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Pediatric Ankle SprainsPediatric Ankle SprainsWhat to watch for !

Denise Theresa Ibrahim, D.O.M&M Orthopaedics

Hope Children’s HospitalFebruary 2010

Epidemiology

• 41% (521) of all musculoskeletal injuries come from sports; responsible for 8% (495/6173) of all ED visits

• mean age 12 2 years• mean age 12.2 years • Sprains, contusions, and fractures were the

most common injury types (34, 30, and 25%, respectively)

Pediatr Emerg Care. 2003 Apr;19(2):65-7 Patterns in childhood sports injury.Damore DT, Amerongen R et al..

Epidemiology

• Female Versus Male – sprains (44% vs 36%)– contusions (37% vs 33%)

fractures (22% vs 31%)– fractures (22% vs 31%)

Pediatr Emerg Care. 2003 Apr;19(2):65-7 Patterns in childhood sports injury.Damore DT, Amerongen R et al..

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Soft Tissue Injuries

• 95% of sports injuries• Ligament sprains and

muscle-tendon strains –2/3

• Contusions 10 to 15%• Lacerations 2 to 3%• Fractures 5%

Most Common Injury

• What is a sprain?– A sprain is a

wrenching or twisting or tearing injury to a g j yligament.

Most Common Injury

• What is a strain?– A strain is an injury

to a muscle or t d d i fttendon, and is often caused by overuse, force, or stretching.

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Differential Diagnosis Acute Ankle Injury

• Sprained ankle • Physeal fractures • Osteochondral fractures • Lateral process fractures of the talus or

calcaneuscalcaneus • Fracture base of the fifth metatarsal/ apophyseal

region• Fracture fifth metatarsal at the metaphyseal-

diaphyseal junction (Jones fracture) • Peroneal tendon subluxation/dislocation • Calcaneocuboid joint sprain

Ankle Anatomy

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Table 1. The West Point Ankle Sprain Grading System

Criteria Grade 1 Grade 2 Grade 3

Location of tenderness

ATFL ATFL, CFL ATFL, CFL, PTFL

Swelling & Slight, localized Moderate, Significant, Ecchymosis localized diffuse

Weight bearing ability

Full weight bearing, Partial WB

Difficult without crutches

Impossible without pain

Ligament damage

Stretched Partially torn Completely torn

Instability None None - slight Definite

Exam• Palpatory Exam provides the most information

Ankle Provocative Tests

• Anterior drawer test-compare laxity to other side

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Ankle Provocative Tests

• Talar Tilt Test- 5 –26 degrees can be normal range, always compare to other side

Ankle Provocative Tests

• External Rotation Stress Test of the Syndesmosis and Squeeze test- externally rotate the foot with the ankle in plantarflexion

When to Consider an Xray• Inability to bear weight both immediately after

the injury and in the Emergency Department.

• Bony tenderness over the posterior edge, tip or distal 6 cm of the lateral malleolusdistal 6 cm of the lateral malleolus.

• Bony tenderness over the posterior edge, tip or distal 6 cm of the medial malleolus.

• Tenderness over the base of the 5th metatarsal.

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What to Watch for?

• Sprain versus Physeal fracture– Tenderness over a

growth plate = f t i bil tifracture=immobilzation

What to Watch for?

• Maissoneuve Fracture

What to Watch for?

• Foot Apophysitides– Sever’s Disease– Navicular Apophysitis

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What to Watch for?Osteochondral Defect Talus

What to Watch for?

• Sever’s Disease– classically described

as causing heel pain in older children, just prior to fusion of theto fusion of the calcaneal apophysis (between ages 12-15 yrs)

Sever’s Disease• radiographic fragmentation

of the apophysis correlated with the patient's symptoms?

• fragmentation of thefragmentation of the apophysis is a normal finding

• Comparison views

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What to Watch for?

• Hypersensitive pain reaction- acts like Reflex sympathetic dystrophy

Goals of Treatment and Followup

• Appropriately rest injury (brace, splint, cast)• range of motion must be restored completely • Muscle strengthening after immobilization• restore facilitate or develop proprioception in• restore, facilitate, or develop proprioception in

the ankle joint • Avoid common complications of recurrence,

prolonged pain, and ankle instability

Treatment• P.R.I.C.E.

– Protection (2 approaches)– Rest– Ice - ice the area immediately,

ice pack or slush bath for 15 to 20 minutes each time and repeat20 minutes each time and repeat every two to three hours while you're awake for the first 48 to 72 hours

– Compression– Elevation

• Rehabilitation- home exercises vs. therapy

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Ankle Brace

Treatment- Posterior Mold Splint-Short leg Walker-Cast

Caution!

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Treatment Options• Immobilization that allows movement until

healing has taken place (3-6 weeks) because the collagen fibers heal the fastest and orient along the lines of force where protected movement occurs

• Early movement also helps in decreasing• Early movement also helps in decreasing swelling and the danger of fibrosis that normally develops in chronic swelling.

Specchiulli F, Cofano RE. A comparison of surgical and conservative treatment in ankle ligament tears. Orthopedics. Jul 2001;24(7):686-8. Trevino SG, Davis P, Hecht PJ. Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am. Jan 1994;25(1):1-16.Wolfe MW, Uhl TL, Mattacola CG. Management of ankle sprains. Am Fam Physician. Jan 1 2001;63(1):93-104.Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. Feb 2007;455:169-72

Treatment Options• The Collaborative Ankle Support Trial (CAST) in

the United Kingdom randomized, controlled trial– compared the clinical effectiveness and cost-

effectiveness of below-knee cast, Aircast brace, Bledsoe boot and a double-layer tubular compression y pbandage.

– 3 months, the below-knee cast was shown to provide an advantage in terms of overall recovery (pain, activities of daily living, sports participation); the Aircast provided minimal advantage; and the Bledsoe boot provided no significant advantage.

Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, et al. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. Feb 2009;13(13):iii, ix-x, 1-121.

Prevention

• Short-term protection– Taping or bracing while you're recovering

from injury and when you're first getting back into your regular activities.

• Long-term protection– work to strengthen and condition the muscles

around the joint that has been injured. • The best brace you can give yourself is

your own "muscle brace."

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Prevention• Taping

– 10% increase in maximal resistance to inversion moments

– after ~40 minutes of vigorous exercise, tape g pprovides insignificant levels of protection

• Bracing– semirigid braces resulted in

a significant reduction in injury compared to unbraced athletes

Treatment-Theraband Exercises

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Who Needs Therapy?• Most grade 3 sprains, some

grade 2• Unable to perform home

exercisesR t i• Recurrent sprains

• Chronic Pain• Hypersensitive pain

reaction- acts like Reflex sympathetic dystrophy

Conclusion• History will elicit the mechanism of injury and

provide valuable clues as to the ligamentous structures that may be injured

• Consider the differential diagnosis of the acutely injured ankle to exclude a serious injury thatinjured ankle to exclude a serious injury that may mimic an ankle sprain

• After pain and swelling are controlled, rehabilitation concentrates on increasing pain-free motion while beginning exercises to prevent loss of strength