A 45-year-old man comes to the physician for a twisted ankle. It occurred while he was playing basketball, but he cannot recall if he everted or inverted his ankle. He ambulates with difficulty but is able to bear weight in the physician's office as he walks to the examination room. His general health is good and he takes no medications.
On examination, there is limited range of motion of the ankle in all directions. Significant ecchymosis and edema are visible at the lateral aspect of the ankle. There is no tenderness at the posterior edge or tip of either malleoli. There is no pain at the base of his fifth metatarsal, and palpation of the navicular area of his foot does not elicit pain.
Which of the following is the most appropriate next step in evaluating this patient's injury?

Question

A 45-year-old man comes to the physician for a twisted ankle.  It occurred while he was playing basketball, but he cannot recall if he everted or inverted his ankle.  He ambulates with difficulty but is able to bear weight in the physician's office as he walks to the examination room.  His general health is good and he takes no medications.
On examination, there is limited range of motion of the ankle in all directions.  Significant ecchymosis and edema are visible at the lateral aspect of the ankle.  There is no tenderness at the posterior edge or tip of either malleoli.  There is no pain at the base of his fifth metatarsal, and palpation of the navicular area of his foot does not elicit pain.
Which of the following is the most appropriate next step in evaluating this patient's injury?

Quizplus · Accepted Answer

11ec193a_993b_71ad_853d_f909e7d34831_MD0002_00 This patient - with swelling, stiffness, and ecchymosis, but no malleolar or metatarsal tenderness - has features to suggest an uncomplicated ankle sprain. Patients with ankle sprains, regardless of apparent severity, may have associated bony fractures that require extensive orthopedic intervention; those with uncomplicated sprains can usually be managed conservatively. The Ottawa ankle rules were developed to determine which patients are likely to have a fracture that would require imaging and additional measures. Factors included in the Ottawa rules include location of pain, specific areas of bony tenderness, and ability to bear weight. The rules have relatively poor specificity and positive predictive value, but their sensitivity for fracture approaches 100%. As a result, patients such as this who have negative findings on the Ottawa assessment are very unlikely to have a significant fracture and may be managed conservatively without additional imaging (Choice E). The Ottawa rules were developed for use in adult patients but are likely valid in children as well. (Choice A) Ecchymosis in ankle sprains is common, and does not suggest a coagulopathy in the absence of more specific findings. (Choice B) CT imaging of the ankle has little utility in the acute management of ankle sprains. It can be helpful in evaluating patients with suspected fracture when x-ray is nondiagnostic, such as those with osteoporosis. It can also be used to assess complex or comminuted fractures. (Choice C) MRI of the ankle is very sensitive for indentifying ligamentous disruptions, but such findings do not generally change management in the acute phase. MRI is useful in evaluating patients with persistent ankle instability who fail to improve as expected. Educational objective: The Ottawa ankle rules can identify patients with ankle sprains who may have an associated fracture that will require imaging. The rules take into consideration the location of pain, specific areas of bony tenderness, and ability to bear weight. __________ References: Accuracy of Ottawa rules to exclude fractures of the ankle and mid-foot: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/12595378) Impact of clinical decision rules on the clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. (http://www.ncbi.nlm.nih.gov/pubmed/17078955)

A 45-Year-Old Man Comes to the Physician for a Twisted