13 high ankle sprains mcasillas.ppt - office of continuing...
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This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.
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High Ankle Sprainsand
Syndesmosis Injury
Mark M. Casillas, M.D.
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Disclosures
• No relevant disclosures
Learning Objectives:
1. Understand that the syndesmotic ligaments are strong
2. Never ever use the term “high ankle sprain”
3. Briefly describe treatment options
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This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.
Lateral Ankle Ligaments
• ATFL (3)
• CFL (4)
• PTFL (5)
Alexander I J, The Foot: Examination and Diagnosis
Medial Ankle Ligaments
• Deltoid
– Superficial (3)
– Deep (1,2,4)
Alexander I J, The Foot: Examination and Diagnosis
Syndesmosis Ligaments
• AITFL (2)
• PITFL (1)
• IOL
Alexander I J, The Foot: Examination and Diagnosis
This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.
Syndesmosis Ligaments
• AITFL (2)
• PITFL (1)
• IOL
Alexander I J, The Foot: Examination and Diagnosis
Syndesmosis Injury
• The syndesmosis
– Stabilizes distal tibia and fibula
– Keeps talus under the tibia
• The tibio‐talar surface
– Must be perfectly matched
– 1 mm lateral shift increases joint surface pressure by 42%
Syndesmosis Injury
• A failed syndesmosis
– Leads to lateral translation
– � tibio‐talar pressure
– Promotes ankle arthritis
– Results in a loss of function
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Classification
• AMA and O’Donoghue
– Stretch
– Partial tear
– Complete rupture
• Never use the term “high ankle sprain”
– Potential confusion with high grade sprain
– Not an anatomic term
History
• Mechanism
– External rotation
• Ability to continue play
• Current complaints
– Pain over the syndesmosis
– Pain over the proximal fibula, mid‐leg, ankle
Physical Examination
• Systematic approach
• Inspection
• Palpation
• Provocative maneuvers
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Provocative Maneuvers
• Resisted motor function
• Squeeze test
• Stress tests
– varus
– valgus
– external rotation
Resisted Motor Function
Squeeze Test
• Syndesmosis injury
• Compress mid‐leg
• Pain at syndesmosis
• Must first rule‐out
– fracture
– contusion
– compartment syndrome
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External Rotation Stress Test
• Syndesmosis injury
• Knee forward facing
• Examiner applies ER
• Pain at syndesmosis
Syndesmosis Imaging
• X‐ray
– Standing
– ER stress test
– Comparison view
– Alignment
– Associated injuries Non-WB ER Stress
Imaging
• X‐ray
– Standing
– ER stress test
– Comparison view
– Alignment
– Associated injuries
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Syndesmosis Imaging
CT
– Axial
– Comparision
– Alignment
– Associated injuries
Syndesmosis Imaging
MR
– AITFL injury
– Alignment
– Associated injuries
Syndesmosis Treatment
• Grade I and II
• Grade III
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Grade I and Grade II Sprains
• Immediate: RICE method
• Subacute: Splint, cast or cast boot
• Rehabilitation: PT, non‐rigid functional ankle brace
• Return to sport: Tape, brace
Grade III Sprains
• Surgical repair with delayed weight bearing
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Grade III Injury with Fracture
Screw Removal
• WB after screw removal
• Spontaneous improved reduction after screw removal (Song et al, FAI 2014)
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Screw Retention
• Physiologic motion
• Osteolysis
• Screw failure
• Pain
• Prominent hardware
Complications
• Instability
• Persistent pain
• Ossification
Learning Objectives:
1. Understand that the syndesmotic ligaments are strong
2. Never ever use the term “high ankle sprain”
3. Briefly describe treatment options
This presentation is the intellectual property of the author. Contactthem for permission to reprint and/or distribute.
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Mark M. Casillas, M.D. – Orthopaedic Surgery, Foot & Ankle
Jeremy L. Dickerson, M.D. – Family Practice, Sports Medicine
Stacé S. Rust, M.D. – Orthopaedic Surgery, Hand, Wrist, Elbow & Shoulder
Ryane M. Galindo – MPAS, PA-C
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