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Beyond sprains: advice on treating ankle injuries. (Range of Differential Diagnoses is Small).

KIAWAH ISLAND, S.C. -- The ankle's relatively simple anatomy makes it one of the least intimidating aspects of sports medicine, Dr. Paul Stricker said at a meeting on pediatric and adolescent sports medicine sponsored by the American Academy of Pediatrics.

Ankle sprains are among the most common sports-related injuries in both children and adults; many physicians have either experienced the injury personally or have seen it in their offices, said Dr. Stricker of the Scripps Clinic, La Jolla, Calif.

All ankle injuries aren't created equal, but the range of differential diagnoses for acute injuries is relatively small.

* Sprains. Sprains due to inversion injuries are the most common ankle injury--accounting for almost 85% of all such injuries--but eversion injuries are often more severe.

Inversion ankle sprains usually occur in the anterior talofibular ligament (ATFL).

Eversion ankle sprains generally involve the deltoid ligament and also can cause fractures to the fibula or foot.

* Rotational or hyperdorsiflexion injuries. These injuries are more likely to injure the syndesmosis (tibiofibular ligament), which is one of the most important contributors to ankle stability, Dr. Stricker said. "You'll hear this referred to as a 'high ankle sprain.'" Be sure to get a mortise view x-ray because there is a need for stabilization surgery if the injury is unstable.

* Physeal injuries. If the child shows signs of discomfort on palpation of the physis area, if it's more tender than a ligament should be, and if x-rays are negative, it's a physis injury until proven otherwise.

Salter III distal tibial physis, or Tillaux fracture, is a common adolescent injury often occurring at age 12-15 years when the distal tibial physis is closing. Children might have a rotational injury that causes a shearing of the physis, and they'll present with severe discomfort and swelling. A CT scan helps determine the amount of displacement. Most children will have to have open reduction internal fixation.

Some ankle injuries are the result of overuse:

* Calcaneal apophysitis or Sever's disease. This condition is most common in 11- to 13-year-olds who play soccer, and is due to repetitive trauma and traction of the Achilles tendon on the apophysis.

* Anterior tibialis, posterior tibialis, or peroneal tendonitis. These overuse injuries may be the problem if there's no history of trauma yet the child has pain with resistance to motion and tenderness all along the ankle.

* Stress fractures. These injuries cause point tenderness, but probably won't show up on an x-ray

* Avulsion fractures. These injuries are often referred from urgent care, and the minor ones can be treated as sprains. Children may have a previous diagnosis of fracture that on closer examination turns out to be a tiny splinter on the distal fibula, Dr. Stricker said.

"We look like heroes because we can tell them that this is something we can treat as a sprain, and they avoid a long leg cast."

* Pain in the proximal fifth metatarsal. This can be a simple avulsion fracture. But if it's in the metaphysis of the fifth metatarsal it is a Jones fracture--a serious condition that will probably require surgery.

Swelling and ecchymosis are common in ankle injuries, but don't use that as a prognosis or to determine how well the child is recovering. Sometimes ankle swelling can persist for 3-4 months, but as long as the patient's pain and function are improving, it's not something to worry about, Dr. Stricker said.

The RICE approach (rest, ice, compression, elevation) is the best basic treatment for ankle injuries, with anti-inflammatories given if needed. Treat simple, nondisplaced fractures with some type of walking cast.

Complete immobilization is not the best treatment for most ankle injuries, and abstinence from weight bearing is unnecessary except in cases of severe fracture. Most children need some support until they can walk without limping, but a stirrup splint or lace-up brace is often sufficient, with one crutch if the child wants it.

Some children feel more confident returning to play with an ankle brace--a stirrup splint or. lace-up--even if their rehabilitation goes well. That's fine as long as the brace is not a quick fix and doesn't replace strength and flexibility exercises, Dr. Stricker said.

Adequate rehabilitation--which varies with the severity of the injury--is important to full recovery. Some simple exercises include stretching the Achilles tendon, writing the alphabet in the air with the big toe, and standing on one leg--supervised, of course.

The sooner children start rehabilitation, the more they reduce the swelling and adhesions. As they recover, they can gradually return to sports-specific activities.

Follow-up is key to preventing future sprains, especially for patients who are desperate to return to play.

At a follow-up appointment, check compliance. Ask if they are doing their exercises. One way to catch them is the balance test. If they can't balance on the injured foot with their eyes closed, they aren't ready to return to play.

As always, consider the unusual--such as occult fractures or osteochondritis--if a patient's ankle injuries aren't improving as expected.

RELATED ARTICLE: Pearls and Pointers for Ankle Exams

* Be consistent. Dr. Stricker said he usually positions the child with the injured leg hanging over the edge of a table.

* Start at the proximal fibula. Then squeeze down the calf to check for specific tibial or fibular pain.

* Get an x-ray under certain conditions. If squeezing the tibia and fibula together at the point where they meet causes pain in the syndesmosis area (the distal tibia-fibula articulation connected by the anterior tibiofibular ligament), get an x-ray.

* Take the least painful course. In cases of inversion injury, start palpation on the medial side--it will be less painful for the child.

* Check for bony avulsion fracture. Palpate the deltoid ligament along the base of the tibia, then move to the tarsal navicular, where the posterior tibialis comes down and inserts--that's the place to palpate for a bony avulsion fracture.

* Do resistance strength testing. For example, have the child dorsiflex against your hand, and push against it, then plantar flex and push down. This might be painful if the child has a lateral sprain.

* Use the talar tilt test. This checks the vertical calcaneal tibular ligament. Cup the heel, hold foot at 90 degrees and put inversion pressure on it, and see if there's a firm end point on the tug. If so, that ligament is fine. Some patients' ligaments are very loose, so be sure to compare both feet.

* Test for syndesmosis injury. Check for tenderness where the tibia and fibula meet. Thede asymptomatic pulmonary hypertension, systemic hypertension, and neurocognitive deficits. More severe sequelae include a failure to thrive, cor pulmonale, mental retardation, and death.

"Most people agree apnea lasting two or more breaths is abnormal," according to Dr. Choi, vice chair of the department of otolaryngology, Children's National Medical Center, Washington. "Our goal is to identify kids who are at risk for adverse outcomes and avoid unnecessary surgery."

A tonsillectomy and adenoidectomy are from 75% to 100% effective. An estimated 400,000 of these procedures are performed each year in the United States.

At least one recent study found children who have the surgery report a marked improvement in quality of life (Arch. Otolaryngol. Head Neck Surg. 128[5]:489-96, 2002).

Other treatment options include tracheotomy, continuous or biphasic positive airway pressure, and uvulopalatopharyngoplasty.

Polysomnography combines many measures to detect sleep apnea: respiratory effort, oronasal flow, pulse oximetry, electromyography (in the anterior tibial region to monitor arousal), electroencephalography or electrooculography (for sleep staging), and esophageal pressure monitoring.

Dr. Choi uses polysomnography if history and physical exam are inconsistent, if a child has persistent symptoms, if severe obstructive sleep apnea syndrome is suspected, or if the child is in a high-risk group. Children at high risk include those who are under 2 years of age, those who are obese, those who show failure to thrive, and those who have a recent respiratory infection, cor pulmonale, a neuromotor disease, or craniofacial or chromosomal abnormalities.

The most severe sleep-related breathing disorder, obstructive sleep apnea, affects about 3% of children. The most common cause is adenotonsillar hypertrophy. It can feature partial or nearly complete upper-airway obstruction, Dr. Choi said. "The thing to remember is that obstructive sleep apnea syndrome occurs during REM sleep, which occurs in the early morning, so parents may miss it because they are not observing their children sleeping at 5 a.m."

Diagnosis of obstructive sleep apnea syndrome is difficult based only on history and physical exam, Dr. Choi continued. She suggested videotaping or performing nocturnal pulse oximetry if polysomnography is not possible.
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Author:Splete, Heidi
Publication:Family Practice News
Geographic Code:1USA
Date:Feb 1, 2003
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