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ACEP Now: Vol 37 – No 02 – February 2018

Case 1

Case 2

Case 3

Photos: Arun Sayal, MD, CCFP(EM)

Written from the perspective of an emergency physician who also runs a weekly minor fracture clinic, this column is intended to highlight a few key ED teaching points for commonly missed and commonly mismanaged ED orthopedic cases.

Case 1

A 22-year-old female falls, injures her ankle, and is non-weight-bearing. Lateral ankle pain is noted. The Ottawa

ankle rules (OAR) indicated X-rays, and the emergency department images are above (Case 1, Figure 1).

Case 2

A 45-year-old male slips on a sidewalk. He has mild lateral pain, his medial malleolus is non-tender, and he is non-weight-bearing. The OAR indicated X-rays, and the emergency department images are above (Case 2, Figure 1).

Case 3

A 13-year-old female slips playing soccer. She has mild lateral pain but is non-weight-bearing. The OAR indicated X-rays, and the emergency department images are above (Case 3, Figure 1).

What Happened in the Emergency Department?

• Case 1: The 22-year-old female was diagnosed with a severe lateral ankle sprain. She was treated with a walking boot, crutches, and follow-up in the minor fracture clinic.
• Case 2: The 45-year-old male was diagnosed with a soft tissue injury (STI) of the ankle. He was treated with an air-stirrup, crutches, and follow-up in the minor fracture clinic.
• Case 3: The 13-year-old female was diagnosed with a Salter-Harris I fracture in the distal fibula. She was treated with an air-stirrup, crutches, and follow-up in the minor fracture clinic

What happened in the end? Well, all three cases were surgical (see Case 1, Figure 2; Case 2, Figure 2; and Case 3, Figure 2).

The details of each case are below, but in the bigger picture, it’s worth discussing reasons the OAR can be “bad to the bone.” The OAR ask us to palpate the posterior aspects of the medial and lateral malleoli. However, there also are important structures to examine in the front and back of the ankle. This article will focus on commonly missed injuries at the front of the ankle joint.

Ankle injuries are frequently seen in emergency departments. The majority of ankle injuries are sprains; fewer than 15 percent of ED X-rays reveal fractures. To reduce the number of X-rays ordered, the OAR were proposed more than 25 years ago. They have subsequently been validated and implemented with reasonable success and acceptance.^1–7