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Orthopedics: Strains,
Sprains, and Fractures
Nursing 870
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
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
Fracture Types
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.
Ankle Sprains
Ankle Sprains: Mechanism
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.
Ankle Sprains: Classification
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.
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.
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.
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
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
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
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
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No bony point tenderness should be present
Active ROM
Anterior drawer test
Talar tilt test
External rotation test
Neurovascular assessment
Anterior drawer test
https://www.youtube.com/watch?v=dprnjn_OTzo
Talar Tilt Test
• https://www.youtube.com/watch?v=Ow8Y-HJwGqA
External Rotation Test
• https://www.youtube.com/watch?v=3CwG4VfLyHw
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
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
Diagnostics: X-rays
Diagnostics: X-rays
• 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
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)
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)
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
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
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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
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.
Return to Activity
• Return-to-play criteria during the recovery phase (3 d to 2 wk
post injury) include the following:
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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:
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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
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].