Emergency Medicine

310 Orthopaedic Emergencies

INJURIES TO THE LOWER TIBIA, ANKLE AND FOOT

2 Refer all other tibial shaft fractures to the orthopaedic team, after giving the

patient analgesia and applying a long-leg plaster of Paris backslab with the

knee slightly f lexed, and the ankle at a right-angle.

ISOLATED FRACTURES OF THE FIBULA

DIAGNOSIS AND MANAGEMENT

1 Associated with a direct blow to the lateral aspect of the lower leg, typically

when playing football.

2 Patients present with local pain, swelling and difficulty walking.

3 Perform a neurovascular assessment especially for an isolated proximal

fracture to exclude damage to the common peroneal nerve causing foot drop.

4 Request full-length anteroposterior and lateral X-rays of the tibia and fibula,

including the ankle and knee joints.

5 Provided there is definitely no injury to the ankle, and no tibial fracture at

another level, apply:

(i) Either a firm crêpe bandage with cotton-wool padding.

(ii) Or a below-knee walking plaster, which affords more protection.

6 Refer the patient to the next fracture clinic.

Inversion ankle injuries

DIAGNOSIS

1 These injuries are common following sports or tripping on a staircase or on

uneven ground.

2 The aim of clinical examination is to distinguish a ligament tear from bony

injury, and to assess the stability of the ankle.

3 Immediate swelling and inability to weight-bear suggest a fracture or serious

ligament tear.

(i) Examine the ankle for evidence of pain over the following specific

sites:

(a) distal fibula and lateral malleolus

(b) distal tibia and medial malleolus

(c) medial (deltoid) ligament and lateral ligament (anterior

talofibular, middle calcaneofibular and posterior talofibular

portions) of the ankle

(d) anterior tibiofibular ligament

(e) base of the fifth metatarsal, navicular and calcaneus

(f) proximal fibula head (for the uncommon but serious

Maisonneuve fracture).

4 Ottawa ankle rules

These prospectively validated clinical decision rules reduce the number of

ankle X-rays requested, without missing clinically significant fractures.