27th March 2019
Ankle Injuries are perhaps the most common injuries one may encounter in a remote or wilderness setting. (1, 2, 3).
The challenges in the remote setting are the diagnosis and decision making; has the casualty sustained a fracture or soft tissue damage? Will an ankle injury require evacuation, immobilisation or simple strapping?
As with all musculoskeletal injury we may identify common signs and symptoms:
A change of skin colour
Reduced (or exaggerated) range of movement
Loss of function
With the exception of gross deformity (bone visable through or under skin) or gross exaggeration of movement, the remainder are non-specific, they do not differentiate between fractures or soft tissue injuries such as sprains or strains.
Ottawa Ankle Rules
The Ottawa Ankle Rules were developed to rule out the need for x-ray in a clinical setting and the results are incredibly accurate (4, 5, 6).
The most common fractures found in ankle injuries are:
Tip of the lateral malleolus or posterior edge of the distal fibula
Tip of the medial malleolus or posteria edge of the distal tibia
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular
The most common ligament injuries occur at:
Anterior talofublar (ATF) ligament
Posterior talofibular (PTF) ligament
Calcaneofibular (CF) ligament
The requirement for an X-Ray is either
The casualty cannot bear weight for four steps
Pain in the malleolar or midfoot zone
Bone tenderness at the posterior edge or tip of the lateral or medial malleolus
Bone tenderness at the base of the fifth metatarsal or at the navicular
If either of these signs are present in a wilderness setting, this would warrant an x-ray in a clinical setting and therefore we can assume a high suspicion of fracture would warrant immobilisation and possible evacuation.
In the absence of such finding we may assume soft tissue injury which may simply require rest and support.
1. Our generic treatment plan for musculoskeletal injuries is here.
If you are still using RICE you need to read this.
2. Additional information of pain management can be found here.
3a. For injuries which require immobilisation Sam Splints can be used with great effect here.
3b. For injuries excluded by the Ottawa Ankle rules and where the casualty can weight-bear consider strapping:
The Remote, Austere, Wilderness and Third World Medicine Discussion Board Moderators (2017) “Survival and Austere Medicine: An introduction”. 3rd edition.
Gentile DA, Morris JA, Schimelpfenig T, Bass SM, Auerbach PS. (1992) “Wilderness Injuries and Illnesses”. Annals of Emergency Medicine. 21(7):853-61
Stiell IG, Greenberg GH, McKnight RD, et al. (1992) “A study to develop clinical decision rules for the use of radiography in acute ankle injuries”. Annals of Emergency Medicine. 21 (4), 384–390.
Stiell IG, McKnight RD, Greenberg GH, et al. (1994) “Implementation of the Ottawa ankle rules”. Journal of the American Medical Association. 271 (11), 827–832.
Stiell I, Wells G, Laupacis A, et al. (1995) "Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group". British Medical Journal. 311 (7005): 594–7.