Evaluation and Management of Ankle Injuries in Urgent Care (Trauma CME)

Table of Contents

 

About This Issue

Understanding the anatomy of the ankle and the mechanisms of injury are crucial elements in providing optimal patient care. A thorough physical examination and appropriate imaging studies offer valuable insights into accurate diagnosis and treatment planning. While ankle injuries are rarely life-threatening, their impact on daily activities can be substantial. Recognizing the significance of ankle function in everyday life underscores the importance of meticulous clinical evaluation and a proactive approach to referral, ensuring comprehensive management and mitigating potential long-term complications. In this issue, you will learn:

The anatomy of the ankle, mechanisms of injury, and common presentations;

Traumatic and nontraumatic causes of ankle pain, the grading system for sprains, and various types of fractures;

Physical examination techniques and when to assess acute ankle injuries with diagnostic imaging; and

The disposition of ankle sprains and fractures, including those that require outpatient referral for further evaluation and treatment.

CODING & CHARTING: Determine if your patient’s ankle injury is either an acute, uncomplicated injury or acute, complicated injury to support proper coding, patient care, and reimbursement. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
6. Differential Diagnosis
   1. Traumatic Causes of Ankle Pain
      1. Ligamentous and Tendinous Injuries
         1. Ankle Sprains
         2. Posterior Tibialis Tendinitis
         3. Peroneal (Fibularis) Tendinitis
         4. Acute Achilles Tendinopathy and Rupture
      2. Distal Tibia and Fibula Fractures
         1. Lateral Malleolar Fractures
         2. Isolated Medial or Posterior Malleolar Fractures
         3. Lateral Malleolar Fractures With Deltoid Ligament Injury
         4. Bimalleolar and Trimalleolar Fractures
   2. Nontraumatic Causes of Ankle Pain
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Assessing Tendon Function
      2. Assessing Vascular Function
8. Diagnostic Studies
   1. Plain Radiographs
   2. Computed Tomography
   3. Magnetic Resonance Imaging
   4. Ultrasound
9. Treatment
   1. Low Ankle Sprain (Lateral or Medial)
   2. High Ankle Sprain
   3. Posterior Tibial Tendinitis
   4. Peroneal (Fibularis) Tendinitis
   5. Acute Achilles Tendinopathy
   6. Achilles Tendon Rupture
   7. Fibular Fracture (Lateral Malleolus Fracture)
   8. Isolated Medial or Posterior Malleolar Fractures
   9. Lateral Malleolar Fractures With Deltoid Ligament Injury
   10. Bimalleolar and Trimalleolar Fractures
10. Special Circumstances/Populations
    1. Elderly Patients
    2. Patients With Diabetes
    3. Pregnant Patients
11. Controversies and Cutting Edge
    1. Shetty Test
    2. CAM Versus CAST in Pediatric Patients
    3. Topical Nitroglycerin Therapy for Tendon Injury
12. Disposition
13. Summary
14. 5 Things That Will Change Your Practice
15. Time- and Cost-Effective Strategies
16. Critical Appraisal of the Literature
17. KidBits: Urgent Care Evaluation and Management of Ankle Injuries in Children
    1. Epidemiology and Pathophysiology
    2. Urgent Care Assessment and Imaging
    3. Evaluation Caveats for Young Children
    4. Management
       1. Mobility Devices
    5. Key Points
    6. References
18. Case Conclusions
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
       1. Problems Addressed
       2. Complexity of Data
       3. Risk of Patient Management
    2. Documentation
20. Coding Challenge: Ankle Injury in Urgent Care
21. Clinical Pathway for Management of Ankle Injuries in Urgent Care
22. References

Abstract

Ankle injuries represent a significant portion of extremity traumas seen in urgent care settings, with acute ankle sprains being among the most common musculoskeletal injuries. This review provides a framework for evaluating and managing ankle injuries in urgent care by discussing outline common presentations, differential diagnoses, and indications for urgent orthopedic referral. Etiology, pathophysiology, and treatment options for various ankle injuries, including ligamentous injuries, fractures, and tendinopathies are also discussed.

Case Presentations

A 42-year-old woman presents to urgent care and states that she lost her balance yesterday when walking near a sidewalk and stepped down “wrong”…

• On examination, the patient refuses to bear weight on her left ankle for fear of pain.
• You notice swelling on the left lateral ankle but no ecchymosis. She has tenderness to palpation over the lateral malleolus and anterior talofibular ligament. The varus/valgus stress test is normal, and the anterior drawer test of her left ankle causes discomfort, but no joint laxity is appreciated. Her toes have normal capillary refill bilaterally.
• You order 3-view left ankle x-ray.
• You wonder if this is an ankle sprain or a possible fracture…

A 34-year-old man presents to urgent care with right ankle/distal calf pain after playing basketball…

• The injury occurred just prior to arrival. He heard and felt a pop in the back of the right ankle when he quickly stopped and changed directions to run forward.
• He notes pain is 7/10 and is unable to bear weight on the affected ankle/foot. On examination he has tenderness to palpation over the Achilles tendon, and you appreciate mild swelling at the right heel.
• The patient is unable to stand on his toes on the right side. His Thompson test is positive on the right. His toes have normal capillary refill bilaterally.
• Based on this mechanism of injury and presentation, what injuries are you concerned for?

A 25-year-old man who fell from a ladder and twisted his right ankle when landing presents to urgent care…

• The patient’s injury occurred earlier this morning, about 4 hours ago. He lost his balance and fell about 2 feet from the ladder to the ground. On landing, he twisted his right ankle and felt immediate pain.
• The patient is unable to bear weight on right ankle secondary to pain. On examination he has pain and swelling noted on the right lateral malleolus. He is unable to tolerate an anterior drawer test of the right ankle or varus/valgus stress testing. He is able to dorsiflex and plantar flex the right ankle. His toes have normal capillary refill bilaterally.
• You order 3-view x-rays of the right ankle and right foot.
• You wonder if it’s a possible fracture due to his mechanism of injury and physical examination…

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Clinical Pathway for Management of Ankle Injuries in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Herzog MM, Kerr ZY, Marshall SW,et al. Epidemiology of ankle sprains and chronic ankle instability. J Athl Train. 2019;54(6):603-610. (Review) DOI: 10.4085/1062-6050-447-17

7. * Draper TR. Non-Achilles ankle tendinopathy. In: Connor R, ed. UpToDate. Wolters Kluwer. Accessed January 8, 2025. Updated May 2, 2024. (Evidence-based clinical resource)

8. * Maughan KL, Boggess BR. Achilles tendinopathy. In: Connor R, ed. UpToDate. Wolters Kluwer. Accessed January 8, 2025. Updated October 29, 2024. (Evidence-based clinical resource)

11. * Gomes YE, Chau M, Banwell HA, et al. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022;23(1):885-896. (Systematic review; 15 articles) DOI: 10.1186/s12891-022-05831-7

19. * Stricker P, Spindler K, Gautier K. Prospective evaluation of history and physical examination: variables to determine radiography in acute ankle injuries. Clin J Sport Med. 1998;8(3):209-214. (Prospective study; 74 patients) DOI: 10.1097/00042752-199807000-00008

21. * Miller T, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med. 2014;44(2):179-188. (Review) DOI: 10.1007/s40279-013-0106-1

25. * Nasrallah K, Haim S, Einal B. Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: current evidence and literature review. Orthop Rev. 2021;13(1):8987. (Review) DOI: 10.4081/or.2021.8987

30. * Jovic D, Johnson D, Tolmie L, et al. Shetty test in ankle and foot trauma: an emergency department pilot study assessing specificity and sensitivity. Emerg Med Australas. 2020;32(4):683-686. (Prospective study; 54 patients) DOI: 10.1111/1742-6723.13541

36. * Kerkhoffs GMMJ, Struijs PAA, Marti RK, et al. Functional treatments for acute ruptures of the lateral ankle ligament: a systematic review. Acta Orthop Scand. 2003;74(1):69-77. (Systematic review; 9 studies) DOI: 10.1080/00016470310013699

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Keywords: ankle sprain, low ankle sprain, high ankle sprain, syndesmotic injury, ankle fracture, Achilles tendinopathy, posterior tibial tendinitis, ligamentous injuries, tendinous injuries, hyperdorsiflexion, posterior tibialis tendinitis, peroneal tendonitis, Achilles tendon rupture, lateral malleolar fracture, posterior malleolar fracture, medial fracture, deltoid ligament injury, bimalleolar fracture, trimalleolar fracture, Maisonneuve fracture, Ottawa Ankle and Foot Rules, Thompson test, anterior drawer test, PRICE-M, Shetty test, Salter-Harris Fracture Classification System, toddler’s fractures, splinting, bracing