Physical Examination

Once significant swelling has taken place, the examination of the ankle becomes more difficult. This may be temporized in the busy ED by the application of ice at triage and getting the patient to elevate the foot. Although tempting, the patient should not be examined in a wheelchair, but on a stretcher. It is critical to examine the joint above and below the injury. Note the position, swelling, and skin integrity of the injured ankle. Ask the patient to plantar and dorsiflex the ankle actively, then put the ankle through a passive range of motion. Soft tissue injuries are more likely when there is a significant difference between the passive and active range of motion. Increased pain with dorsiflexion is suggestive of a syndesmosis injury. Palpate the area of obvious injury last: Hurt the patient initially and their cooperation will rapidly diminish. Compare the injured ankle to the normal ankle. Tenderness of the knee, the fibular head, or the proximal fibular shaft suggests a fibulotibial ligament tear or a Maisonneuve fracture. Compress the fibula toward the tibia just above the midpoint of the calf in order to exclude clinically an isolated syndesmotic sprain. Starting at least 6 cm proximal, palpate the posterior aspects of lateral and medial malleoli to the distal tips of the shaft. Examine the Achilles tendon. If there is tenderness or a defect, perform the Thompson test. With the patient prone on a stretcher, squeeze the calf: loss of plantar flexion indicates a complete rupture of the tendon. Palpate the midfoot and hindfoot over the calcaneus, the tarsals, and the base of the fifth metacarpal. Patients can complain of an ankle injury when they have actually injured the foot or the Achilles tendon. Injuries to these structures are not excluded with the three-view ankle series.

Many acutely injured ankles are too painful or swollen for tests of ligamentous stability to be performed accurately. In these circumstances, the tests can be deferred to the physician who is going to follow the case. If the circumstances allow an examination, perform the following: With the foot hanging freely, grasp the posterior calcaneus with one hand and stabilize the distal leg with the other hand. With the foot in a few degrees of plantar flexion, test the anteroposterior stability of the joint by moving the foot while holding the tibia in a stable position. A positive anterior drawer test is greater than 5 mm of movement in comparison to the normal ankle. Evert and invert the foot. More than a 10° movement in comparison to the other foot is a positive talar tilt test. Inversion instability or anterioposterior laxity suggests the disruption of two or more of the lateral collateral ligaments. Eversion instability suggests a disruption of the deltoid complex. Some orthopedists feel that the anterior drawer test and the talar tilt test should be performed as stress radiographs, with comparison films of the other ankle before any conclusions are made. This is not practical in the ED, and these tests can be done in follow-up or consultation.

Perform a neurovascular examination. This includes palpation of the dorsalis pedis and posterior tibial pulse and capillary refill. Check the foot for motor and sensory impairment. Ask the patient to walk four steps: if the patient can transfer weight from one foot to another and the findings on physical examination as outlined above are normal, the likelihood of a significant fracture is nil.

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