Pediatric emergency medicine trisk 0813 0813
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The approach (Fig. 40.10 ) to the evaluation and diagnosis of traumatic ankle
injuries relies primarily on physical findings and the results of radiographic
evaluation. Initially, pulses and sensation are assessed. Loss of pulses and/or
sensation suggests a fracture/dislocation and the need for a rapid reduction; when
available without delay, orthopedic consultation is advisable. After providing
analgesia, immobilize the site to prevent further compromise, and obtain a
radiograph. If neurovascular status is adequate and the general inspection reveals
no obvious abnormalities, proceed with the rest of the physical examination as
described previously.
Next, examine the area for open wounds. If present, apply a sterile saline
dressing and immobilize the extremity before obtaining a radiograph. Consider
administering intravenous antibiotics and tetanus prophylaxis.
If radiographic studies indicate a fracture or dislocation, provide treatment of
the specific injury (see Chapter 111 Musculoskeletal Trauma ). Administer
analgesia as needed.
If no fracture is evident on the radiograph, but tenderness is elicited over a
physis, the diagnosis of an S-H type I injury can be made clinically and
appropriate immobilization is performed (see Chapter 111 Musculoskeletal
Trauma ). One study demonstrated that approximately 18% of children with
tenderness at the distal fibular physis and normal radiographs will develop new
periosteal bone formation, thus implying the presence of an occult fracture. A
negative radiographic result with bony tenderness remote from a physis suggests
the diagnosis of contusion while absence of focal bony tenderness often suggests
a ligamentous injury. A stable ankle in a patient who has pain with ligamentous
stress or palpation characterizes a grade I sprain. A grade II sprain is more severe;
instability is insignificant. Joint instability indicates a torn ligament and a grade
III sprain.
