Case One Case One

A 26 year old female presents with a painful ankle. She Physical examination reveals a swollen ankle with soft relates that she twisted her ankle over the weekend tissue ecchymosis and tenderness to palpation at the while playing in her recreational soccer league. She anterolateral lateral malleolus extending into the soft immediately iced the ankle, but it has swelled tissue distally. A positive drawer sign is elicited with a considerably and it is painful to bear weight. She is able solid end point. She is unable to bear weight on the to ambulate only with crutches. ankle.

Ottawa Ankle Rules Ankle radiographs are necessary if Stiell and colleagues assessed the utility of decision rules in there is pain near either malleolus ordering radiographs for acutely injured ankles. and: • Sensitivity: 100% • Inability to bear weight Ottawa Ankle immediately and in the emergency • All 50 ankle fractures and 19 foot fractures identified Rules department • Compliance resulted in a 30% reduction in utilization OR • Bone tenderness at the posterior edge or tip of either malleolus Stiell IG et al. JAMA 1993; 269:1127‐1132 Ottawa Ankle Rules Case One

Case One Ankle Anatomy

The lateral ligamentous complex of the ankle consists of: • Anterior talofibular ligament (ATF) • Calcaneofibular ligament (CFL) • Posterior talofibular ligament (PTL) Anterior Talofibular Ligament

• Originates from the anterior border and tip of the Lateral Ankle lateral malleolus • Travels obliquely forward to insert on the neck of the Anatomy talus • Primary restraint against inversion and torsional stress when the foot is in plantar flexion • Most commonly injured ligament in ankle sprains

ANKLE SPRAINS Mechanisms of Injury Case Two Mechanism Ligament Injured Plantar flexion/inversion ATF An eighteen year old male athlete presents with a swollen and painful ankle. He sprained his ankle two PTF weeks ago; he was placed in an air stirrup for one CF week and then began a home physical therapy Dorsiflexion/inversion CF regimen. He has not improved despite treatment and Dorsiflexion/external rotation Syndesmosis religiously performing the therapy that you have recommended. Eversion/external rotation Deltoid Case Two

Physical examination reveals a swollen ankle with no point tenderness over the medial malleolus nor the anterior talofibular ligament. He has negative drawer and talar tilt tests. He ambulates favoring the ankle.

OSTEOCHONDRITIS DESSICANS Causes of Persistent Ankle Pain Pathophysiology • Inadequately rehabilitated ankle • OCD is a form of osteochondrosis limited to the • Occult fracture articular epiphysis. • Osteochondritis dessicans • Articular epiphyses fail as a result of compression. • Instability • Both trauma and ischemia probably are involved in the pathology. • Trauma is most likely the primary insult, with ischemia occurring secondarily. OSTEOCHONDRITIS DESSICANS Ankle Stage I Normal radiograph • OCD occurs more frequently in the talus than in the tibial plafond, since tibial cartilage is stiffer than talar cartilage. Partially detached osteochondral Berndt and Stage II fragment • The usual sites of OCD of the talar dome are the Harty posteromedial aspect (56%) and the anterolateral aspect (44%) of the talus. Radiographic Stage III Complete, nondisplaced fracture • Occasionally, mirror image osteochondral defects of Classification remaining within the bony crater the talus and distal tibia occur, suggesting trauma as a potential cause of both lesions. Detached, loose osteochondral Stage IV fragment

Anderson MRI Classification

Stage I: Bone marrow edema OCD OF THE Stage IIa: Subchondral cyst ANKLE Stage IIb: Incomplete separation of the osteochondral MRI Imaging fragment Stage III: Fluid around an undetached, nondisplaced osteochondral fragment Stage IV: Displaced osteochondral fragment Nonoperative in youngsters with Nonoperative open physes

OCD OF THE OCD OF THE Treatment in adults dependent on ANKLE Activity restriction and ANKLE size of lesion Treatment ‐ immobilization Treatment ‐ Stage I Stage II Surgical intervention for large Weight bearing lesions or smaller lesions that do restricted for 6‐8 weeks not heal with conservative therapy

Surgical management Case Three

OCD OF THE A 25 year old male presents for evaluation of persistent ankle pain after injuring his ankle while snowboarding 2 ANKLE Arthroscopy produces better outcomes than open procedures weeks ago. He indicates that his ankle “twisted” in his Treatment ‐ boot after he unexpectedly hit a mogul in deep powder. Stage III and He experienced considerable pain, and so he slowly IV Options include excision, curettage, worked his way down the mountain and was seen in fixation and drilling depending on the clinic at the base of the mountain. X‐rays were characteristics of lesion taken and were negative, He was told he sprained his ankle and was placed in an air stirrup. Case Three

Physical examination reveals a mildly swollen ankle with appreciable palpable tenderness laterally. He has negative anterior drawer and talar tilt tests. He is able to bear weight on the ankle and ambulate, but it is painful.

Articulates superolaterally with the fibula, helping Bony stabilize the ankle mortise Anatomy of Lateral the Hindfoot Process of the Talus Articulates inferomedially with the calcaneus, forming the lateral portion of the subtalar joint Fractures frequently overlooked History of rapid inversion/dorsiflexion on initial presentation (33‐41%) injury Fractures of Second most common fracture Diagnosis of Palpable point tenderness over the lateral of the talus process – located just anterior and the Lateral Lateral inferior to the lateral malleolus Process of the Common snowboarding injury Process Usually visualized on standard ankle Talus Fractures radiographs Frequently misdiagnosed as an CT imaging may be necessary to confirm ankle sprain diagnosis

Nonweight‐bearing, short leg LATERAL cast for 6 weeks for small, non‐ PROCESS displaced fracture followed by FRACTURES LATERAL 2 weeks in walking cast MRI Imaging PROCESS FRACTURES Large, displaced fragments Treatment best treated with surgical reduction and fixation Case Four Case Four

A twenty year old junior college football player Physical examination reveals a swollen ankle with presents to your office the morning after injuring his palpable tenderness only over the anterior tib‐fib ankle in a game. He was tackled while caring the ball ligament and the proximal syndesmosis. Anterior with his foot fixed on the turf to make a cut. He was drawer and talar tilt tests are negative. An external helped off of the field and evaluated by the team rotation stress test is positive. He is unable to bear trainer. His ankle was iced, and he was given crutches weight on the ankle. to ambulate. After the game, he was told to continue icing the ankle and to follow‐up with his physicians in the morning.

Case Four Case Four SYNDESMOSIS SPRAIN Mechanism of Injury SYNDESMOSIS • Dorsiflexion, external SPRAIN rotation injury Anatomy • Common injury on artificial turf with increased shoe/turf interface

SYNDESMOSIS SPRAIN Nonweight‐bearing cast or External Rotation Stress Test boot until pain free SYNDESMOSIS • Performed with patient seated Physical therapy with brace and foot in dorsiflexion SPRAIN limiting external rotation • External rotation force applied Treatment – • Sensitivity = 20% Stable Injuries Recovery typically prolonged • Specificity = 85% and highly variable Beware of Unstable Injuries!