Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine

2. Collagen-Vascular Illnesses

3. Chromosomal Abnormalities

4. Generalized

5. Sexual Abuse

6. Hematology

7. Trauma and Surgery
--Surgery in Pediatrics: Timing and Indications for Procedures
--Fractures in Children

The Evaluation of Ankle Injuries

Drs. Nguyen, Kinsey, Weisgerber, Stallworth, Wright

Introduction: Pediatricians are asked to evaluate injured ankles frequently.  Most (85%) injuries are inversion during plantar flexion and injure the talofibular ligament.  The anterior drawer test (foot in neutral position, pull forward on the calcaneous) is a test of the integrity of the anterior talofibular ligament.

The talar tilt test tests calcaneofibular ligament and the deltoid ligament.  When doing these tests must always compare the two sides.

Sprains: Classification.  Definition: sprain: ligamentous injury; strain: muscle injury.  Fractures should be suspected whenever there is pain medially or if there is point tenderness over the distal fibula or metatarsal (usually 5th).  Otherwise, the pediatrician is faced with determining the need for x-ray and/or referral to orthopedics.

• Grade I: Able to walk after injury; some swelling, no eccymosis, negative anterior drawer test; mild swelling.  Many physicians do not X-Ray these patients.
• Grade II: Moderate pain, ecchymosis and swelling; positive anterior drawer test and talar tilt test.  Usually x-ray, wear compression bandage; may need physical therapy.  Recovery in 2-4 weeks.
• Grade III: Severe pain; unable to bear weight; often associated with avulsion fracture; positive anterior drawer and talar tilt test; refer to orthopedics; 4-6 weeks recovery time.

History of Injury must always be obtained about:

• position of the ankle at the time of injury: if fixed at time of injury, more trouble; also if ankly in dorsiflexion or eversion more likely to produce medial symptoms and therefore more likely to have fracture.
• ability to bear weight immediately after injury: if unable, more severe injury
• popping or snapping noise: if present, possible tendon rupture
• history of previous difficulty with joint

Physical Examination: As Above. In addition to anterior drawer and talar tilt tests, palpation along the anterior talo-fibular ligament as well as distal fibula and particularly the 5th metatarsal bone or (more uncommonly) the navicular bone.

Treatment: Varies with the severity of the injury; the following are guidelines:

• P= Protection. G 1: ace or air cast; G 2: air cast or stirrup ankle support; G3: cast/surgery
• R=Rest.  Use crutches until normal heel-toe gait is restored.
• I= Ice.  Ice is used particularly in the first 24 hours.
• C=Compression. As soon as possible to decrease swelling.
• E=Elevation
• M=Medication (antiinflammatories); Mobilization: early if pain free; Modalities such as exercise and proprioception training to prevent reinjury – particularly for G2 and 3 strains.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004