40: Ankle Pain

 A 42-year-old man injures his ankle on a slope.  He lost his balance and fell.  He’s not sure if it inverted or was rotated externally or all both.  He denies and other injuries, but is unable to bear weight.

On exam he has a good pulse and skin is intact without echymosis and the compartments are soft.  His ankle is tender bilaterally with mild swelling.  The foot is not tender.

His x-ray is shown below.

What type of injury to you see?

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Answer: Maisonneuve Injury

 

Note the widened mortise (between talus and medial maleolus) on image on the left

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EXCERPT ON ANKLE INJURIES

from

QUICK ESSENTIALS: EMERGENCY MEDICINE

Achilles: Rupture: Thompson’s squeeze test.  Splint in position of comfort; (OR)
Quinolones: Warn all patients to stop med and avoid exercise if any pain or swelling.  Risk higher age>60, immune suppression or steroids.

Ankle: Inversion most common mechanism.  X-ray: 150$, but only 10% +.

Ottawa tool: No X-ray needed if able to walk 4 steps & maleoli, 5th metatarsal & navicular all non-tender.  Misses: Talus, wide mortise without fracture, calcaneus. If total effusion >15mm & XR – get a CT

Calcaneus: Fall, twist.  Xray: Boehler’s angle <20ï‚°, consider CT.
Rx: Call ortho, OR in 1-2wk
Comps: Fx blister, L-spine fx, other heel, compartment.

Maisonnueve: Medial ankle injury with proximal fibula fracture.  Ankle film may show only wide mortise.  Injury: External rotation mechanism; syndesmosis torn, peroneal nerve (test EHL function)
Rx: ORIF

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