Information Sheet for Candidates

Your next patient in a suburban emergency

department is a 20 year old basketball player, John.
He injured his right ankle during a basketball game
yesterday, when he dunked a ball and coming down
he twisted his ankle. His foot turned inwards
underneath him and because of quite severe pain he
stopped playing. Marked swelling appeared on the
lateral side of the ankle but with ice treatment by the
trainer and resting the foot , the swelling has gone
down although it is still sore to walk on the foot.
Your task is to:
Perform an examination (tell the patient what
you are doing!)
Explain your findings and the most likely
diagnosis to the examiner
Explain your management plan to the patient

EXAMINATION: (LOOK, LISTEN, FEEL !!!!):

Or inspection - movement testing - palpation!
INSPECTION:
Swelling, deformity, bruising, old scars, gait for possible limping
John has a slight limp because of pain on lateral side of ankle!
MOVEMENT (ACTIVE AND PASSIVE!):
Flexion, extension (dorsiflexion), inversion, eversion, circular movement.
John complains about pain on plantar flexion and inversion
PALPATION (start on non tender side!):
Tenderness, effusion. Special attention to bony prominences like medial and lateral
malleolus and base of fifth metatarsal (Ottawa rules!).
Ligaments:
MEDIAL: deltoid ligament
LATERAL: anterior talofibular ligament
calcaneofibular ligament
posterior talofibular ligament
Tibiofibular ligament!
Anterior draw sign!

John is tender over the anterolateral area (anterior talofibular ligament area!)
OTTAWA ANKLE RULES:
X-ray if pain near the malleoli and any of the following:
Inability to weight bear ( immediately following the injury and during
examination!)
Bone tenderness over distal 6 cm of tibia or fibula or over the inferior tip of
malleolus.
CLASSIFICATION OF SPRAINS:

GRADE I :
GRADE II :
GRADE III:

partial tear, usually of anterior talofibular ligament, little swelling, pain on

movement, normal ROM, tenderness next to the tip of the malleolus.
pain at rest, limited weight bearing, moderately severe localised pain and
swelling, calcaneofibular ligament usually involved, tenderness directly
inferior to malleolus, mild to moderate instability
complete tear of two or more ligaments, severe pain, immediate swelling,
joint movement with AP stressing (anterior draw test), ankle
reconstruction recommended!

MANAGEMENT:
R:
rest for 48 hours with early mobilisation with short term use of crutches
depending on extent of injury, when able to weightbear comfortably then walk,
when able to walk comfortably then run, when able to run, then twist and turn,
physiotherapy referral, consider wobble board.
I:
cold therapy with covered ice packs (not directly on skin!) for about 20 minutes
every 3-4 hours (vasoconstriction and reduces inflammation)
C:
compression bandage
E:

elevation

R:

review in 48 hours, then 7 days

S:

special strapping, especially if early return to sport required

QUESTIONS:
?When can I go back to playing basketball again? :
on extent of injury.

3-6 weeks with support, depending

?Can I drive my car?: Not for about a week, to allow rest and healing!
?Do I need crutches? Yes, for the first two days and perhaps even longer depending on
extent of the injury.