Emergency Medicine feelingofwine

Hello Steemians. This is @feelingofwine working as an emergency physician in South Korea.
Today, I'd like to share with you the tip of how to manage ankle sprain.


Ankle is one of the joint which can be injured easily with ordinary movement such as sports activities or walking. If not severely injured, there would be no problem in walking and daily life. But if injury is severe, ankle injury can cause severe pain and swelling which result in gait disturbance. In this situation, many people visit Emergency Room (ER) with ankle injury. (Since I am doing a doctor in Korea, all information I explain in this article is based on Korean Medical services. Medical service can be influenced by cultural background, medical accessibility, insurance status, and personal characteristics. Please keep this in mind when you read this article.)


It is well-known that cost of ER is much more expensive than out-patient-visit because of its native characteristics. If it is daytime of weekday, we can go to orthopedic hospital nearby. But what if it is nighttime or weekend so that there is no medical services available except for expensive ER ?? Should we wait till out-patient clinic open ?? Is it ok even if we go hospital late ?? Today, Emergency Physician will give you the tip (I hope this is the best for patient ^^) of ankle injury.


anatomy of ankle



The foot bears the weight of human body and ankle connects foot and lower leg which function as joint to give wider movement of foot.


Mechanism of ankle injury




As you see in the pictures, ankle injury occurs most with sprain toward inside. This is called “inversion” in medical term.


Result of ankle injury


When ankle is injured, diagnosis of sprain, fracture, and dislocation is possible respectively in order of severity. All diagnosis can result in severe pain with swelling, but treatment is very different.



  • Sprain


Sprain means stretching of ligament which causes inflammation of tissue and results in swelling. Usually, ankle can move only in back and forth (side movement is pretty much restricted compared to back and forth movement). So, when inversion occurs, Calcaneofibular ligament which connects Calcaneus bone (base of foot) and Fibula bone (Lateral side of lower leg) can be stretched and cut off in severe case.


The Treatment of sprain is often called RICE (Rest, Ice, Compression, Elevation) with splint apply. It will usually recover in 2~4 weeks with leg rest. The purpose of treatment is not to bear weight so that injured tissue can take rest. To achieve this purpose, crutches can be useful.



In this picture, we can see the lateral side of ankle is swollen.



Splint looks like above picture.



  • Fracture


In case of fracture, if displacement is not severe, sometimes observation with splint is enough. If the situation requires operation, there are two cases; pre-scheduled operation which can be done in 2~3 days and emergent operation which must be done in hours. The emergent operation case is open fracture which displaced bone pricked out of skin so that you can see bone with your eyes. When bone punctures out of skin, it can cause infection into the bone and requires massive irrigation and antibiotic management. The pre-scheduled operation means that displacement of bone exists but did not cause other problem. So the operation can be done with regular schedule and cause no medical problem with delayed management.


Both operation cases would put pin into bone to fix displaced bone. The detail of operation skill and management needs consultation of orthopedic surgeon.




  • Dislocation



This is the most dangerous injury of ankle. Ankle is injured by so strong force that it cannot maintain its normal anatomic structure. If dislocated structure is not repaired as soon as possible, it can result in sensory and motor loss due to neurological and vascular damage and tissue necrosis. It is easy to make diagnosis because ankle is definitely rotated. Dislocation accompanies fracture in most cases and requires operational treatment. Reduction of dislocated joint must be done ASAP to prevent further deterioration of normal tissue. Of course, early management of doctor is necessary.


Conclusion


The patient with ankle injury may be curious about what kind of diagnosis it is and what should be done for treatment. Ankle is obviously rotated from normal variation in dislocation and bone punctures out of skin in open fracture that patients come to ER with 911 call and receive early radiograph and emergent management.


It is difficult to distinguish simple fracture and sprain till radiographic image because both diagnosis shares same symptom like pain and swelling. Sprain is enough with RICE treatment mentioned above but fracture may need operational treatment. What is important here is that even if operation is needed in simple fracture, it is not an urgent situation which must be done in minute or hour scale. When ankle injury patient comes to ER and is diagnosed as simple fracture, they would receive splint, get education to take rest at home, and come back to out-patient clinic of orthopedic department in a few days for further treatment consultation.


Therefore, as an emergency physician, I’d like to recommend you the following process when you get ankle injury;


1) If ankle is rotated or you can see bone through skin -> directly go to ER or orthopedic clinic


2) not that severe -> in weekday, go to out-patient-visit or in nighttime or weekend, take rest with RICE treatment and go to out-patient-visit in weekday daytime


Thank you very much for reading this article.
Let's make the world better place together ^^. Have a nice day.


Reference>



  1. Tintinalli’s Emergency Medicine 8th ed.

  2. images from google and shutterstock



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