Sonographic Findings of Chondral Avulsion Fractures of the Lateral Ankle Ligaments in Children

In this series, we aimed to describe the sonographic findings of chondral avulsion fractures that develop concomitant with lateral ankle ligament injury in children. We performed stress sonography during a manual anterior drawer stress procedure of the ankle in 9 skeletally immature patients who had recently had a lateral ankle sprain. Echo videos were obtained through the course of treatment, and all videos were reviewed. We elucidated the common features of chondral avulsion fractures of the lateral ankle ligaments in the children. The features of avulsion fractures on conventional sonography included absence of a fracture with hyperechoic spots (sonographic occult fracture type), cortical discontinuity with hyperechoic spots (cortical disruption fracture type), fracture line in the cortical bone (double‐line fracture type), and a step‐off deformity of the cortical bone with cartilage (displaced fracture type). In contrast, the features of chondral fractures on stress sonography included abnormal motion of the chondral lesions and mobility/fluidity of hyperechoic spots along the chondral fracture site. The presence of hyperechoic spots around the chondral lesion is an important sonographic sign for diagnosing chondral fractures concomitant with ankle lateral ligament injury. Hence, we believe that stress sonography should be considered for the detection of chondral fractures concomitant with radiographically negative ankle lateral ligament injuries in skeletally immature patients with lateral ankle pain and ankle sprains, if hyperechoic spots are present in the cartilage of the distal fibula.     

Usefulness of ultrasonographic detection of talocrural effusion in ankle sprains.

OBJECTIVE: Ankle sprain severity is difficult to assess initially in the emergency department, yet it governs treatment decisions. Ultrasonography readily shows fluid present in the talocrural joint, which is difficult to assess by physical examination. The purpose of this study was to evaluate the prevalence of ultrasonographic talocrural joint effusion in moderate and severe ankle sprains and to determine the cause of effusions by magnetic resonance imaging (MRI). METHODS: Consecutive patients 18 to 55 years of age with moderate and severe ankle sprains within the previous 48 hours were included if they had no history of abnormalities in the same ankle within the last 12 months. When ultrasonography with the ankle in the neutral position showed talocrural effusion, MRI was performed within 8 days. RESULTS: Of the 110 patients (83 men and 27 women; mean age, 24.2 years), 40 (36.4%; 95% confidence interval, 27.6%-46.1%) had joint effusion on ultrasonography and MRI. In 39 of these 40 patients, MRI visualized damage to the anterior talofibular ligament (positive predictive value, 97.5%; 95% confidence interval, 85.3%-99.9%), accompanied in 5 (12.8%) cases by damage to the calcaneofibular ligament. In 14 (35%) cases, MRI showed cartilage damage or bony contusion. CONCLUSIONS: Talocrural effusion on ultrasonography may identify patients with severe ankle sprains. Magnetic resonance imaging should be performed in patients with talocrural effusion. Further work is needed to evaluate the usefulness of MRI in acute ankle sprains without talocrural effusion.     

The accuracy of ultrasound evaluation in foot and ankle trauma

ObjectivesFoot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas.MethodsOttawa Ankle Rules–positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US.ResultsOne hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal.ConclusionsUltrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.     

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BackgroundWhereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.MethodsThis was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.ResultsOf 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.ConclusionFractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.Level of evidence3b     

X线检查在踝关节骨折诊断中的应用及影像学特点研究

目的:探讨X线检查在踝关节骨折诊断中的应用及影像学特点。方法:回顾性分析我院2018年10月至2019年6月收治的50例踝关节扭伤导致踝关节骨折的患者,所有患者进行X线检查,并将检查结果与多层螺旋CT作对比。结果:50例踝关节骨折的患者均经多层螺旋CT检查证实为骨折。其中中X线检查诊断出45例,诊断符合率为90.00%。其中包括9例内踝骨折,11例外踝骨折,19例踝骨粉碎性骨折,5例距骨骨折,1例合并根骨骨折。5例为踝关节周围软组织肿胀合并关节囊肿胀。结论:X线检查在踝关节骨折诊断中的应用价值高,诊断符合率高,X线表现中踝关节周围软组织肿胀合并关节囊肿胀的患者需要着重考虑是否存在踝关节骨折。该检查方法值得临床推广应用。     

军事训练致踝关节损伤的临床治疗

目的探讨针对军人踝关节损伤的临床治疗方案。方法回顾分析作者医院2008年1月~2011年3月收治的男性军人踝关节损伤196例,统计分析其具体的临床损伤类型,并评估不同损伤类型治疗后的疗效。结果纳入本研究的军人踝关节损伤以韧带损伤为主（153例,78%）,其次是踝关节骨折损伤（43例22%）。在韧带损伤组中,以单纯外侧副韧带损伤、侧副韧带合并下胫腓韧带损伤和单纯内侧副韧带损伤为主;在踝关节骨折损伤组中,骨折类型以内翻内收型、外翻外展型、外旋型和直接暴力型为主。经综合治疗后,随访12个月后发现,韧带损伤组：治疗优良150例（98%）、治疗尚可3例（2%）,踝关节骨折损伤组：治疗优良37例（86%）、治疗尚可6例（14%）。结论韧带损伤是削弱我军战斗力的主要影响因素之一。针对军人踝关节损伤的综合治疗是安全、有效的治疗方式。     

A typical snowboarding injury--fracture of the processus lateralis tali

Before the development of the snowboard sport, the fracture of the lateral process of the talus was a very rare injury. Since the increasing popularity of snowboarding, starting in Europe at about 1980, these fractures occurred more frequently. The largest epidemiological serie from Kirkpatrick in 1998 reports an incidence of 2.3% of all snowboarding injuries representing 15% of all snowboarding ankle injuries [1]. The common mechanism for fracture is dorsiflexion of the ankle and inversion of the hindfoot. Early diagnosis is emphasized in all series reviewed in the literature to prevent long-term complications [4]. Because routine radiographs failed to determine either the size or comminution of the fractured process, CT imaging was used to accurately assess the size, displacement, and comminution of the fractured process. CT scans also showed the extent of subtalar joint involvement, any associated tendon pathology, or additional fractures [5]. Many of these fractures are not visible on plain radiographs and require computed tomography imaging to be diagnosed. Diagnosis of this fracture pattern is paramount; the physician should be very suspicious of anterolateral ankle pain in the snowboarder, where subtle fractures that may require surgical intervention can be confused with anterior talofibular ligament sprains [1]. Most authors agree, that nondisplaced fractures are best treated with cast immobilization and that displaced fractures require a surgical treatment: Single large displaced fragments are reduced and internally fixed, small displaced or comminuted fragments may need surgical excision. After two to three days bedrest with elevated leg, ambulation is started under partial weight bearing of 10-15 kg for 6 weeks. Physicians caring for snowboarders should look specifically for fracture of the lateral process of the talus in a snowboarder with a lateral ankle or foot injury [3]. This fracture can mimic a lateral ankle sprain, yet the fracture is easily missed on plain radiographs of the ankle. Because displaced or comminuted fractures can cause long-term disability, primary care physicians and specialists alike need to be aware of the association of this fracture with snowboarding [3].     

Implementation of the Ottawa Ankle Rules by nurses working in an accident and emergency department.

OBJECTIVE: To assess whether accident and emergency (A&E) nurses using the Ottawa Ankle Rules could detect all ankle fractures. DESIGN: Prospective observational study. SETTING: A&E department of a university teaching hospital. SUBJECTS: All patients who presented with ankle injuries who were initially assessed by a nurse taught the Ottawa Ankle Rules. OUTCOME MEASURES: (1) The numbers of patients referred by the nurse for ankle radiography; (2) of these, the number with ankle fractures; (3) of those not sent for radiography initially by the nurse, the number who subsequently had x rays (ordered by the doctor) and had a fracture; (4) of those having no x rays, the number who reattended later. RESULTS: 324 patients were eligible; 238 had x rays at the request of the nurse (73%); 48 of these (20%) were diagnosed as having a fracture. Of those 86 patients not sent for radiography by the nurse, 19 subsequently had x ray examinations at the request of a doctor and no fracture was detected. Of the 67 not sent for radiography, none returned within the subsequent eight weeks. CONCLUSIONS: Nurses can apply the Ottawa Ankle Rules safely without missing acute fractures; that is, of those who were not sent for radiography by nurses, none subsequently reattended the A&E department or the trauma service of the Bristol Royal Infirmary during the following two months.     

Intrasound Vibration Testing in Acute Ankle Injuries

Objectives: To determine the accuracy of intrasound vibration testing (IVT) in comparison with plain radiography in the diagnosis of acute ankle fractures.
Methods: A group-sequential, nonrandomized, double-blind, observational study design was used. A convenience sample of patients were studied, aged <10 years, with acute ankle injuries, undergoing ankle radiography, evaluated at a community teaching hospital ED. Excluded were cases involving injuries of <24 hours' duration, inadequate documentation, protocol violation, or positive IVT on the uninjured ankle. IVT was performed with the intrasound apparatus placed on the anterior and posterior aspects of the medial and lateral malleoli of the uninjured and injured ankles; positive IVT was defined as patient withdrawal secondary to pain.
Results: Of 105 patients enrolled, 8 were excluded; 1 for inadequate documentation, 5 for protocol violation, and 2 for positive IVT of the uninjured ankle. Of the 97 patients analyzed, 13 had fractures identified by radiography, including 9 lateral malleolar, 1 medial malleolar, 1 bimalleolar, and 2 talar fractures. Only 5 of the 13 fractures were detected with IVT (sensitivity = 39%; 95% CI: 14–68%). Seventy of 84 nonfractured ankles hadnegative IVT (specificity = 83%; 95% CI: 74–91%). Of the 19 with positive IVT, 5 had fractures (positive predictive value of 26%; 95% CI: 9–51%). Of the 78 with negative IVT, 70 had no fracture (negative predictive value of 90%; 95% CI: 81–96%). Overall, 75 of 97 IVTs were correct (77%), most of which were among patients without fractures.
Conclusion: IVT was not a useful test for predicting fractures in patients with acute ankle injuries.     

Lateral and syndesmotic ankle sprain injuries: a narrative literature review

Objective

The purpose of this article is to review the literature that discusses normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic sprain, and assessment and diagnostic procedures, and to present a treatment algorithm based on normal ligament healing principles.

Methods

Literature was searched for years 2000 to 2010 in PubMed and CINAHL. Key search terms were ankle sprain$, ankle injury and ankle injuries, inversion injury, proprioception, rehabilitation, physical therapy, anterior talofibular ligament, syndesmosis, syndesmotic injury, and ligament healing.

Discussion

Most ankle sprains respond favorably to nonsurgical treatment, such as those offered by physical therapists, doctors of chiropractic, and rehabilitation specialists. A comprehensive history and examination aid in diagnosing the severity and type of ankle sprain. Based on the diagnosis and an understanding of ligament healing properties, a progressive treatment regimen can be developed. During the acute inflammatory phase, the goal of care is to reduce inflammation and pain and to protect the ligament from further injury. During the reparative and remodeling phase, the goal is to progress the rehabilitation appropriately to facilitate healing and restore the mechanical strength and proprioception. Radiographic imaging techniques may need to be used to rule out fractures, complete ligament tears, or instability of the ankle mortise. A period of immobilization and ambulating with crutches in a nonweightbearing gait may be necessary to allow for proper ligament healing before commencing a more active treatment approach. Surgery should be considered in the case of grade 3 syndesmotic sprain injuries or those ankle sprains that are recalcitrant to conservative care.

Conclusion

An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future reinjury. Most ankle sprains can be successfully managed using a nonsurgical approach.     

Ultrasonography of anterosuperior calcaneal process fracture: report of 2 cases.

OBJECTIVE: The purpose of this series is to describe the ultrasonographic findings of anterosuperior calcaneal process (ASCP) fracture. METHODS: Two patients with ASCP fractures were examined with ultrasonography. Both of them had pain over the lateral aspect of the ankle 10 to 13 months after an injury. Initial radiographs had shown no evidence of bone fracture or bone avulsion. RESULTS: In both cases, ultrasonography revealed the presence of a bone fragment adjacent to the ASCP suggestive of a misdiagnosed fracture. The latter was confirmed by radiographs. In 1 case, a hypoechoic thickening of the calcaneocuboid component of the bifurcate ligament was also identified on ultrasonographic scans. CONCLUSIONS: Ultrasonography is potentially valuable in detecting clinically or radiographically occult ASCP fractures.     

101例军事训练致踝关节损伤MRI表现与损伤特点

目的 探讨军事训练踝关节损伤的MRI表现与损伤特点。方法 以2019年就诊于新疆军区总医院北京路医疗区的军事训练踝关节损伤患者为研究对象,问卷调查收集相关资料,行踝关节MRI平扫。检查结果由3名专科医师对韧带、肌腱、骨质等影像表现进行分析并确定损伤情况。依据服役年限随机分为新、老兵组,分析两组踝关节损伤不同程度的特点。结果 101例对象被纳入研究,损伤101侧。韧带损伤：距腓前韧带33侧,距腓后韧带39侧,跟腓韧带5侧,三角韧带7侧,胫舟韧带1侧。肌腱损伤：踇长屈肌腱21侧,胫骨后肌腱18侧,趾长屈肌腱7侧,腓骨长肌腱4侧,腓骨短肌腱1侧,跟腱炎21侧,跟腱滑囊炎5侧。骨质损伤：软骨损伤7侧,骨折6侧,骨髓水肿60侧,脱位1侧。新兵踝关节损伤以骨质损伤与混合损伤两种类型为主。老兵组软组织损伤占比率明显高于新兵组(P<0.05)。结论 军事训练致踝关节损伤MRI表现损伤特点在新老兵中存在显著不同。     

The effectiveness of balance training programs on reducing the incidence of ankle sprains in adolescent athletes

Ankle sprains are one of the most common sport-related injuries treated by rehabilitation professionals. These injuries often result in lost participation and can lead to subsequent injury episodes. Therefore, it is important to determine appropriate means of preventing these injuries. There has recently been an increase in the popularity of balance training programs for the prevention of knee anterior cruciate ligament (ACL) injury, with some thought that starting these programs in younger athletes may be most beneficial. However, there is the potential that these types of training programs may also be beneficial for decreasing the risk of other lower extremity injuries, including ankle sprains in the adolescent athlete.     

Transient peroneal nerve palsies from injuries placed in traction splints

Two patients thought to have distal femur fractures presented to the emergency department (ED) of a level 1 trauma center with traction splints applied to their lower extremities. Both patients had varying degrees of peroneal nerve palsies. Neither patient sustained a fracture, but both had a lateral collateral ligament injury and one an associated anterior cruciate ligament tear. One patient had a sensory and motor block, while the other had loss of sensation on the dorsum of his foot. After removal of the traction splint both regained peroneal nerve function within 6 hours. Although assessment of ligamentous knee injuries are not a priority in the trauma setting, clinicians should be aware of this possible complication in a patient with a lateral soft tissue injury to the knee who is placed in a traction splint that is not indicated for immobilization of this type of injury.     

Place de l’échographie dans le diagnostic de gravité d’une entorse latérale de l’articulation talocrurale et ses complications chez le sportif

Due to the non-specific clinical presentation, and specifically due to the lack of an ankle “Lachmann”, ultrasonography provides crucial information for the diagnosis of severity of a lateral sprain involving the talocrural joint. Ultrasonography enables to differentiate between minor injuries without ligament lesions and serious sprains with a more or less extensive ligament tear. Effusion in the talocrural joint, which can be identified readily with ultrasounds, is a sign of severity. Ultrasonography is also essential for analyzing the ligaments in a subject with an unstable ankle late after a sprain. The performance is equivalent to that of an arthroscan (the gold standard exam for chronic post-trauma ankle pain) for identifying sequelar ligament lesions.     

Overutilizers Anonymous

In spite of improvements in facilities and equipment, skiing injuries still run the gamut from minor tendinitis to complete disruption of a ligament or fracture of a bone. Dr Johnson notes that knee injuries are predominant in both downhill and cross-country skiers, commonly as a result of internal rotation and valgus stress. Snowboarding injuries, such as ligament sprains and fractures, are usually due to direct impact.     

Ankle joint evertor-invertor muscle torque ratio decrease due to recurrent lateral ligament sprains

OBJECTIVE: To determine an ankle inversion-eversion movement range part where evertor/invertor muscles torque ratio is altered after recurrent ankle lateral ligament sprains. DESIGN: The ankle evertor/invertor muscles torque ratios were determined in the different range parts of angular positions by the muscle isokinetic movements. BACKGROUND: It is important to determine the movement range part where the evertor muscle weakness after the ankle lateral ligament sprains is more expressed and a repeated trauma of the lateral ligaments is more probable. METHODS: Twenty-eight male handball players participated in the tests using an ankle isokinetic inversion-eversion movement investigation dynamometer system. Thirty-three ankle joints were uninjured, but 23 underwent recurrent lateral ligament sprains. RESULTS: The ankle evertor/invertor muscles torque ratio for the sprained ankles was significantly lower in comparison with the uninjured joints in inversion positions at 50 degrees and 60 degrees of the range of movements in all applied velocities, except the slowest movement (30 degrees /s). CONCLUSIONS: The recurrent ankle lateral ligament sprains reduced the evertor/invertor muscles torque ratio in the inversion positions of the range of movements and therefore the evertor muscle weakness was more expressed in the beginning of the eversion movement.     

Foot fractures frequently misdiagnosed as ankle sprains

Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.     

Ankle injuries in athletes: A review of the literature

Ankle injuries are commonplace in the athletic population, with lateral ligament sprains accounting for the majority of them. The medial ligament complex, the distal tibiofibular syndesmosis as well as any of the bones that constitute the ankle joint can also be injured. Typical mechanisms of injury include inversion-plantarflexion and external rotation on a supinated, dorsiflexed or pronated foot. Lesions of the ankle present with similar symptoms of pain, swelling and tenderness. Therefore, a thorough history and physical examination must be obtained to make the correct diagnosis. This is especially critical for athletes as certain injuries can lead to termination of their career if not treated accurately on time. Imaging may be useful in some cases to confirm or rule out differential diagnoses. Most injuries can be managed conservatively using the Protection, Rest, Ice, Compression and Elevation protocol followed by a comprehensive rehabilitation programme. Surgery is reserved for grade III ligament tears that are refractory to initial non-operative treatment and displaced fractures that are unlikely to unite without surgical intervention. The objective of this review is to discuss the common ankle injuries encountered in the athletic population and the approaches to their diagnosis and management.