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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 276: Ankle Injuries Daniel A. Handel; Sarah Andrus Gaines

INTRODUCTION AND EPIDEMIOLOGY

Given the mobility of the ankle joint and our bipedal existence, ankle injuries are a common complaint. They

represent 14.6% of all visits to the ED.1 Fractures of the lateral malleolus are more prevalent in men younger

than 50 years old and in women older than 50 years old.2,3 Previous ankle sprain and participation in sports

like soccer, basketball, rugby, and football are risk factors for ankle injuries.4,5,6,7 A review of the NationalElectronic Injury Surveillance System in 2009 reported an incidence of ankle sprains of 206 per 100,000

people in the United States.8

ANATOMY

The proximal part of the ankle mortise is comprised of the distal fibula and tibia that fits on top of the talus.These bones are wider anteriorly than posteriorly. Joint stability is provided by medial and lateral malleoliextending on either side of the talus. The medial deltoid ligament, lateral ligament complex, and

syndesmosis are the three distinct groups of ligaments that stabilize the ankle9 (Figure 276-1). The deltoidligament is the strongest of these ligaments and is a thick, triangular band of tissue originating from themedial malleolus. The lateral ligament complex consists of the lateral malleolus that attaches to the anteriorand posterior aspects of the talus and calcaneus by the anterior talofibular, posterior talofibular, andcalcaneofibular ligaments, respectively. This ligament complex, the anterior talofibular ligament inparticular, is the weakest and most commonly injured in lateral sprains and represents 85% of all ankle

sprains.10 The syndesmosis, which holds the tibia and fibula together, is a group of four distinct ligamentsattaching the distal tibia to the fibula just above the talus (Figure 276-1). The syndesmosis allows the fibula to

rotate and carries approximately 16% of the axial load.9

FIGURE 276-1.

Ligaments of the ankle joint. A. The three lateral ligaments: the anterior and posterior talofibular ligamentsand the calcaneofibular ligament. B. The four bands of the deltoid ligament: the anterior and posteriortibiotalar, the tibiocalcaneal, and the tibionavicular. C. Anterior and posterior view of the ankle syndesmosis.The ligaments of the syndesmosis are the anterior inferior tibiofibular ligament, the posterior inferiortibiofibular ligament, the transverse ligament, and the interosseous ligament, which connects the entirelength of the tibia and fibula.

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The ankle is considered a hinged joint, but ligamentous attachments allow for some rotation and translation

within the mortise of the talar dome.9 Branches of the sciatic nerve, the superficial peroneal, deep peroneal,peroneal, and tibial, innervate the four muscle groups of the ankle joint with branches of the popliteal artery

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serving as the blood supply (Figure 276-2). The tibialis anterior, extensor digitorum longus, and extensorhallucis longus muscles run over the anterior aspect of the joint and are responsible for dorsiflexion.Inversion is accomplished by the tibialis posterior, flexor digitorum longus, and flexor hallucis longus. Theperoneus longus and brevis muscles, sharing a common synovial sheath held in place by a groove on theposterior aspect of the lateral malleolus and superior retinaculum, run laterally to evert and plantarflex thejoint. Plantarflexion is primarily accomplished by the gastrocnemius and soleus muscles.

FIGURE 276-2.

Neurovascular anatomy of ankle.

CLINICAL FEATURES

HISTORY

Understanding the mechanism and timing of the injury is important. Document these details along with anyprevious bony or so� tissue injuries. Patients with signs of neurovascular compromise, including coldnessand numbness of the foot, a rapid onset of swelling, extreme pain, and complicating conditions such as

diabetes, require urgent evaluation.5 A normal-appearing ankle does not preclude the need for furtherinquiry. Due to the significant swelling typically present a�er acute injuries, examining the ankle is

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challenging but can be helped by elevation of the injured extremity and ice applied at triage. Peroneal

spasms may mask any instability in the joint.9

PHYSICAL EXAMINATION

Place the patient on a stretcher to perform a thorough evaluation. A systemic approach to the examinationdecreases the chance of missed injuries. Starting with the skin and so� tissues, note any ecchymosis,abrasions, or swelling. Note the position, swelling, and skin integrity of the joint as well as any areas oftenderness or crepitus. Joints above and below the ankle need to be examined for any concomitant injuries.Suspect a Maisonneuve fracture (or fibulotibialis ligament tear) if there is tenderness of the fibular head orproximal fibular sha�. Palpate the area of obvious injury last. Test the functionality of the joint with bothactive and passive plantarflexion, dorsiflexion, and full range-of-motion exercises. Peroneal tendon injuriescan occur from forced dorsiflexion, which presents as weakness on eversion (Figure 276-3). Check stability inexternal rotation, varus, and valgus. Palpate the posterior aspects of the lateral and medial malleoli, startingproximally to the joint and working distally. If there is a concern for isolated fibular fractures, check for

evidence of injury to the syndesmosis or deltoid ligament.9 A positive anterior drawer test (Figure 276-4) isindicative of a torn anterior talofibular ligament. A positive anterior drawer test, swelling, and a hematomaare signs of a grade III sprain. Syndesmosis injuries can be deceiving because the patient describes anklepain, but there is typically little ankle edema or ecchymosis. The crossed-leg test (compressing the fibula

toward the tibia just above the midpoint of the calf11) can detect a syndesmosis injury and is indicated ifpressure to the medial aspect of the knee elicits pain in the syndesmosis (Figure 276-5). The squeeze test isperformed by squeezing the calf just above the ankle joint. Pain indicates syndesmosis injury.

Calcaneofibular ligament instability can be detected with the inversion stress test or talar tilt.6 If theexamination is uncomforTable for the patient, consider a hematoma block, sedation, or both to perform a

more thorough examination.11

FIGURE 276-3.

Peroneal tendon of the foot, lateral view.

FIGURE 276-4.

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Technique for performing the anterior drawer stress test of the ankle. [Reproduced with permission fromSimon RR, Sherman SC, Koenigsknecht SJ: Emergency Orthopedics, The Extremities, 5th ed. © 2007,McGraw-Hill Inc., New York.]

FIGURE 276-5.

The crossed-leg test. The a�ected leg is crossed over the opposite leg as demonstrated. If pain results at thearrow sites when pressure is applied to the medial side of the a�ected knee, the test is positive and indicatessyndesmosis injury. [Copyright © 2010 by the American Orthopaedic Foot and Ankle Society, Inc., originallypublished in Foot & Ankle International in Kiter E, Bozkurt M: The crossed-leg test for examination of anklesyndemosis injuries. Foot Ankle Int 2: 187, 2005, and reproduced here with permission.]

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Examine areas in close proximity to the ankle as well. What may be described as an ankle injury may end upbeing an injury to the Achilles tendon or foot and cannot be excluded by ankle radiographic imaging. Assessthe integrity of the Achilles tendon. Fluoroquinolones and corticosteroids increase the risk of such an

injury.12 Perform the Thompson test (see Figure 44-4 in chapter titled "Leg and Foot Lacerations") if there istenderness or a defect. Place the patient prone on the stretcher and squeeze the calf. Loss of plantarflexionindicates a complete Achilles tendon rupture. Palpate the hindfoot and midfoot over the calcaneus, tarsals,and base of the fi�h metatarsal to check for areas of tenderness that may require further investigation.

Perform a neurovascular examination. Check dorsalis pedis and posterior tibial pulses and document digitalcapillary refill. Inability to dorsiflex the toes suggests a tibial nerve injury. Inability to plantarflex the great toeis suspicious for peroneal nerve injury.

If there are any significantly displaced fractures or dislocations, immobilize the joint in a neutral positionwith a well-padded splint to reduce further so� tissue injury. Follow this with elevation and application of iceto reduce edema. Emergently reduce any displaced fractures or dislocations with neurovascular compromise(see later treatment section under "Dislocations").

DIAGNOSIS

IMAGING

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The Ottawa Ankle Rules for Ankle and Midfoot Injuries2,13,14,15,16,17 are easily applied by physicians and

triage nurses.18,19 The rules are summarized in Figure 276-6.

FIGURE 276-6.

Ottawa Ankle Rules for Ankle and Midfoot Injuries. Ankle radiographs are required only if there is any pain inthe malleolar zone or midfoot zone along with bony tenderness in any of these four locations or the inabilityto bear weight both immediately and in the ED.

The rules were originally developed for patients older than age 18 years who were able to cooperate, werenot intoxicated, and had no distracting injuries or decreased sensation. Assuming the patient does not haveany bony tenderness, assess the ability to bear weight by having the patient take four steps, resulting in twotransfers to and from the injured ankle. The initial studies demonstrated a 30% reduction for the need of

ankle radiographs.16,20

The standard ankle trauma series consists of three views: anteroposterior, 15-degree internal oblique, andlateral views. See Figure 276-7 for normal anatomy. About 95% of all ankle fractures can be detected with any

two of these views.9

FIGURE 276-7.

Normal ankle radiograph. A. Anteroposterior view. B. Lateral view. C. Oblique view. [Image used withpermission of Robert DeMayo, MD.]

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When there is an abnormal motion of the talus within the mortis, there is stress on the malleoli andligaments, which causes the injury. Fractures above the talus and those that cause disruption of both sides ofthe joint have the potential to create an unsTable injury. Instability of the joint is usually diagnosed based onplain radiographs because pain and swelling make it di�icult to determine true stability of an acutely injuredankle. If radiographs are normal but there is concern about stability, weight-bearing ankle films can be

helpful. US can detect Achilles tendon injuries21 and ankle fractures.22

CT and MRI may play a role in better delineating pathology. Ideal imaging for a CT includes both axial anddirect coronal images with sagittal reformations. To obtain these images, keep the ankle between neutraland 20 degrees of plantarflexion when possible, similar to that for plain radiographs. CT can be used for

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operative planning by orthopedic surgeons and to evaluate comminuted fractures and complex bony injuries

like pilon fractures and malunions.7 MRI can help define so� tissue, muscle, ligamentous, and tendon injuries

and is used more in the outpatient setting for subacute and chronic pain presentations.9,23

TENDON INJURIES

CLINICAL FEATURES

A peroneal tendon subluxation and dislocation occurs when there is a sudden hyperdorsiflexion of the foot ina position of eversion, as in skiing. The superior retinaculum, which holds the peroneal tendons in place, istorn from the posterolateral malleolus. This leads to a small avulsion fracture in more severe injuries with adislocation or anterior subluxation of the peroneal tendon over the tip of the fibula. Consider this injurywhen there is ecchymosis or tenderness over the posterior edge of the lateral malleolus and no tendernessover the talofibular ligament.

Achilles tendon ruptures happen with sudden plantarflexion of the foot. A complete tendon rupture willbecome apparent with palpation of a defect over the Achilles tendon and is identified by the Thompson test(Figure 276-8). US can also identify Achilles tendon ruptures (Figure 276-9).

FIGURE 276-8.

Thompson test. There is no plantarflexion with squeezing the calf of the a�ected leg, or less plantarflexioncompared with the normal leg. [Adapted with permission from Stone CK, Humphries RL. Current Diagnosisand Treatment Emergency Medicine, 7th ed. Copyright @ The McGraw Hill Companies, 2011. Figure 28-20.]

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FIGURE 276-9.

Ultrasound of ruptured Achilles tendon. [Used with permission fromhttp://www.em.emory.edu/ultrasound/ImageWeek/achilles_tendon_rupture1.html; Drs. Backster andCiardulli, Department of Emergency Medicine at Emory University.]

TREATMENT

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The treatment for both types of tendon rupture is o�en operative repair, especially for those who wish toreturn to full activity.

LIGAMENT INJURIES

CLINICAL FEATURES

The most common type of ankle sprains is one to the lateral ankle. Typically, these are minor and are due toan inversion injury when the ankle is plantarflexed. Sprains are categorized into three grades. Grade Iinvolves no tearing of the ligaments with minimal functional loss, pain, swelling, and ecchymosis. Weightbearing is tolerable. Grade II sprains occur with a partial tear and some loss of functional ability. Grade IIsprains tend to be more painful, with swelling, ecchymosis, and di�iculty bearing weight. Grade III sprainsresult from a complete tear, with significant functional loss, pain, swelling, and bruising, and almost a

universal inability to bear weight.6 It has been argued, however, that assigning a grade to the sprain is less

important than the stability of the joint.24 Joint stability is the primary determinant of a treatment plan for asprain.

An isolated sprain of the medial deltoid ligament is rare. Medial deltoid ligament tears are usually associatedwith a fibular fracture or tear of the tibial-fibular syndesmosis from an eversion injury. If there is significantmedial malleolus tenderness and swelling, suspect a Maisonneuve fracture of the proximal fibula and fibularsha�. Negative radiographs should suggest syndesmosis tears.

Injuries to the tibiofibular syndesmotic complex are associated with hyperdorsiflexion injuries when the talusmoves superiorly and separates the tibia and fibula. This leads to a partial or complete tear of thesyndesmosis with complaints of pain just above the talus.

If there is concern for an unsTable ligamentous injury, weight-bearing views of the ankle can help diagnosis—an unsTable ligamentous injury may demonstrate talar shi�.

TREATMENT

The immediate goals are to decrease pain and swelling and protect ligaments from further injury. The PRICEprotocol (protection, rest, ice, compression, elevation) involves elevating the ankle and protecting it with a

compressive device along with applying ice and resting up to 72 hours to allow the ligaments to heal.6 Thereis controversy as to whether or not early immobilization versus functional treatment results in the best

outcomes. There is a trend toward favoring early functional treatment over immobilization.7 Patientsreturned to mobility anywhere between 4.6 and 7.1 days sooner with functional treatment when compared

with immobilization.25 Functional treatment usually consists of three phases: (1) PRICE protocol within thefirst 24 hours of injury; (2) motion and strength exercises to begin within 48 to 72 hours; and (3) endurancetraining, focused toward specific sports when applicable, and training to improve balance a�er the second

phase begins.6

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In patients with a lateral ligament sprain, a sTable joint, and the ability to bear weight, treatment consists ofanalgesics, an elastic bandage or ankle brace, and no sports involvement, with follow-up in a week if noimprovement. Lace-up supports may reduce persistent swelling when compared to elastic bandages or rigid

ankle supports.26 For patients who are unable to bear weight but have a sTable joint, provide an ankle braceand crutches and have them follow-up with either their primary care provider or orthopedic surgeon within 1week for repeat evaluation. Given the trend for early immobilization, functional braces, such as semirigid(e.g., Aircast) and so�, lace-up braces, are commonly used. There is no consensus as to which leads to a more

favorable outcome,27 although early rehabilitation of low-grade ankle sprains results in a good outcome.28

Another option is an inflaTable cast boot (also called walking fracture boot or air cast boot) that molds to thefoot with inflaTable air bladders. This device can also be used for sTable ankle fractures.

Treat medial ligament sprains with PRICE and early referral to an orthopedic surgeon given the risk forundetected underlying fractures. Consider early orthopedic referral for syndesmotic complex sprains giventhe expected prolonged recovery time.

Refer patients with an unsTable joint to an orthopedic surgeon a�er placement of a posterior splint forstabilization. Establish contact with the orthopedic surgeon early because the timing of treatment andfollow-up is ultimately at his or her discretion.

There is no consensus as to whether surgery versus conservative treatment results in more favorable

outcomes.29 Cryotherapy with ice will help decrease pain and limit swelling and should be applied directly to

the ankle or splint but not le� on for >20 minutes at a time. Therapeutic ultrasonography is not helpful.5

DISLOCATIONS

CLINICAL FEATURES

Most ankle dislocations are associated with a fracture and can occur in one of four planes. Posteriordislocations are the most common and occur with a backward force on the plantarflexed foot, usuallyresulting in rupture of the tibiofibular ligaments or a lateral malleolus fracture. The less common anteriordislocation results from a force on the dorsiflexed foot with an associated anterior tibial fracture. A lateraldislocation results in ligamentous disruption and fracture of one or both malleoli (Figure 276-10). An axialcompression force can drive the talus upward with an associated fracture of the talar dome and disruption ofthe syndesmosis.

FIGURE 276-10.

Open fracture with dislocation. A. Anteroposterior view. B. Lateral view. [Image used with permission ofRobert DeMayo, MD.]

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TREATMENT

There is a significant concern for neurovascular compromise. Check carefully for an open fracture in theseinstances. If the patient has intact pulses, dislocations associated with fractures should be reduced by anorthopedic surgeon. If vascular compromise is present, as evidenced by a dusky foot or absent pulses, orthere is tenting of the skin, an immediate reduction by the emergency physician is warranted without anypre-reduction radiographs.

First provide appropriate sedation and analgesia before attempts at reduction. Grasp the heel and foot withboth hands, and gently apply traction and rotation opposite to the direction of the mechanism of injury.

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Confirm pulses and distal perfusion, and then apply a splint and elevate the foot while waiting for orthopedicevaluation. Confirm and document distal perfusion again a�er splint application. Any dislocations thatcannot be reduced using closed techniques will require open reduction.

MUSCULAR INJURIES

CLINICAL FEATURES

Strains are injuries to muscle or tendons not usually associated with a specific injury but due to repetitivestress and overuse. Common muscles and tendons involved include the extensor digitorum longus, extensorhallucis longus, peroneus brevis and longus, and anterior tibial tendon (Figure 276-11). Strains can be due toathletics or poorly fitting footwear. Contusions are usually caused by direct trauma from a projectile like abaseball or hockey puck. Fractures associated with contusions are rare and usually involve only the bonycortex.

FIGURE 276-11.

Muscles of the ankle.

TREATMENT

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For overuse injuries, analgesics, especially nonsteroidal anti-inflammatory drugs, will help, along with restand cessation of the activities that are causing the strain. Targeted exercises may help in the recovery as well.Contusions are treated symptomatically with analgesia and ice.

FRACTURES

CLINICAL FEATURES

Radiographically, ankle fractures are described as unimalleolar, bimalleolar (Figure 276-12), and trimalleolar(Figure 276-13). A bimalleolar fracture is fracture of the lateral and medial malleoli; trimalleolar fractureadditionally involves the posterior malleolus.

FIGURE 276-12.

Bimalleolar fracture. A. Anteroposterior view. B. Lateral view. [Image used with permission of Robert DeMayo,MD.]

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FIGURE 276-13.

Trimalleolar fracture. A. Anteroposterior view. B. Lateral view. [Image used with permission of RobertDeMayo, MD.]

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The ankle consists of a ring of bone and ligaments around the talus. The ring is composed of the tibia,

tibiofibular ligament, fibula, lateral and medial ankle ligaments, and calcaneus.30 A single ring disruption istypically a sTable injury. Injuries involving two or more components of the ring are unsTable injuries andusually need surgical fixation.

The Danis-Weber and Lauge-Hansen schemes are used by orthopedic surgeons to classify ankle fracturesand help determine surgical repair. The Danis-Weber system classifies fracture patterns based on the level of

the fracture of the fibula.31,32,33 The Lauge-Hansen system classifies fractures based on the position of the

foot at the time of injury.34

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Critical aspects of the examination for ankle fractures are summarized in Table 276-1.

TABLE 276-1

Associated and Occult Injuries of the Ankle

Injury Clinical SuspicionConfirmatory

Test

Maisonneuve fracture Examine proximal fibula and sha�, tenderness to palpation;

proximal fracture and syndesmosis tear indicate unstable

fracture9

Fibula

radiograph

Peroneal tendon

dislocation

Palpable anterior tendon dislocation or subluxation Clinical

examination

Usually identified in

follow-up of ankle

sprains

   

Osteochondral

injuries

Di�use ankle swelling, passive plantarflexion Ankle mortise

view/CT

Syndesmosis tear Significant ankle pain, positive squeeze test Widened mortise

with weight

bearing

Anterior calcaneal

process fracture

Tenderness more inferoanterior than a typical ankle sprain Lateral ankle

radiograph/CT

Lateral talar process

fracture

Tenderness just distal to the tip of fibula Ankle mortise

view/CT

Os trigonum Tenderness anterior to Achilles tendon Lateral ankle

radiograph

TREATMENT

The goal is to restore the anatomic relationship of the ankle, maintain reduction during the healing, andmobilize the ankle early. Treat small fibular avulsion fractures as sTable ankle sprains (see earlier section,

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*Implies that communication is established at time of diagnosis and specific time of consultation has been set.

Consultation can be delayed in the ED in fractures without neurovascular compromise and appropriate splinting.

"Ligament Injuries") if they are minimally displaced (<3 mm in diameter) and there is no sign of medialligament injury.

Most other ankle fractures require immobilization by either cast alone or surgical repair and casting.35,36

Severe comminuted fractures are at risk for compartment syndrome, fat emboli, and poor healing. Urgentorthopedic consultations in the ED is necessary. Until definitive fracture treatment can be provided, apply aposterior splint and keep the patient non–weight bearing (see Figure 267-15 in chapter 267, "InitialEvaluation and Management of Orthopedic Injuries, Posterior Ankle Mold). Provide analgesics, and remindthe patient to elevate the leg and apply ice. Table 276-2 provides guidelines for orthopedic consultation andfollow-up.

TABLE 276-2

Timing of Consultation

Immediate Consultation in ED Deferred Consultation* Within 1 Week

All open fractures Stable unimalleolar fractures Potentially unstable sprains

All fracture dislocations Unstable ligamentous injuries  

All dislocations Acute peroneal dislocations  

All trimalleolar fractures†    

All bimalleolar fractures†    

Unstable unimalleolar fractures†    

Maisonneuve fractures†    

OPEN FRACTURES

The most important prognostic factor in open ankle fractures is the amount of energy involved in the injuryand amount of so� tissue damage involved. Open fractures require rapid surgical management that involves

aggressive debridement of nonviable tissue and either internal or external fixation.9 Administer empiric

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1. 

2. 

3. 

4. 

5. 

antibiotics, most commonly IV cefazolin, and add an aminoglycoside for contaminated wounds. Useclindamycin in patients with a penicillin allergy. Update the tetanus status of the patient as needed.

While waiting for the orthopedic surgeon, irrigate the wound with several liters of normal saline, then applysterile gauze soaked in saline over the open wound, and secure it in place with a gauze roll. Do not use iodinesolutions, as they are caustic to tissues. Splint the injury to stabilize it while obtaining radiographs andcoordinating orthopedic care.

DISPOSITION AND FOLLOW-UP

To date, there is no established standard of care regarding the time of orthopedic consultation and follow-up.Whether or not an orthopedic surgeon sees the patient in the ED depends on the specialist resourcesavailable. Table 276-2 can serve as a general guideline for local practice standards and resources. Most severefractures require orthopedic consultation in the ED.

Acknowledgments: The authors would like to thank Drs. John A. Michael and Ian G. Stiell for theircontributions to previous editions of this chapter. We would also like to thank Drs. Esther Choo and RobertDeMayo for the radiology images.

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