Emergency Medicine

312 Orthopaedic Emergencies

INJURIES TO THE LOWER TIBIA, ANKLE AND FOOT

Other ankle injuries

DIAGNOSIS

1 Eversion injuries damaging the medial malleolus and medial deltoid

ligament, hyperflexion injuries or rotational injuries tend to cause more

complicated damage.

2 Examine the ankle as before to localize the maximum area of tenderness.

(i) Palpate the upper fibula for pain suggesting a high, oblique

fracture (Maisonneuve) in addition.

(ii) The Maisonneuve fracture is a rare, unstable ankle injury

associated with a widened ankle mortice and tibiofibular diastasis

from tearing of the syndesmosis.

3 X-ray all patients meeting the Ottawa criteria on page 311, and include the

upper tibia and fibula if there is proximal bony tenderness.

MANAGEMENT

1 Refer all fractures, a widened ankle mortice, or patients who are totally

unable to bear weight, to the orthopaedic team.

2 Otherwise treat as in point (3) on page 311.

Dislocation of the ankle

DIAGNOSIS AND MANAGEMENT

1 This dislocation is most commonly posterior and is clinically obvious.

2 Give morphine 5 mg i.v. and metoclopramide 10 mg i.v. and X-ray

immediately.

3 Then use procedural sedation with a second doctor present in a monitored

resuscitation area to reduce this urgently, to prevent ischaemic pressure

necrosis of the skin stretched across the malleolus.

4 Reduce the ankle dislocation by steady traction on the heel, applying gentle

dorsif lexion to the foot.

5 After the reduction, re-examine the neurovascular status, and support the

lower leg in a plastic splint or padded plaster backslab, before sending the

patient for post-reduction X-rays.

6 Refer the patient to the orthopaedic team.

Fractures and dislocation of the talus

DIAGNOSIS

1 The talus articulates in three joints: the ankle joint with the tibia and fibula,

the subtalar joint with the calcaneus, and the mid-tarsal joint with the navic-

ular (along with the calcaneus and cuboid).