Makindo Medical Notes

Isolated lateral malleolar #: No talar shift and undisplaced

Inversion (common) or eversion (less Common) injury

Unstable if medial (deltoid) ligament complex disrupted. Document examination of medial malleolus and deltoid ligament.

1. Avulsion of the tip of the lateral malleolus – treat as sprain. Can try an Orthopaedic boot if needed for comfort.

2. Proximal Weber A or Weber B without talar shift or deltoid ligament rupture - Orthopaedic boot

3. Weber B or C with suspicion of deltoid ligament rupture – ensure adequate position in below knee backslab

1. Discharge with patient advice leaflet

2. Fracture clinic

3. Immediate referral to ortho

Medial malleolar # or talar shift with no # seen

Check for fibula head tenderness: may indicate # at this site – Maisonneuve #.

Reduce in ED as required, with adequate analgesia +/- sedation

Immediate referral to ortho  

Isolated lateral

malleolar # with talar shift

Inversion (common) or eversion (less Common) injury 

Talar shift indicates medial (deltoid) ligament is torn. Accurate reduction essential to ensure joint congruity and avoid post traumatic OA

Reduce in ED with adequate

analgesia +/- sedation. BK slab POP and split the cast to ensure position maintained. Ensure ankle is at 90^o flexion

Immediate referral to ortho after reduction. Refer to ED if unable to reduce in MIU/UCC

Bi/Tri malleolar # with displacement of talus.

A more severe variation of above leads to the medial malleolus being avulsed rather than ligament rupture.

May be difficult to reduce accurately by manipulation and usually require fixation

Manipulate initially to achieve improved position and, therefore, reduce swelling that can lead to a delay in surgery. BK slab POP and split the cast to ensure position maintained. Ensure ankle is at 90^o flexion

Immediate referral to ortho after reduction. Senior review if reduction difficult.

If fail to reduce despite good sedation & analgesia will need early operative reduction.

Avoid repeated attempts in ED.

Clinically dislocated ankle injury

Rare but significant forces involved and clinically unstable

May compromise neurovascular supply. Often tight white skin.

Record neurovascular status pre and post reduction. Manipulate before X-Ray to reduce pressure on skin and vessels. Full Below Knee POP and split the cast to ensure position maintained. Ensure ankle is at 90^o flexion

Immediate referral to ortho

Foot

Talus

Forced dorsiflexion. A, rare injury but most, often # is through the neck. Occ small flake # are seen without displacement

BK backslab for analgesia Flake # may be managed conservatively.

 Treat talar dome # with BKPOP slab, crutches and Fracture clinic follow up.

 Refer ortho if any concern, particularly if intra articular bone fragments- CT early

Sprain or rupture of lateral ligament complex

Severe adduction force causing inversion may sprain or, more rarely, completely rupture the lateral ligament complex. Pain and swelling are common with reduced ability to weight bear.

Use Ottawa ankle rules to assess need for X-Ray.

Greatest tenderness is often immediately below and anterior to the tip of the fibula. May be difficult to assess initially due to pain

Consider Orthopaedic boot for 5/7 in severe sprains.

Otherwise soft tissue management advice +/- crutches with appropriate advice sheet.

Next available ED physio appointment or referral to local physio via patient’s own GP

Rupture of Achilles tendon

Abrupt onset of severe posterior ankle pain. No movement on squeezing the calf. May be a palpable defect

May retain the ability to plantar flex foot but will have no movement on squeezing calf. Refer if in doubt

May be missed if calf squeeze not performed. 

Below Knee POP in full equinus.

In all patients under 55 years old and especially those active patients with physically demanding employment then discuss with on-call ortho team for consideration of percutaneous surgery. Otherwise Fracture clinic

Strained calf muscle

Similar to Achilles rupture –Achilles clinically intact

Document that Achilles tested and intact clinically

Rest, analgesia and advice that

will take several weeks to heal and bruising may be significant.

Discharge – consider ED physio clinic