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Ligament injury

Ankle ligament injuries

  • Lateral ligament sprain most common
  • Ottawa rules help decide who needs an X-ray
    • Ankle X-ray if there is pain in the malleolar zone and any of: tenderness over the posterior edge or tip of lateral malleolus; tenderness over the posterior edge or tip of medial malleolus; or inability to weight-bear both immediately after injury and now 
    • Foot X-ray if there is pain in the midfoot zone and any of: tenderness over the navicular bone; tenderness over base of 5thmetatarsal; or inability to weight-bear both immediately after and now
  • Other examination
    • Palpate deltoid ligament (medially) and lateral ligament complex (anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament)
    • Palpate fibula up to knee (check for associated head of fibula fracture)
    • Squeeze test – squeeze mid-lower leg to test syndesmosis (positive test is pain at syndesmosis, requires urgent orthopaedic assessment if not intact)
    • Test weight-bearing (4 steps)
    • If the patient is not in too much pain
      • Anterior drawer test (hold foot still and push lower leg anteriorly and posteriorly) – tests talofibular ligament
      • Tilt test (invert foot at ankle and compare to other side) – tests lateral ligament complex, bias towards calcaneofibular ligament
    • + distal neurovascular exam (check peroneal and sural nerves)
  • Generic management
    • Acutely, apply an ice pack for 20 minutes
    • Give patient crutches, analgesia and advice
    • Advice:
      • NSAIDs
      • RICERest, Ice (20 minutes four times a day), Compression (elastic bandage) and Elevation for 24 hours
      • Then mobilise and weight-bear as able (walking on it will hurt but not harm)
      • Try to fully weight-bear on it for ~ 2 minutes twice a day for a month (e.g. while cleaning teeth)
      • Physio if not better in 1-2 weeks 
  • Specific management

Grading of ankle ligament injuries and their management

GradeDefinitionClinical findingsSpecific management 
1Ligament stretch with microscopic tearingLocal tenderness, minimal swelling, no joint instabilityElastic compression bandage (for 2 weeks)Heals in 2-4 weeks 
2Ligament stretch with partial tearingLocal tenderness, oedema, ecchymosis, partial loss of joint motion but definite end pointStirrup splint (for 4 weeks)Heals in 4-12 weeks 
3Complete rupture of ligamentMarked swelling, severe pain, gross ankle instabilityAircast boot (for 6 weeks)May require surgical repairHeals in 3-6 months 

Knee anatomy

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Knee ligament injuries

Structure damagedMechanismSymptoms
Cruciate ligamentsAnterior: forced flexion, hyperextension of knee (e.g. during tackle) or rotation injury to extended knee Posterior: tibia forced backwards, e.g. fall on object or against dashboard in road traffic accidentMay hear ‘pop’Knee collapses when put weight on itImmediate painDifficulty weight-bearingRapidly forming haemarthrosis 
Collateral ligamentsMedial: blow to lateral side of kneeLateral: blow to medial side of knee (check peroneal nerve) Lateral ligament injuries are uncommonPain on inner/outer kneeImmediate painDifficulty weight-bearingMay have symptoms of instability (if high grade injury)
Meniscus tearsRotational injury to flexed kneeImmediate painDifficulty weight-bearingSlowly forming effusion Clicking and locking (locking limiting extension)
  • Ottawa rules help decide who needs a knee X-ray: age >55; inability to weight-bear both immediately after injury and now; isolated patella tenderness; head of fibula tenderness; or inability to flex to 90˚
  • Knee examination may be difficult due to swelling and patients may need to return for full examination after 1 week
  • General management 
    • Acutely, apply an ice pack for 20 minutes
    • Give patient crutches, analgesia and advice
    • Advice:
      • NSAIDs
      • RICE: Rest, Ice (20 minutes four times a day), Compression (elastic bandage) and Elevation for 24 hours
      • Then mobilise and weight-bear as able (walking on it will hurt but not harm)
      • Try to fully weight-bear on it for ~ 2 minutes twice a day for a month (e.g. while cleaning teeth)
      • Physio if not better in 1-2 weeks

Specific management:

Grading of knee ligament injuries and their management

GradeDefinitionClinical findingsSpecific management 
1Ligament stretch with microscopic tearingKnee stable on clinical testingElastic or wool & crepe bandage (for 2 weeks)Heals in 2-4 weeks 
2Ligament stretch with partial tearingLaxity but definite end pointKnee brace (for 4 weeks, or until no laxity on examination)Heals in 4-12 weeks 
3Complete rupture of ligamentJoint opens >1cmMedial/lateral collateral ligament: knee brace (for 6-12 weeks or until no laxity on examination)Anterior/posterior cruciate ligament: cast and surgical reconstruction 
Meniscus Damage to menisciKnee gives way, clicks and locksArthroscopic repair if locked knee or knee is no better in 2 weeks
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