Ankle fractures

Ankle fractures:

Start with good H&P:

History:

Mechanism, height of the fall, direction of the foot inversion

Consider age, steroid use, hx of neoplasm, prior surgeries, hardware

Physical:

Start from the knee down, neurovascular intact, ROM, strength, severe tenderness, instability, rash/ulcers

Ottawa Ankle rules 

Classification of the injury: stable/unstable?

Many classifications are available but for ED we can use Closed Ring System: 

Think of an ankle as a ring of bone and ligaments surrounding the talus consisting of the tibia, the medial malleolus and medial deltoid ligaments, the fibula and lateral ligaments and calcaneus.

A single disruption in the ring - stability most likely preserved

Two disruptions - think instability and will likely cause the joint to shift.

Exceptions: Lateral malleolus fracture even with no medial injury may become unstable.

Isolated syndesmosis injury

Approach to ankle injuries x-ray interpretation

Here is an EM focused summary

Look at the cortical disruption of each bone

Look at the soft tissue swelling

Look at the spaces between the bones

Look within the bones

Ask for a mortise view (no, it’s not a GOT character) in addition to the standard AP and lateral views

Look at the tib/fib, knee and base of the 5th metatarsal

Key areas:

Talar shift: look to make sure there is congruence between the clear space on either side of the talus; go further - measure the medial clear space and the lateral clear space. If they are incongruent or the medial clear space is >4mm the ankle is likely unstable.

Talar tilt: The lines in red below should be parallel. Talar tilt indicates an unstable ankle 

Just a few commonly missed fractures at the ED:

High ankle sprain: The isolated syndesmosis injury - isolated distal tibiofibular syndesmosis injury, with ligamentous disruption can result in unstable ankle injury.

Look at the tibio-fibular clear-space: Measure the gap between the tibia and fibula 1cm proximal to the tibial plafond on both the AP view and mortise view. They should be <6mm. If  >6mm, suspect a syndesmosis injury.

Tillaux fracture - fracture is an intra-articular Salter-Harris class III fracture of the distal tibia with avulsion of the anterolateral tibial epiphysis.

Remember that in children, the ligaments tend to be stronger than the growth plate. Tillaux fractures can be considered “the syndesmosis injury of children”

Snowboarder’s fracture - A snowboarder’s fracture is a lateral process of the talus fracture that is commonly misdiagnosed as a simple ankle sprain. 

Lateral process of the talus fracture also known as a snowboarder’s fracture

Bottom line: 

Reassess including the if the pt is still neurovascular intact

If pt can’t ambulate get further workup

If in doubt call radiology

Persistent pain but pt wants to go hoe, splint with ortho follow up

References: CoreEM, EMDoc, Uptodate, Radiopedia

5th metatarsal fracture

Normal Apophysis in children runs parallel to the bone.  

Dancer’s or Avulsion (pseudo-Jones) Fracture @ cuboid articulation - hard sole shoe for 4-6 weeks and weight bearing as tolerated (WBAT) with orthopedics follow up in a week

Jones Fracture @ intermetatarsal articulation - high risk of non union, pt will need a splint and non weigth bearing activity (NWB) for 6-8 weeks with orthopedics follow up

Metatarsal shaft fracture - high risk of non union, will need a splint, NWB for 10-20 weeks, with orthopedics follow up

Below is a 5 minute video by amazing Dr. Anna Pickens (former Maimo attending) for visual review of the fractures:

http://www.emdocs.net/em-in-5-5th-metatarsal-fractures/

https://youtu.be/4k1dvPdpW4E

POTD: High-Pressure Injection Injury

High-Pressure Injection Injury

·      Patients present with seemingly innocuous findings after high-pressure injection injury

·      Their condition often rapidly deteriorate

·      Substances can be paint, paint stripper, grease, oil, water or air.

·      This is a surgical emergency and early consultation is critical for surgical decompression and debridement

·      Less viscous substances can penetrate deeper with less pressure, leading to worsened outcomes, even if initially the wound may appear benign on the exterior, and even if the patient’s pain is initially minimal

·      Paint and paint thinners produce a large and early inflammatory response leading to ischemia and tissue death and the rate of associated amputation is high.

·      Initial emergency department management:

o   pain control, radiographs (look for free air), elevation, splinting, IV antibiotics, tdap, emergent hand specialist consultation

o   These injuries are not high-risk injuries for tetanus, and prophylaxis, even if indicated, therefore tdap should not delay other steps in management.

o   In fact, none of the emergency department interventions, (besides pain control), is as important as recognition of the potential severity of the injury and early consultation with a hand specialist

o   There is no amount of cleansing this wound in the ED that is recommended because the penetration is deep and this patient needs to go to the OR.

·      It is interesting to note that although digital blocks are excellent tools to relieve pain and provide anesthesia, they are not recommended in high-pressure injection injury as one of our major concerns is compartment syndrome.

o   Digital blocks can lead to an increase in compartment pressure and worsen injury/tissue ischemia. Systemic pain control is recommended.

The below picture is of a hand in the OR, you can see the initial presentation appears someone benign and once the hand is opened up, you see a lot of tissue necrosis.

Below pictures show benign physical exam findings and some free air on xray

Sources: Tintinalli, Rosen's Emergency Medicine, uptodate, Peer IX, ortho blog for photos: http://www.cmcedmasters.com/ortho-blog/high-pressure-injection-injuries