1. Orthopedics: Strains, Sprains, and Fractures Nursing 870

2. Definitions Sprain: an injury involving the stretching or tearing of a ligament Ligaments are the fibrous band of connective tissue that joins the end of one bone with another Strain: injury involving the stretching or tearing of a muscle or tendon Tendons are fibrous cords of tissue that attach muscles to bone Acute strain occurs at the junction where the muscle is becoming a tendon Chronic strains are injuries that gradually build up from overuse or repetitive stress, resulting in tendinitis

3. Fractures The continuity of the bone is disrupted Fracture types: Stable fracture. The broken ends of the bone line up and are barely out of place. Open, compound fracture. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture. This type of fracture has a horizontal fracture line. Oblique fracture. This type of fracture has an angled pattern. Comminuted fracture. In this type of fracture, the bone shatters into three or more pieces. Others; site specific

4. Fracture Types

5. Ankle Sprains An ankle sprain is usually that of an inversion-type twist of the foot, followed by pain and swelling. The most commonly injured site is the lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.

6. Ankle Sprains

7. Ankle Sprains: Mechanism

8. Ankle Sprains: Classification Grade 1 injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight. Grade 2 injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients usually have difficulty bearing weight. Grade 3 injuries involve complete rupture of the ligament, with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing severe pain.

9. Ankle Sprains: Classification

10. Ankle Sprains: Patho During forced dorsiflexion, the posterior talofibular ligaments (PTFL) can rupture. With forced internal rotation, anterior talofibular ligament (ATFL) rupture is followed by injury to the PTFL. Extreme external rotation disrupts the deep deltoid ligament on the medial side, and adduction in neutral and dorsiflexed positions can disrupt the calcaneofibular ligament (CFL). In plantarflexion, the ATFL can be injured.

11. Ankle Sprains: Etiology There are a number of contributing factors, which can be classified as either predisposing or provocative: Predisposing factors can result from a lack of physical conditioning; they include poor muscle tone and shortened and/or contracted joint capsule or tendons. Poor proprioception can also be a factor, as can inadequate training or experience with the physical activity being performed. Provocative factors include accidents and other unforeseen circumstances that result in mechanical stresses that exceed the tensile limits of the ankle joint capsule and ligaments. Obesity can contribute to sprains by increasing kinetic energy to a point that exceeds joint-design stress limits.

12. Ankle Sprains: Etiology Recurrent sprains: The exact etiology of recurrent ankle sprains is unknown; however, many factors may play a role One possibility is that recurrent sprains result primarily from ligaments healing in a lengthened position due to scar tissue filling in the gap between the torn, separated ends The weakness of the healed ligament may be due to the inherent weakness of the scar. In a study by Bosien et al, 22% of patients with recurrent ankle sprains had persistent peroneal weakness. The authors believed that this contributed to recurrent injury, especially in incompletely rehabilitated ankle sprains.

13. Ankle Sprains: Epidemiology Most ankle sprains are self-treated and are never reported to a health care provider Estimated to constitute up to 30% of injuries seen in sports medicine clinics and are the most frequently seen musculoskeletal injury seen by primary care providers. More than 23,000 people per day in the United States, including athletes and nonathletes, require medical care for ankle sprains Female athletes are 25% more likely to sustain ankle injuries than male athletes Female basketball players are at a higher risk of a first-time inversion injury than those participating in other sports Males who performed at a higher level of athletic competition; male athletes were 3 times more likely to experience medial ankle sprains than female athletes

14. Ankle Sprains: Prognosis In a systematic literature review, 36-85% of patients with acute ankle sprains reported full recovery at 2 weeks to 36 months, independent of the initial grade of sprain, with most recovery occurring within the first 6 months 3-34% of patients reported re-sprains at 2 weeks to 96 months after the initial injury (Verhagen, de Keizer, & van Dijk, 1995) If recurrent ankle sprains are treated early and appropriate rehabilitation is initiated, the prognosis is excellent with conservative treatment

15. Ankle Sprains: History Mechanism of injury: usually of an inversion-type twist of the foot followed by pain and swelling Past history of any ankle injuries, treatment and results Level and intensity of their sports and activity Medical history Determine the presence of any complicating conditions, such as arthritis, connective tissue disease, diabetes, neuropathy, or trauma

16. Ankle Sprains: PE Look for areas of tenderness and swelling Ecchymosis may be present and may be tender The degree of swelling or ecchymosis may be proportional to the likelihood of fracture No bony point tenderness should be present Active ROM Anterior drawer test Talar tilt test External rotation test Neurovascular assessment

17. Anterior drawer test https://www.youtube.com/watch?v=dprnjn_OTzo

18. Talar Tilt Test https://www.youtube.com/watch?v=Ow8Y-HJwGqA

19. External Rotation Test https://www.youtube.com/watch?v=3CwG4VfLyHw

20. Differential If pain persists despite rehabilitation, diagnoses to consider include Intra-articular meniscoid lesions ; also is known as impingement syndrome. Peroneal tendon subluxation Talar dome fracture Anterior process fracture of the calcaneus Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy Others Achilles tendon rupture Fracture

21. Diagnostics: X-rays The use of radiographs is guided by the Ottawa Ankle Rules. An ankle x-ray is required only if the patient has pain in the malleolar zone and any of the following 3 findings Bone tenderness at the posterior edge or tip of the lateral malleolus (ie, the lower 6 cm of the fibula) Bone tenderness at the posterior edge or tip of the medial malleolus (ie, the lower 6 cm of the tibia) Inability to bear weight immediately after the injury and in the emergency department

22. Diagnostics: X-rays

23. OR A foot radiographic series is required only if the patient has any pain in the midfoot zone and any of the following 3 findings: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight immediately after the injury and in the emergency department

24. Other Diagnostics Stress Films CT May be indicated if imaging of soft tissues is warranted or if bone imaging beyond radiography is indicated Useful for evaluating osteochondritis dissecans and stress fractures MRI May be a useful evaluation when a syndesmotic or high ankle sprain is suspected or if osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain Bone Scan Can detect subtle bone abnormalities (e.g., stress fracture, osteochondral defects)

25. Ankle Sprains: Acute Treatment The goals of acute treatment are to control pain, minimize swelling, and maintain or regain ROM Should last for 1-3 days after the injury Rest, ice, compression, and elevation (RICE) OR Protection, relative rest, ice, compression, elevation, and support (PRICES) Depending on the severity, protective devices are used for 4-21 days Criteria for discontinuing use of a device include Minimal swelling and pain ROM should be smooth, particularly with dorsiflexion and plantar flexion Relative rest Use of posterior splinting and crutches with non–weight-bearing ambulation I For more severe ankle sprains (ie, when foot motion and weight bearing are extremely painful)

26. Ankle Sprains: Acute Treatment Pain Control NSAIDs use is controversial Some argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, which ultimately increases the speed of recovery. Others believe that acutely used NSAIDs can lead to increased swelling if, owing to platelet inhibition, bleeding occurs. Acetaminophen

27. Ankle Sprains: Chronic Treatment Recurrent lateral ankle sprains, Treatment should begin with a trial of conservative therapy for approximately 2-3 months The treatment goals include the patient regaining full strength in the affected ankle Provide protective support as needed Returning to activity participation Use of ROM and strength exercises, Weight-bearing, Multidirectional balance exercises May require referral to orthopedics or podiatry PT

28. Ankle Sprain: Indications for Surgical Intervention Absolute indications for surgery A distal talofibular ligament third-degree sprain that causes widening of the ankle mortise A deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise In selected young patients with high athletic demands who have both anterior talofibular and calcaneofibular complete ruptures, surgical repair may be the treatment of choice.

29. Return to Activity Return-to-play criteria during the recovery phase (3 d to 2 wk post injury) include the following: Full, pain-free active and passive ROM No pain or tenderness Strength of ankle muscles 70-80% of that on the uninvolved side Ability to balance on 1 leg for 30 seconds with eyes closed Return-to-play criteria during the functional phase (2-6 weeks postinjury) include the following: Normal ROM of the ankle joint No pain or tenderness Satisfactory clinical examination Strength of ankle muscles 90% of the uninvolved side Ability to complete functional examination

30. References Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114(2):92-6. [Medline].[Medline]