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CLINICAL SCIENCE SESSION

ANKLE SPRAIN
Pembimbing:
dr. R. Andri Primadhi Sp.OT
Disusun Oleh :
Sri Hudaya Widihastha

1301-1213-0520

Novra Christy Grace Sumbayak

1301-1213-0503

Theruna A/L Huthamaputiran1301-1213-2559


Nadia Ayu Destianti

1301-1214-0002

Harvir Singh Sidhu

1301-1214-2011

BAGIAN ILMU BEDAH SUB BAGIAN ORTHOPAEDI


FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN
RUMAH SAKIT UMUM PUSAT DR. HASAN SADIKIN BANDUNG
2014

Ankle sprains are the most common of all sports related injuries, accounting for
over 25 per cent of cases. They are probably even more common in pedestrians and
country walkers who stumble on stairways, pavements and potholes. In more than 75
per cent of cases it is the lateral ligament complex that is injured, in particular the
anterior talofibular and calcaneofibular ligaments. 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.
This may amount to no more than a painful wrenching of the soft tissues what is
commonly called a sprained ankle. If more severe force is applied, the ligaments may
be strained to the point of rupture. With a partial tear, most of the ligament remains
intact and, once it has healed, it is able to support the weight of the body. With a
complete tear, the ligament may still heal but it never regains its original form and the
joint will probably be unstable.
FUNCTIONAL 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. In
plantarflexion the ligament essentially changes its orientation from horizontal with
respect to the floor, to almost vertical. 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.
The 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. The deep portion is intra-articular, running directly from the medial
malleolus to the medial surface of the talus. Its 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. This strong ligament complex still permits some movement at
the tibio - fibular joint during flexion and extension of the ankle.
PATHOLOGY
The common twisted ankle is due to unbalanced loading with the ankle inverted
and plantarflexed. First the anterior talofibular and then the calcaneofibular ligament is
strained; sometimes the talocalcaneal ligaments also are injured. If fibres are torn there
is bleeding into the soft tissues.
ACUTE INJURY OF LATERAL LIGAMENTS
Clinical features
A history of a twisting injury followed by pain and swelling could suggest anything
from a minor sprain to a fracture. If the patient is able to walk, and bruising is only faint
and slow to appear, it is probably a sprain; if bruising is marked and the patient unable
to put any weight on the foot, this suggests a more severe injury. Tenderness is maximal
just distal and slightly anterior to the lateral malleolus. 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
About 15 per cent of ankle sprains reaching the Emergency Department are
associated with an ankle fracture. This complication can be excluded by obtaining an xray, but there are doubts as to whether all patients with ankle injuries should be
subjected to x-ray examination. Almost 2 decades ago The Ottawa Ankle Rules were
developed to assist in making this decision. 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;
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(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. If x-ray examination is considered necessary,
anteroposterior, lateral and mortise (30-degree oblique) views of the ankle should be
obtained.
Localized soft tissue swelling and, in some cases, a small avulsion fracture of the
tip of the lateral malleolus or the anterolateral surface of the talus may be the only
corroborative signs of a lateral ligament injury.
Persistent inability to weightbear over 1 week or longer should call for reexamination and review of all the initial negative x-rays. For patients who have had
persistent pain, swelling, instability and impaired function over 6 weeks or longer,
despite appropriate early treatment, magnetic resonance imaging (MRI) or computed
tomography (CT) will be required to assess the extent of soft tissue injury or subtle bony
changes.
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.
More recently the acronym has been extended to PRICE by adding protection
(crutches, splint or brace) and still further to PRICER, adding rehabilitation (supported
return to function). The 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.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) in the acute phase
can be helpful, with the usual contraindications and caveats. There is evidence that in
acute injuries topical non-steroidal anti-inflammatory (NSAI) gels or creams might be as
beneficial as oral preparations, probably with a better risk profile.
OPERATIVE TREATMENT
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If the ankle does not start to settle within 1 or 2 weeks of starting RICE, further
review and investigation are called for. Persistent problems at 12 weeks after injury,
despite physiotherapy, may signal the need for operative treatment. Arthroscopic repair
or ligament substitution is now effective in many cases, allowing a return to full function
and sports.
RECURRENT LATERAL INSTABILITY
Recurrent sprains are potentially associated with added cartilage damage, and
warrant careful investigation by MRI, arthroscopy and examination under anaesthesia.
Clinical features
The patient gives a history of a sprained ankle that never quite seems to recover
and is followed by recurrent giving way or a feeling of instability when walking on
uneven surfaces. This is said to occur in about 20 per cent of cases after acute lateral
collateral ligament tears (Colville, 1994).
The ankle looks normal and passive movements are full, however stress tests for
abnormal lateral ligament laxity may show either excessive talar tilting in the sagittal
plane or anterior displacement (an anterior drawer sign) in the coronal plane. In the
chronic phase these tests are painless and can be performed either manually or with
the use of special mechanical stress devices. Both ankles are tested, so as to allow
comparison of the abnormal with the normal side.
Talar tilt test With the ankle held in the neutral position, the examiner stabilizes
the tibia by grasping the leg with one hand above the ankle; the other hand is then used
to force the heel into maximum inversion. The range of movement can be estimated
clinically and compared with that of the normal ankle. Inversion laxity suggests injury to
both the calcaneofibular and anterior talofibular ligaments.
Anterior drawer test The patient should be sitting with the knee flexed to 90
degrees and the ankle in 10 degrees of plantarflexion. The lower leg is stabilized with
one hand while the other hand forces the patients heel forward under the tibia. In a
positive test the talus can be felt sliding forwards and backwards. With an isolated tear

of the anterior talofibular ligament, the anterior drawer test may be positive in the
absence of abnormal talar tilt.
Treatment
Recurrent giving way can sometimes be prevented by modifying shoe-wear,
raising the outer side of the heel and extending it laterally. More effectively, the
secondary dynamic ankle stabilizers, the peronei, can be strengthened and brought into
play by specific physiotherapy regimes. Ankle exercises to strengthen the peroneal
muscles are helpful, and a light brace can be worn during stressful activities.
Most patients with functional instability can be improved and returned to sport by
arthroscopic debridement of the impinging tissue within the ankle joint, followed by
physiotherapy. Various operations for mechanical stabilization fall mainly into two
groups: (1) those that aim to repair or tighten the ligaments, (2) those that are designed
to construct a check-rein against the unstable movement. The BrostrmKarlsson or
Gould operation is an example of the first type: the anterior talofibular and
calcaneofibular ligaments are exposed and repaired, usually by an overlapping or
double-breasting technique (Karlsson et al., 1988).
Postoperatively the ankle is immobilized in eversion for 2 weeks; a below-knee
cast is then applied for another 4 weeks, during which time the patient can bear weight.
The brace can usually be discarded after 3 months but it may need to be used from time
to time for sports activities.
DELTOID LIGAMENT TEARS
Rupture of the deltoid ligament is usually associated with either a fracture of the
distal end of the fibula or tearing of the distal tibiofibular ligaments (or both). The effect
is to destabilize the talus and allow it to move into eversion and external rotation. The
diagnosis is made by x-ray: there is widening of the medial joint space in the mortise
view; sometimes the talus is tilted, and diastasis of the tibiofibular joint may be obvious.
Treatment

Provided the medial joint space is completely reduced, the ligament will heal. The
fibular fracture or diastasis must be accurately reduced, if necessary by open operation
and internal fixation. Occasionally the medial joint space cannot be reduced; it should
then be explored in order to free any soft tissue trapped in the joint. A below-knee cast
is applied with the foot plantigrade and is retained for 8 weeks.
DISLOCATION OF PERONEAL TENDONS
Acute dislocation of the peroneal tendons may accompany or may be mistaken
for a 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 a below knee cast for 6
weeks will help in a proportion of cases; the remainder will complain of residual
symptoms. Recurrent subluxation or dislocation is unmistakable; the patient can
demonstrate that the peroneal tendons dislocate forwards over the fibula during
dorsiflexion and eversion.
Treatment is operative and is based on the observation that the attachment of the
retinaculum to the periosteum on the front of the fibula has come adrift, creating a
pouch into which the tendons displace. Whichever method of stabilization is used, it is
important to also assess the state of the tendons themselves, as an associated
longitudinal split tear is commonly found, and this will lead to continuing pain and
dysfunction around the lateral border of the ankle if it is not repaired.
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. These injuries may
occur in isolation, but they are usually associated with fractures of the malleoli or
rupture of the collateral ligaments.
Clinical features
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Following a twisting injury, the patient complains of pain in the front of the ankle.
There is swelling and marked tenderness directly over the inferior tibiofibular joint. A
squeeze test has been described by Hopkinson et al. (1990); when the leg is firmly
compressed some way above the ankle, the patient experiences pain over the
syndesmosis. Be sure, though, to exclude a fracture before carrying out the test.
X-ray
With a partial tear the fibula usually lies in its normal position and the x-ray looks
normal. With a complete tear the tibiofibular joint is separated and the ankle mortise is
widened; sometimes this becomes apparent only when the ankle is stressed in
abduction. There may be associated fractures of the distal tibia or fibula, or an isolated
fracture more proximally in the fibula.
Treatment
Partial tears can be treated by strapping the ankle firmly for 23 weeks.
Thereafter exercises are encouraged. Complete tears are best managed by internal
fixation with a transverse screw just above the joint. This must be done as soon as
possible so that the tibiofibular space does not become clogged with organizing
haematoma and fibrous tissue. If the patient is seen late and the 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 which the screw is removed. However, some
degree of instability usually persists.

DAFTAR PUSTAKA
1. Warwick D, Nayagam S. Apley's System of Orthopaedic and Fractures. 9th ed.
London: Hodder Arnold; 2010.

2. Thompson JC. Netter's Concise Orthopaedic Anatomy. 2nd ed. Philadelphia:


Saunders; 2010.

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