Rosen & Barkin's 5-Minute Emergency Medicine Consult (58 page)

Immobilize ankle as necessary.

• Prevent further injury; avoid weight bearing if painful.
  
• RICE (rest, ice, compression, elevation)
  

• The goal of treatment is reduction of pain and return to normal activity without long-term pain or joint laxity.
  
• Existing evidence supports early mobilization and functional treatment:
  
  • Unstable ankles (i.e., grade III) or those with severe pain may benefit from brief immobilization followed by early return to functional treatment.
    
• Grade I or II sprains can be treated with functional support (elastic bandage, air splint, gel splint, etc.):
  
  • Recent evidence suggests an elastic bandage dressing coupled with an air stirrup splint is superior to other forms of immobilization.
    
• Grade III sprains can be treated by immobilization (sugar tong with posterior splint or elastic bandage dressing coupled with air stirrup splint) and early orthopedic consultation or referral.
  
• Crutches may be needed initially for comfort, but encourage weight bearing as tolerated for grades I and II.
  
• Once acute pain and swelling have resolved, strengthening exercises and proprioceptive training (e.g., balance board, small circle walking) improve ankle strength and function and prevent reinjury.
  
• Full sports activities may be resumed only when running and turning are pain free.
  
• Ankle taping, air splints, or gel splints reduce the risk of recurrent injury in high-risk sports such as basketball, volleyball, soccer, and running.
  

• NSAIDs are useful in treating acute pain:
  
  • Ibuprofen: 800 mg (peds: 5–10 mg/kg) PO TID
    
• Topical NSAIDs have been shown to control pain and shorten healing time with acute ankle sprain:
  
  • Diclofenac sodium 1% gel: Apply 4g to affected area QID
    
• Narcotic analgesics may be required for severe pain.
  

FOLLOW-UP

An isolated ankle sprain should not require admission.

An isolated ankle sprain may be safely discharged from the ED with appropriate treatment, prescriptions, aftercare instructions, and referrals.

Patient copies of any radiographs obtained may facilitate early follow-up.

• Patients with grade I and II sprains should be instructed to follow up with the primary care physician in 1–2 wk.
  
• Patients with grade III sprains and syndesmosis injuries should be referred to an orthopedic surgeon or sports medicine specialist within 7–10 days.
  

• The Ottawa Ankle Rules may decrease the need for radiographs.
  
• Immobilization with an elastic bandage dressing coupled with an air stirrup splint followed by early functional therapy may shorten healing time.
  

• Beynnon BD, Renström PA, Haugh L, et al. A prospective, randomized clinical investigation of the treatment of 1st-time ankle sprains.
  Am J Sports Med
  . 2006;35:1401–1402.
  
• Ho K, Abu-Laban RB. Ankle and foot. In: Marx JA, Hockberger RS, Walls RM, et al., eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  , 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010:670–697.
  
• Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: Immobilization versus functional treatment.
  Clin Orthop Relat Res
  . 2007;455:169–172.
  
• Predel HG, Hamelsky S, Gold M, et al. Efficacy and safety of diclofenac diethylamine 2.32% gel in acute ankle sprain.
  Med Sci Sports Exerc.
  2012;44(9):1629–1636.
  
• Stiell IG, McKnight RD, Greenberg GH, et al. Decision rules for use of radiography in acute ankle injuries: Refinement and prospective validation.
  JAMA
  . 1993;269:1127–1132.
  

CODES

• 845.00 Sprain of ankle, unspecified site
  
• 845.02 Sprain of calcaneofibular (ligament) of ankle
  
• 845.09 Other sprains and strains of ankle
  

BASICS

• Chronic inflammatory disease, primarily affects the axial skeleton with predilection toward the spine and sacroiliac (SI) joints:
  
  • SI joints 100%
    
  • Cervical spine 75%
    
  • Thoracic spine 70%
    
  • LS spine 50%
    
  • Hip joints 30%
    
  • Shoulder joints 30%
    
• Spondylitis
  (inflammation of vertebrae) of ankylosing spondylitis (AS) begins at the insertions of the outer fibers of the annulus fibrosus (enthesitis) of the vertebrae:
  
  • Ossification (syndesmophyte formation) may lead to complete fusion,
    ankylosis,
    of the vertebrae.
    
  • Extensive spinal involvement causes the radiographic appearance of the brittle “bamboo spine.”
    
• Onset 15–35 yr of age
  
• Male to female ratio is between 2:1 and 3:1.
  

Strong genetic component. HLA-B27 is present in 80–90% of patients with AS.

Disease is likely triggered by environmental factors such as infection in genetically predisposed individuals.

DIAGNOSIS

• Spinal: Low back pain with sacroiliitis is the most common presentation:
  
  • Inflammatory back pain, improving with movement and exercise.
    
  • Higher risk for serious injury from milder traumatic mechanisms.
    
• Extraspinal inflammatory conditions (which may precede spinal symptoms):
  
  • Ocular (the most common):
    
    • Uveitis (25–40% occurrence). Usually acute and unilateral in onset. Can alternate eyes.
      
  • Cardiac:
    
    • Slight increased risk of CAD
      
    • Increased risk for valvular incompetence with prolonged course of AS.
      
  • Pulmonary:
    
    • Progressive restrictive lung disease due to limited expansion and fibrosis
      
  • GI:
    
    • 5–10% of patients with inflammatory bowel disease.
      
  • GU:
    
    • Risk for IgA nephropathy or amyloidosis. Also increased risk for NSAID nephropathy from anti-inflammatory use.
      
  • Enthesitis (inflammation at tendon or ligament insertion):
    
    • Often Achilles tendonitis or plantar fasciitis
      

• Patients <40 yr of age with insidious onset of low back pain >3 mo, radiating into gluteal areas from SI region, and progressing to involve the entire spinal region:
  
  • Worse with rest and improved with mild activity. Pain in 2nd half of night waking patient from sleep
    
  • Women may have more cervical and extraspinal manifestations than men.
    
• Possible prior history of uveitis, restrictive pulmonary disease, inflammatory bowel disease, enthesitis, or migrating or polyarthritis.
  

• Tenderness over SI joints elicited with direct pressure over both of patient’s ASIS simultaneously.
  
• Dactylitis or enthesitis.
  
• Flattening of the normal lumbar lordosis
  
• Exaggeration of thoracic kyphosis
  
• Limitation of spinal movement
  
• Reduction in chest expansion
  

• Patients with juvenile ankylosing spondylitis (JAS) may commonly be misdiagnosed as recurrent sprains
  
• Onset of JAS is late childhood or adolescence (between 8 and 12 yr, before age 20); primarily boys.
  
• JAS has a much greater predilection for extraspinal joints and entheses of the lower extremities; in addition to SI tenderness, examine for:
  
  • Asymmetrical pauciarthritis of the joints of the lower extremities
    
  • Enthesitis of the ankle, knee, or tarsal bones. Plantar fasciitis and Achilles tendonitis are often common findings.
    

• Exclude fracture and neurologic injury in any patient with suspected AS for any new spinal pain (even without trauma).
  
• Exclude sepsis or septic joint if clinically indicated.
  
• Evaluate for sacroiliitis with pelvic rock test (compression) or Patrick test (downward pressure on the knee of a flexed and externally rotated leg and the contralateral ASIS causing sacral distraction).
  

• CBC may show mild leukocytosis with slight to moderate anemia and thrombocytosis.
  
• BUN, creatinine, and electrolytes may be useful to assess renal involvement.
  
• Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) may be elevated, but are of limited use in the ED.
  
• HLA-B27 testing can be performed by a specialist. A negative result does not rule out AS.