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CLINICAL SCIENCE SESSION

ANKLE SPRAIN
PERSEPTOR :
dr. Gibran T Sp.OT

Disusun Oleh :
Sri Hudaya Widihastha
1301-1213-0520
Novra Christy Grace Sumbayak 1301-1213-0503
Theruna A/L Huthamaputiran
13011213-2559
Nadia Ayu Destianti
13011214-0002
Harvir Singh Sidhu
1301-

Ankle sprains : most common of all


sports related injuries 25% of cases.
75 % of cases lateral ligament
complex injury, 90 % anterior talofibular
(ATFL) only and 60 % with
calcaneofibular ligaments (CFL).
Medial ligament injuries are usually
associated with a fracture or joint injury.

A sudden twist of the ankle momentarily


tenses the structures around the joint (#1 is
inversion) painful wrenching of the soft
tissues (sprained ankle).
If more severe force is applied, the
ligaments may be strained to the point of
rupture.
partial tear, most of the ligament remains intact
and, once it has healed, it is able to support the
weight of the body.
complete tear, the ligament may still heal but it
never regains its original form and the joint will
probably be unstable.

ANATOMY
The lateral collateral ligaments
consist of the anterior talofibular, the
posterior talofibular and (between
them) the calcaneofibular ligaments.
The anterior talofibular ligament (ATFL)
runs almost horizontally from the
anterior edge of the lateral malleolus to
the neck of the talus; it is relaxed in
dorsiflexion and tense in plantarflexion.

The calcaneofibular ligament stretches from the


tip of the lateral malleolus to the posterolateral
part of the calcaneum, thus it helps also to
stabilize the subtalar joint. Maximum tension is
produced by inversion and dorsiflexion of the
ankle.
The posterior talofibular ligament runs from the
posterior border of the lateral malleolus to the
posterior part of the talus.

The medial collateral (deltoid) ligament


consists of superficial and deep portions.
Superficial fibres spread like a fan from the
medial malleolus as far anteriorly as the
navicular and inferiorly to the calcaneum and
talus. Its chief function is to resist eversion of
the hindfoot.
Deep portion is intra-articular, running directly
from medial malleolus to medial surface of the
talus. Principal effect is to prevent external
rotation of the talus.
The combined action of restraining eversion and
external rotation makes the deltoid ligament the
major stabilizer of the ankle.

The distal tibiofibular joint is held by


four ligaments: anterior, posterior,
inferior transverse and the
interosseous ligament, which is
really a thickened part of the
interosseous membrane.

History Taking (Anamnesa)

pop
Pain
Swelling
+/- ability to bear weight

Physical Examination
Edema
Ecchymosis
ATFL (CFL) TTP (Tenderness to
palpation)
+/- Anterior Drawer Test
Talar Tilt Test
Technique : stabilize tibia, dorsi-flexion
foot, invert foot

PATHOLOGY
twisted ankle is due to unbalanced
loading with the ankle inverted and
plantarflexed.
First ATFL then CFL strained; sometimes
talocalcaneal ligaments (TCL) also injured.
If fibres are torn bleeding into the soft
tissues.
There may be a small fracture of an
adjacent tarsal bone or (on the lateral
side) the base of the fifth metatarsal.

ACUTE INJURY OF LATERAL


LIGAMENTS
RECURRENT LATERAL INSTABILITY
DELTOID LIGAMENT TEARS
DISLOCATION OF PERONEAL
TENDONS
TEARS OF INFERIOR TIBIOFIBULAR
LIGAMENTS

ACUTE INJURY OF LATERAL


LIGAMENTS
A history of a twisting injury followed by
pain and swelling minor sprain to a
fracture.
patient is able to walk, and bruising is only
faint and slow to appear probably a sprain;
bruising is marked and patient unable to put
any weight on the foot more severe injury.

It is impossible to test for abnormal


mobility without using local or general
anaesthesia.

Undisplaced fractures of the fibula or


the tarsal bones, or even the fifth
metatarsal bone are easily missed
and injuries of the distal tibiofibular
joint and the peroneal tendon sheath
cause features that mimic those of a
lateral ligament strain.

IMAGING
The Ottawa Ankle Rules. X-ray
examination is called for if there is:
(1) pain around the malleolus;
(2) inability to take weight on the ankle
immediately after the injury;
(3) inability to take four steps in the
Emergency Department;
(4) bone tenderness at the posterior
edge or
tip of the medial or lateral
malleolus or the base of the fifth
metatarsal bone.

TREATMENT
Initial treatment consists of rest, ice,
compression and elevation (RICE), which is
continued for 13 weeks depending on the
severity of the injury and the response to
treatment.
Cold compresses should be applied for about
20 minutes every 2 hours, and after any
activity that exacerbates the symptoms.
PRICE by adding protection (crutches, splint
or brace)
PRICER by adding rehabilitation (supported
return to function).

Principles remain the same a


phased approach, to support the
injured part during the first few weeks
and then allow early mobilization and
a supported return to function.
(NSAI) gels or creams might be as
beneficial as oral preparations,
probably with a better risk profile.

RECURRENT LATERAL
INSTABILITY
History of a sprained ankle that never recover,
followed by recurrent giving way or a feeling of
instability when walking on uneven surfaces.
20% cases after acute lateral collateral ligament
tears.
Ankle looks normal and passive movements are
full, however stress tests for abnormal lateral
ligament laxity excessive talar tilting in
sagittal plane or anterior displacement (an
anterior drawer sign) in coronal plane.
Compare both ankles, abnormal with the normal
side.

TREATMENT
Ankle exercises strengthen peroneal
muscles
Light brace worn during stressful
activities.
If patient continue to experience
mechanical instability during everyday
activities, reconstruction of the lateral
ligament should be considered.

Operations for mechanical stabilization


fall mainly into two groups:
(1)repair or tighten the ligaments
ex : The BrostrmKarlsson or Gould operation
(2) construct a check-rein against the
unstable movement.
ex : a substitute ligament is constructed by
using peroneus brevis to act as a tenodesis
and prevent sudden movements into varus

DELTOID LIGAMENT
TEARS
Rupture of deltoid ligament usually associated
with fracture of the distal end of the fibula or
tearing of distal tibiofibular ligaments (or
both).
The effect is to destabilize the talus and allow
it to move into eversion and external rotation.
Diagnosis by x-ray: widening of the medial
joint space in mortise view; sometimes talus is
tilted, and diastasis of tibiofibular joint may be
obvious.

TREATMENT
Fibular fracture or diastasis must be
accurately reduced, if necessary by
open operation and internal fixation.
Occasionally medial joint space cannot
be reduced; it should then be explored
in order to free any soft tissue trapped
in the joint.
Below-knee cast is applied with the foot
plantigrade and retained for 8 weeks.

DISLOCATION OF PERONEAL
TENDONS
Acute dislocation of peroneal tendons may
accompany or may be mistaken for lateral
ligament strain.
Tell-tale signs on x-ray are an oblique fracture
of the lateral malleolus (the so-called rim
fracture) or a small flake of bone lying lateral
to the lateral malleolus (avulsion of the
retinaculum).
Treatment in below knee cast for 6 weeks will
help in a proportion of cases; the remainder
will complain of residual symptoms.

TEARS OF INFERIOR
TIBIOFIBULAR
LIGAMENTS

The inferior tibiofibular ligaments may


be torn, allowing partial or complete
separation of the tibiofibular joint
(diastasis).
Complete diastasis, with tearing of both
the anterior and posterior fibres, follows a
severe abduction strain.
Partial diastasis, with tearing of only the
anterior fibres, is due to an external
rotation force.

CLINICAL FEATURES
Following a twisting injury, the
patient complains pain in the front
ankle. There is swelling and marked
tenderness directly over the inferior
tibiofibular joint.

TREATMENT
Partial tears can be treated by strapping
the ankle firmly for 23 weeks.
Complete tears best managed by
internal fixation with a transverse screw
just above the joint. Must be done as
soon as possible so that tibiofibular
space does not become clogged with
organizing haematoma and fibrous
tissue.

If the patient is seen late and ankle is


painful and unstable, open clearance
of the syndesmosis and transverse
screw fixation may be warranted.
The ankle is immobilized in plaster
for 8 weeks, after screw is removed.

THANK YOU