Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm

Hans Polzer, Karl Georg Kanz, Wolf Christian Prall, Florian Haasters, Ben Ockert, Wolf Mutschler, Stefan Grote, Hans Polzer, Karl Georg Kanz, Wolf Christian Prall, Florian Haasters, Ben Ockert, Wolf Mutschler, Stefan Grote

Abstract

Acute ankle injuries are among the most common injuries in emergency departments. However, there are still no standardized examination procedures or evidence-based treatment. Therefore, the aim of this study was to systematically search the current literature, classify the evidence, and develop an algorithm for the diagnosis and treatment of acute ankle injuries. We systematically searched PubMed and the Cochrane Database for randomized controlled trials, meta-analyses, systematic reviews or, if applicable, observational studies and classified them according to their level of evidence. According to the currently available literature, the following recommendations have been formulated: i) the Ottawa Ankle/Foot Rule should be applied in order to rule out fractures; ii) physical examination is sufficient for diagnosing injuries to the lateral ligament complex; iii) classification into stable and unstable injuries is applicable and of clinical importance; iv) the squeeze-, crossed leg- and external rotation test are indicative for injuries of the syndesmosis; v) magnetic resonance imaging is recommended to verify injuries of the syndesmosis; vi) stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications; vii) early functional treatment leads to the fastest recovery and the least rate of reinjury; viii) supervised rehabilitation reduces residual symptoms and re-injuries. Taken these recommendations into account, we present an applicable and evidence-based, step by step, decision pathway for the diagnosis and treatment of acute ankle injuries, which can be implemented in any emergency department or doctor's practice. It provides quality assurance for the patient and promotes confidence in the attending physician.

Keywords: ankle injury; ankle sprain; diagnosis; evidence based algorithm; treatment..

Figures

Figure 1
Figure 1
Flow chart for selecting articles to be included in the study.
Figure 2
Figure 2
Ottawa foot and ankle rule. Anatomy of the right foot and ankle. The regions that must be examined for bone tenderness are labeled in black. (A–B) Ottawa Ankle Rule. (C–D) Ottawa Foot Rule.
Figure 3
Figure 3
Algorithm for diagnosis and treatment of acute ankle injuries.
Figure 4
Figure 4
Clinical tests of the lateral ligament complex. (A) The anterior drawer test for the anterior talofibulare ligament (ATFL) is performed with the knee joint flexed. The ankle joint is held in 10–15° plantar flexion, and the clinician presses the heel forward while holding back the tibia. (B) The talar tilt test for the ATFL and calcaneofibular ligament (CFL) is carried out with the ankle in the neutral position. The heel is held stable while inverting the talus and calcaneus on the tibia.
Figure 5
Figure 5
Clinical tests for injury of the syndesmosis. The tests are considered positive if pain is triggered in the area of the syndesmosis. (A) The external rotation test is performed with the tibia fixed and an external rotation is applied. (B) For the squeeze test, the tibia and fibula are compressed above the midpoint of the calf. (C) For the crossed leg test, the patient places the leg to be tested across the kneecap of the other leg. The pivot point is at the junction of the middle and distal thirds of the tibia and a gentle force is applied on the medial side of the knee by the patient.

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Source: PubMed

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