Ankle Sprains and Fractures in Aduls

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314 Orthopaedic Nursing November/December 2009 Volume 28 Number 6

tarflexed. The ATFL is the weakest of the lateral ankleligaments and is often the ligament sprained when a pa-tient sustains an ankle sprain. The PTFL, like the ATFL,connects the talus and tibia but provides stability to theposterior aspect of the lateral ankle. The CFL providesankle stability by connecting the calcaneus and the lat-eral malleolus and limiting ankle inversion. The CFL isthe strongest of the lateral ankle ligaments. It is at riskof a sprain if the ankle is dorsiflexed and an inversionforce is applied (Griffen, 2005; Koval & Zuckerman,2002).

Medially, the ankle is stabilized by the deltoid liga-ment. This ligament complex has a deep and superficialcomponent. The deltoid ligaments are stout and requirea higher energy of force (compared with the lateralankle ligaments) before injury occurs. The deltoid liga-ment provides stability against lateral displacement ofthe talus. Isolated injuries to the deltoid ligaments arerare and occur from an eversion injury (Carr, 2008;Griffen, 2005; Koval & Zuckerman, 2002).

The ankle syndesmotic ligaments are located justproximal to the ankle joint. The syndesmotic ligamentsconnect the tibia shaft and the fibula shaft and holdthem into position within the tibial plafond or anklejoint. The syndesmosis of the ankle consists of threemain ligaments: the anterior inferior tibiofibular liga-ment, the interosseous ligaments, and the posterior in-ferior tibiofibular ligament (Carr, 2008; Griffen, 2005;Koval & Zuckerman, 2002). The syndesmotic ligamentsresist axial and rotation forces against the ankle. Theseligaments are important in the maintenance of anklejoint alignment. Even a slight 1-mm shift of the positionof the tibias articulation with the talus can result in al-teration of weight distribution upon the talus, leading toearly arthritis (Carr, 2008; Koval & Zuckerman, 2002).

Ankle biomechanics can vary slightly from person toperson. However, even a small shift of tibiotalar align-ment can result in poor outcome after ankle injury asankle injury outcomes are highly dependent on thealignment of the ankle mortise (McConnell, Creevy, &Tornetta, 2004). In the stance phase, the ankle carries

The orthopaedic nurse will undoubtedly care for patients

with ankle injuries. Ankle sprains and fractures are common

injuries seen in orthopaedic practices in the United States.

To provide comprehensive nursing care of these injuries,

nurses should understand ankle biomechanics as well as

anatomy. Knowledge of fracture classification schemes,pathology of injury, and treatment modalities is also

important. Fracture classification schemes vary as do

treatment modalities. Ankle sprains and fractures can be

treated operatively or nonoperatively, and orthopaedic

nurses play an important role in the care of patients with

such ankle injuries.

Ankle sprains and fractures are common injuriesencountered in the orthopaedic setting. Fivemillion ankle injuries occur annually in theUnited States with ankle sprains accounting for

40% of sports injuries (Griffen, 2005). The orthopaedic

clinician must understand ankle biomechanics, fractureclassification schemes, pathophysiology of injury, andtreatment modalities to care for the patient with anankle injury.

Ankle Anatomy and BiomechanicsUnderstanding ankle anatomy and biomechanics is im-portant to understanding ankle injuries. The ankle hasseveral bony landmarks. Three bones articulate to formthe ankle joint: the fibula, the tibia, and the talus (seeFigure 1). The lateral malleolus of the fibula and the me-dial malleolus of the tibia provide the palpable land-marks of the ankle. The distal tibial articular surface iscalled the plafond or pilon. The plafond articulates with

the talus and together, the plafond and talus distributethe stress of weight bearing through the ankle joint(Carr, 2008; Griffen, 2005; Koval & Zuckerman, 2002).

Laterally, the ankle is supported by three ankle liga-ments: the anterior talofibular ligament (ATFL), cal-caneal fibular ligament (CFL), and the posteriortalofibular ligament (PTFL; see Figure 2). All three lat-eral ankle ligaments work together to provide lateralstability to the ankle joint. The ATFL connects the fibulaand talus and maintains stability of the anterior aspectof the lateral ankle. The ATFL provides stability againstanterior movement of the talus when the ankle is plan-

Kelly Small, MSN, RN, FNP-BC, Family Nurse Practitioner, StudentHealth Center, University of Missouri, Columbia.

The author has disclosed that she has no financial relationships relatedto this article.

Ankle Sprains and Fractures in AdultsKelly Small

ORTHOPAEDICESSENTIALS

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Orthopaedic Nursing November/December 2009 Volume 28 Number 6 315

up to four times an individuals body weight (Koval &Zuckerman, 2002).

Dorsiflexion and plantarflexion are the primary mo-tions that occur at the ankle joint. Normal ankle rangeof motion (ROM) is 30 of ankle dorsiflexion and 45 ofplantarflexion. However, only 10 of dorsiflexion and20 of plantarflexion are needed for normal gait (Koval

& Zuckerman, 2002). Inversion and eversion move-ments of the ankle are also important for normal gait.The subtalar joint (joint between the talus and calca-neus) allows for inversion and eversion movements ofthe ankle.

Ankle ExaminationWhen assessing a patient with ankle injury, a history ofthe injury should be obtained from the patient first. Theclinician should ask the patient to describe the activityor movement that caused the injury and when the injuryoccurred. It is important to note whether painprevented the patient from weight bearing after theinjury. This information will help guide the clinician inthe determination of the need for radiographs. The clin-ician will find it helpful to ask the patient to point tospecifically where the pain occurs and to inquire aboutalleviating and aggravating factors. The patient shouldbe assessed for comorbidities such as diabetes that canprolong healing times and increase the risk for woundand other complications. The patient should also be

questioned about prior injuries to the ankle or chronicfeelings of ankle instability.

Physical examination of the ankle begins withinspection of the skin for ecchymosis and swelling,which are usually present. Palpation of the ankle forareas of point tenderness is necessary. Areas of maximaltenderness are used to determine the need for radi-ographic studies (Bachmann, Kolb, Koller, Steurer, &Riet, 2003). The clinician should palpate over themedial and lateral ankle ligaments as well as over thesyndesmotic ligament to assess for pain. Pain withpalpation of the ligaments suggests a ligamentous in-jury. ROM and strength of the ankle should be assessed;however, the patient seen after an acute injury will havedecreased strength and ROM due to pain.

Several tests have been described in the literature toassess the ankle, but the sensitivity and specificity ofthese tests are unknown (Williams, Jones, & Amendola,2007). Examination of ankle stability includes the talartilt and anterior drawer test. The anterior drawer test(see Figure 3) is performed by stabilizing the distal tibiaarea with one hand and pulling forward on the foot with

FIGURE 1. Landmarks of the ankle joint. The circle demon-strates a lateral malleolus fracture (Weber type A). This lateralmalleolus fracture was treated without surgery, and the patientwas allowed to weight bear as tolerated in a fracture boot.

FIGURE 2. Lateral ankle ligaments and ankle anatomy. ATFL,anterior talofibular ligament; CFL calcaneal fibular ligament;PTFL posterior talofibular ligament. FIGURE 3. Demonstration of the anterior drawer test.

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the other hand. This should be performed on the unin-jured side to compare. Greater anterior translationwhen compared with the uninjured side is positive foran ankle sprain involving the ATFL. The talar tilt (seeFigure 4) involves stressing the CFL by placing one handon the distal tibia and providing inversion stress on theankle with the other hand. A positive talar tilt occurswhen the ankle inverts more than the contralateral, un-injured side (Griffen, 2005). It is often impossible to usethese tests in examination of the acute ankle sprain be-cause of the amount of pain the patient is experiencing.These tests are often used to assess ligament stabilityafter adequate healing time.

Next, the clinician should evaluate the syndesmosis.The squeeze test (see Figure 5) is used to evaluate syn-

desmotic injury. This is performed by squeezing thetibia and fibula together at mid-calf. Pain in the area ofthe syndesmosis (anterior ankle, just above the anklejoint) can be a clue to syndesmotic injury. Pain in thesyndesmotic area with external rotation of the ankle isalso indicative of syndesmotic sprain (Koval &Zuckerman, 2002).

RadiographyThe need for radiographing patients with ankle injury isguided by the Ottawa Ankle Rules. The Ottawa AnkleRules have 100% sensitivity in determining the need forankle radiographs of patients with a history of ankleinjury (Bachmann et al., 2003). Table 1 outlines findings

that require the clinician to order ankle radiographs,according to the Ottawa Ankle Rules.If the need for radiographs is determined, the ankle

should be evaluated with anterior posterior, lateral, andmortise views. A mortise view is taken with the leg in-ternally rotated 1520 (Koval & Zuckerman, 2002).Sometimes a stress view of the ankle is used. In the ex-ternal rotation stress view, the clinician holds the leg inan internally rotated position with one hand as if takinga mortise view. With the other hand, the clinician dorsi-flexes the ankle to neutral position and externallyrotates the ankle. This view stresses the medial ankle lig-aments and syndesmotic ligaments to assess forcomplete rupture or injury. If there is severe enoughinjury, the medial mortise space is increased and the

talus will displace laterally toward the fibula (Koval &Zuckerman, 2002; McConnell et al., 2004).

Ankle SprainsSprains of the ankle are common. Lateral ankle liga-ment injuries account for most sprains because theankle biomechanics and anatomy place it at most risk tosustain inversion injuries (Carr, 2008). Most sprainsoccur from a plantarflexed and inverted injury to theankle (DiGiovanni, Partal, & Baumhauer, 2004; Griffen,2005). Usually, the ATFL is injured first and if the forceis great enough, the CFL sustains an injury. Anklesprains are sometimes graded from 1 to 3, depending onthe severity of the injury. Grade 1 sprains are consid-

ered mild sprains; grade 3 sprains are the most severe.Treatment of ankle sprains is usually accomplished

in phases. Phase 1 consists of a common acronymPRICE (Osborne & Rizzo, 2003) used in the treatmentof ankle sprains. Another acronym, PRINCE, is pre-ferred by the author. Protection, Rest, Ice, Nonsteroidalanti-inflammatory drugs (NSAIDS), Compression, andElevation are all important in healing of an anklesprain. The ankle should be protected from further

FIGURE 4.Talar tilt test.

FIGURE 5. Squeeze test. A positive test is noted if there is painin the area of the syndesmosis (noted by the circle).

TABLE 1. OTTAWA ANKLE RULES

Inability to bear weight immediately after injury and when

seen for examination

Complaints of pain in the midfoot or around the medial/lateral malleoli

Pain to palpation on the posterior half or tip of the lateral

malleolus

Pain to palpation on the posterior half or tip of the medial

malleolus

Pain to palpation on the base of the fifth metatarsal

Pain to palpation of the navicular bone

Note. Based on Accuracy of Ottawa Ankle Rules to ExcludeFractures of the Ankle and Mid Foot, by L. M. Bachmann, E.Kolb, M. T. Koller, J. Steurer, and G. Riet, 2003, British Medical

Journal, 326, pp. 417419.

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ankle fracture, and Figure 7 depicts a bimalleolar equiv-alent fracture. Trimalleolar fractures (see Figure 8)refer to fracture of the medial malleolus (or deltoid liga-ment rupture) and a lateral malleolus fracture with theaddition of a posterior malleolar, or posterior tibia,fracture (Carr, 2008; Koval & Zuckerman, 2002).

Pilon fractures (see Figure 9) are a variant of anklefractures of the tibia that involve the major weight-bear-ing part of the ankle joint, the tibial plafond. Pilon frac-tures are severe in nature and occur from axial loadingmechanisms (Koval & Zuckerman, 2002). The force sus-tained, when a person falls off a ladder and lands on thefeet, is an example of an axial loading mechanism thatcan lead to a pilon fracture. Pilon fractures requiremuch more extensive fixation than a basic ankle frac-ture. Patients are required to be nonweight bearing

longer and have longer recovery periods (Pollak,McCarthy, Bess, Agel, & Swiontkowski, 2005).Two common classification schemes are used to clas-

sify ankle fractures. Danis-Weber classification is asimple classification of three basic types of ankle frac-tures based on the level of the fibula fracture. Type Afractures are fractures of the fibula distal to the jointline or ankle mortise. Type B fractures are fracturesoccurring at the level of the mortise. One half of Webertype B injuries have concurrent injury to the syn-desmotic ligaments as well (Baumhauer, Nawoczenski,DiGiovanni, & Flemister, 2004). Type C fractures refer

to fibular fractures occurring proximal to level of theankle joint. The majority of these fractures have anassociated injury to the ankle syndesmosis (Carr, 2008;Koval & Zuckerman, 2002).

A downfall of the Danis-Weber classification systemis that it accounts only for injuries to the fibula. Often,injuries to the posterior and medial aspects of the ankle

FIGURE 7. Radiographs of a bimalleolar equivalent ankle frac-ture. This fracture can also be classified as a Weber type B frac-ture or supination-external rotation fracture according to Lauge-Hansen. (A) Radiographs taken after injury. The white arrowdemonstrates the fracture of the lateral malleolus. The blackarrow demonstrates medial mortise widening consistent withdeltoid and syndesmosis ligament injury. (B) Postoperativex-rays. This patient required only fixation of the lateral malleo-lus because there was enough ligamentous intactness to keepthe joint stable after lateral fixation alone.

FIGURE 8. Trimalleolar ankle fracture. (A) Lateral radiographshowing the posterior malleolus fracture (P) and (B) anteriorposterior radiograph showing the lateral malleolus fracture(L) and medial malleolus fracture (M). Radiographs (C and D)taken postoperatively showing fixation of the medial and lateralmalleolus fracture. A screw was placed across the syndesmosisbecause it was unstable on intraoperative examination.

FIGURE 9. Radiographs of a pilon fracture. Anterior posteriorview (A) and lateral view (B) of the patient on initially presen-tation to emergency department. The fibular fracture was fixedand an external fixator was placed (C), and then the patientwas taken to the operating room 10 days later for definitivefixation of the tibia (D).

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joint also occur in addition to lateral injuries of thefibula. A second classification, Lauge-Hansen, accountsfor the full set of injuries. Ankle fractures are classifiedon the basis of mechanism of injury and pathology. Thefirst part of the classification scheme refers to the posi-tion of the ankle at the time of injury. Two positions areidentified: pronation and supination. Second, the type

of force applied to the ankle is noted. This can beadduction, external rotation, or abduction (Carr, 2008;Koval & Zuckerman, 2002).

There are four Lauge-Hansen classifications combin-ing the position and type of force: supination-adduction,supination-external rotation, pronation-abduction, andpronation-external rotation. Lauge-Hansen furtherdivided each classification into phases (Carr, 2008;Koval & Zuckerman, 2002). Some ankle injuries canpass through a total of four phases or stop at the first,second, or third phase. In supination injuries, the forceof injury starts on the lateral ankle and these structuresfail first. In pronation injuries, the medial ankle is placedunder tension first and the medial ankle is injured first.

Ankle Fracture TreatmentIn the emergency department, ankle fractures arereduced under conscious sedation, and splints are placed.If the fracture is open or a dislocation is unable to bereduced, the patient is taken to the operating roomurgently (Carr, 2008).

Some fractures are able to be treated without surgery.Isolated Weber type A (unimalleolar fractures below thesyndesmosis; see Figure 1) can be treated withoutsurgery in a fracture boot or an air splint. Early weightbearing is allowed. Treatment plans for stable Webertype B fractures vary among institutions as there is not aclear consensus on a gold standard for nonoperativetreatment of these fractures. Weber type B fractures con-sidered to be stable on stress radiographs are those iso-lated fibular fractures with no syndesmotic widening onstress radiographic views of the ankle (see Figure 10).These injuries are usually treated in fracture boots orankle splints. Early weight bearing is usually allowed, al-though sometimes weight bearing is restricted for 6weeks (Port, McVie, Naylor, & Kreibich, 1996).

Unstable Weber type B fractures and all Weber typeC fractures require surgical management. If surgery isrequired for an ankle fracture, the patients most oftenundergo open reduction and internal fixation. Open re-duction refers to incisional exploration of the fracturesite with reduction of the fracture fragments. Internalfixation involves placement of implants, usually plate

and screws, to hold the fracture in place. After fixationof the lateral malleolus, the ankle is stressed duringsurgery to determine the stability of fixation. If lateralmalleolus fixation alone is not stable enough, more fixa-tion is required (see Figure 9). Patients are placed insplints immediately after the operation and are usuallyplaced in a removable fracture boot after 12 weeks.Usually, patients are required to be nonweight bearingfor 6 weeks until radiographic findings show adequatehealing (Carr, 2008; Koval & Zuckerman, 2002). Afterhealing, patients are allowed to progress their weightbearing and wean out of the fracture boot.

Nursing CareThe patient with an ankle sprain or fracture will requireastute nursing care. Education for patients with ankleinjuries is paramount. These patients do not plan for theinjury or surgery (if needed) and thus patients are oftenfrustrated and anxious. Helping the patients under-stand their injuries is an important role of the nurse.Educating on the rationale for weight-bearing restric-tions and fracture boots/casts as protecting the anklefrom further injury helps the patients adhere to their re-strictions. Many patients are frustrated by restrictionsof their daily activities but need to understand the im-portance of adhering to their discharge plan (Kneale &Davis, 2006; Maher, Salmond, & Pellino, 2002).

Patients should also be counseled about the effectslifestyle and comorbidities may have on their injury.

Tobacco cessation should be encouraged and resourcesfor tobacco cessation should be provided for all tobaccousers, as nicotine can cause wound complications anddelayed bone healing. Patients with diabetes should becounseled on tight glycemic control so that healing isnot delayed. Patients with diabetes will also need to bemonitored more frequently with postoperative clinicvisits, especially if diabetic neuropathy is present.Patients with diabetic neuropathy are at higher risk ofskin breakdown, wound problems, and development ofpostoperative Charcot foot and ankle abnormalities(Kneale & Davis, 2006; Maher et al., 2002). In addition,

FIGURE 10. Stable external rotation stress view. The medialmortise and syndesmosis do not widen when external rotationstress is applied while the x-ray is taken. This patient can betreated without surgery and was treated in a walking boot for6 weeks and allowed to weight bear as tolerated.

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patients should also be counseled to avoid NSAIDS asthey can delay bone healing (Simon, Manigrasso, &OConnor, 2002).

Postoperative pain management is also important.Monitoring for pain and providing pain relief are impor-tant in the immediate postoperative period. After24 hr, most patients can be managed with oral pain med-

ications at home (Smith, Agudelo, Parekh, & Shank, 2006).

RecoveryReturn to full activities is usually not encouraged untilaround 68 weeks after an ankle sprain (DiGiovanniet al., 2004; Osborne & Rizzo, 2003). At this point, thecollagen fibers are strong enough to withstand moststressors (DiGiovanni et al., 2004).

Recovery time is longer after an ankle fracture.Patients should use caution as total healing and remod-eling of the injured ligaments and bones can take up to612 months. Most patients are allowed to begin return-ing to normal activities after about 3 months as long asthe fracture shows signs of healing on radiographs

(Carr, 2008). However, when returning to daily activi-ties, such as driving, patients should be counseled onbeing cautious. Egol, Shelkhazadeh, Mogatederi,Barnett, and Koval (2003) found that it took up to 9weeks after an ankle fracture for braking reaction timeto return to normal.

Prevention of future injury is important after anklefracture and injury. Muscle weakness and imbalancecan lead to recurrent ankle sprains, so adequate physi-cal therapy is important to decrease the chance offuture ankle sprain and injury (Baumhauer et al., 2004).Ankle taping and lace-up ankle braces are two mecha-nisms that have been found to reduce recurrence ofankle injuries in athletes (DiGiovanni et al., 2004).

Determining when an athlete can return to sports

after ankle injury is not an exact science. Richie (2006)recommended assessing for several tasks before the pa-tient returns to play. One method includes asking thepatient to run down stairs. The patient with unstable orweak ankle ligaments will be apprehensive to do this. Inaddition, assessing to see whether the patient can standon his or her toes and heels and balance solely on the in-jured leg can be used to assess for readiness to return toplay (Richie, 2006).

Ankle injuries and fractures are common orthopaedicdiagnosis encountered by the orthopaedic clinician.Proper knowledge, assessment, and management ofthese injuries are important for orthopaedic nurses in awide variety of settings.

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ving an automobile after operative treatment of anklefracture. Journal of Bone and Joint Surgery, 85,17161724.

Griffen, L. (Ed.). (2005).Essentials of musculoskeletal care.Rosemont, IL: American Academy of OrthopaedicSurgeons.

Koval, K. J., & Zuckerman, J. D. (Eds.). (2002).Handbookof fractures (3rd ed.). Philadelphia: Lippincott Williams& Wilkins.

Kneale, J. D., & Davis, P. S. (Eds.). (2006). Orthopaedic andtrauma nursing. London: Churchill Livingstone.

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Maher, A. B., Salmond, S. W., & Pellino, T. A. (Eds.).Orthopaedic nursing (3rd ed.). Philadelphia: W. B.Saunders.

McConnell, T., Creevy, W., & Tornetta, P. (2004). Stress ex-amination of supination external rotation-type fibularfractures. Journal of Bone and Joint Surgery, 86,21712178.

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Osborne, M. D., & Rizzo, T. D. (2003). Preventions and

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Swiontkowski, M. F. (2003). Outcomes after treatmentof high-energy tibial plafond fractures.Journal of Bone

and Joint Surgery, 85(10), 18931900.Port, A. M., McVie, J. L., Naylor, G., & Kreibich, D. N.

(1996). Comparison of two conservative methods oftreating an isolated fracture of the lateral malleolus.

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For more than 30 additional continuing nursing education articles

related to orthopaedic topics, go to www.nursingcenter.com/ce.

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