Boot Cast? Lace Up Ankle Brace Aircast? Early range of motions Ice NSAIDs or Tylenol both found equally effective for pain Not used for reducing swelling Return to activity when pain free heel-to-toe walking and able to do 10 single leg hops on affected side without pain Deltoid (Medial) Sprain Eversion mechanism Not as common as lateral sprain Can take longer time to recover, often 3-6 weeks Concern if injury produces medial AND lateral pain Evaluate for widening of ankle mortise 17

19 Deltoid (Medial) Sprain Deltoid (Medial) Sprain Treatment Immobilization (Cast or Walking Boot) Physical Therapy Expectations for longer recovery 18

$+/- posterior) Can affect syndesmosis Concern for Maisonneuve fracture (proximal fibula) Expectation for much longer recovery Can be 6-8 weeks High Ankle Sprain$

20 High Ankle Sprain Less common but more severe injury Ankle with excessive external rotation while foot is dorsiflexed Affects Tibiofibular ligament (anterior +/- posterior) Can affect syndesmosis Concern for Maisonneuve fracture (proximal fibula) Expectation for much longer recovery Can be 6-8 weeks High Ankle Sprain 19

21 High Ankle Sprain Treatment Immobilization Refer to Ortho In some cases surgery is required (unstable ankle) Osteochondral Defect of Talus May be a result of trauma or possibly overuse Pain usually along anterior or posterior ankle joint Pain with activity May get painful popping or catching in the joint Refer to ortho May require surgical management 20

Peroneus brevis pulls on the base of the fifth

22 Osteochondral Defect of Talus Avulsion Fracture of 5 th Metatarsal Inversion mechanism of ankle Peroneus brevis pulls on the base of the fifth metatarsal Most common misdiagnosed foot fracture 21

23 Avulsion Fracture of 5 th Metatarsal Avulsion Fracture of 5 th Metatarsal 22

24 Avulsion Fracture of 5 th Metatarsal Treatment Boot for approximately 4-6 weeks May do ok with post operative shoe Thank You! QUESTIONS? mehalstead@wustl.edu 23

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Ankle Injuries Outline Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Anatomy: Ankle Mortise Bony Anatomy Lateral Ligament Complex Medial Ligament Complex Ankle Sprains