Imaging

About 15 per cent of ankle sprains reaching the Emergency Department are associated
with an ankle fracture. This complication can be excluded by obtaining an x-ray, but there are
doubts as to whether all patients with ankle injuries should be subjected to x-ray examination.
Almost 2 decades ago The Ottawa Ankle Rules were developed to assist in making this
decision. X-ray examination is called for if there is: (1) pain around the malleolus; (2)
inability to take weight on the ankle immediately after the injury; (3) inability to take four
steps in the Emergency Department; (4) bone tenderness at the posterior edge or tip of the
medial or lateral malleolus or the base of the fifth metatarsal bone. If x-ray examination is
considered necessary, anteroposterior, lateral and mortise (30-degree oblique) views of the
ankle should be obtained. Localized soft tissue swelling and, in some cases, a small avulsion
fracture of the tip of the lateral malleolus or the anterolateral surface of the talus may be the
only corroborative signs of a lateral ligament injury. However, it is important to exclude other
injuries, such as an undisplaced fibular fracture or diastasis of the tibiofibular syndesmosis. If
tenderness extends onto the foot, or if swelling is so severe that the area cannot be properly
examined, additional x-rays of the foot are essential.
Persistent inability to weightbear over 1 week or longer should call for re-examination
and review of all the initial negative x-rays. For patients who have had persistent pain,
swelling, instability and impaired function over 6 weeks or longer, despite appropriate early
treatment, magnetic resonance imaging (MRI) or computed tomography (CT) will be required
to assess the extent of soft tissue injury or subtle bony changes.
Treatment
Initial treatment consists of rest, ice, compression and elevation (RICE), which is
continued for 13 weeks depending on the severity of the injury and the response to
treatment. Cold compresses should be applied for about 20 minutes every 2 hours, and after
any activity that exacerbates the symptoms. More recently the acronym has been extended to
PRICE by adding protection (crutches, splint or brace) and still further to PRICER, adding
rehabilitation (supported return to function). The principles remain the same a phased
approach, to support the injured part during the first few weeks and then allow early
mobilization and a supported return to function. An advice leaflet for patients is probably
helpful. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in the acute phase can be
helpful, with the usual contraindications and caveats. There is evidence that in acute injuries
topical non-steroidal anti-inflammatory (NSAI) gels or creams might be as beneficial as oral
preparations, probably with a better risk profile. Functional treatment, i.e. protected
mobilization, leads to earlier recovery of all grades of injury without jeopardizing stability
than either rigid immobilization or early operative treatment.
OPERATIVE TREATMENT
If the ankle does not start to settle within 1 or 2 weeks of starting RICE, further
review and investigation are called for. Persistent problems at 12 weeks after injury, despite
physiotherapy, may signal the need for operative treatment. Residual complaints of ankle pain
and stiffness, a sensation of instability or giving way and intermittent swelling are suggestive
of cartilage damage or impinging scar tissue within the ankle. Arthroscopic repair or ligament
substitution is now effective in many cases, allowing a return to full function and sports.