Pediatric emergency medicine trisk 0809 0809
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Palpate the dorsalis pedis and posterior tibial arteries. Note skin temperature,
color, and capillary refill. The absence of pulses or the presence of pallor requires
immediate attention. A Doppler device may help identify pulses.
Vascular compromise is usually caused by a posterior dislocation. Traction
reduction of the deformity should be attempted as rapidly as is feasible by
performing the following steps: (i) sedate the patient; (ii) apply longitudinal
traction to the foot; (iii) if relocation is not accomplished in step (ii), apply
longitudinal traction and pull the foot in a posterior to anterior direction; and (iv)
immobilize the ankle and obtain radiographs. If the vascular status has not been
compromised, continue with the examination and evaluate the nerves that cross
the ankle. Test soft touch and pain sensation of the foot.
Bony Palpation
Trace all three bones of the ankle joint (tibia, fibula, and talus), searching for
areas of point tenderness. It is very important to palpate the distal tibial and
fibular physes because fractures in these areas may not be evident on radiographs.
Any tenderness found along a physis should be considered an S-H type I fracture,
even if radiographic studies are negative. Also keep in mind that the only clue to
a juvenile Tillaux fracture may be tenderness at the lateral tibial physis.
Remember to palpate the fibula proximal to the ankle joint; external rotation, and
triplanar injuries may be associated with high fibular fractures.
Finally, examine the foot. This should include palpation of the dome of the
talus. This is performed most easily with the foot in plantar flexion. Palpate the
base of the fifth metatarsal. Tenderness here suggests an avulsion of the peroneus
brevis tendon, potentially with a pseudo-Jones or Jones fracture.
Once one area of point tenderness is found, continue to examine the entire
joint. A single injury may cause many abnormalities.
Ligament Palpation
Palpate for tenderness along all three lateral ligaments, remembering that each
one arises from the distal fibula. The ATFL can be further tested by inverting and
plantar flexing the foot. This will increase pain if injury to this ligament is
present. Swelling extending beyond an area of lateral ligament tenderness is
highly suggestive of significant ligament injury.
Examine the superficial fibers of deltoid ligament on the medial aspect of the
joint. The deep fibers are intra-articular and nonpalpable; therefore, rupture may
be present with limited medial tenderness. Isolated injuries to the deltoid ligament
