FIGURE 40.6 Anteroposterior and lateral views of two-fragment triplanar fracture L, lateral; M, medial; P, posterior; A, anterior FIGURE 40.7 Lateral view of the ankle ATFL, anterior talofibular ligament; PTFL, posterior talofibular ligament; CFL, calcaneofibular ligament Injuries Associated With Ankle Sprains Approximately 7% of ankle sprains are accompanied by osteochondral fractures of the talus The medial dome is more commonly fractured than the lateral dome Avulsions of the peroneus brevis tendon from the base of the fifth metatarsal have been observed in up to 14% of patients with ankle ligament ruptures If this injury occurs in children younger than 15 years, the avulsed fragment is usually an apophysis and is considered an S-H type I injury, often called a pseudo-Jones fracture In older patients, the fracture is more distal on the fifth metacarpal at the metaphyseal–diaphyseal junction and is known as a Jones fracture FIGURE 40.8 Ankle eversion injury ATFL, anterior talofibular ligament TABLE 40.4 CLASSIFICATION OF ANKLE SPRAINS Grade I: Mild sprain Grade II: Moderate sprain Grade III: Severe sprain Ligament injury Swelling Tenderness Functional loss Minor Mild Mild, local Minimal Joint stability Stable Near complete tear Moderate Moderate, diffuse Ambulates with difficulty No/mild instability Complete rupture Severe Marked Inability to bear weight Unstable EVALUATION AND DECISION History Trying to obtain a reliable history in ankle injuries can be difficult Commonly, the description is: “I twisted it and it hurts.” Nevertheless, the mechanism of injury, if obtainable, can provide a clue to the diagnosis Other questions include the following: (i) When did the injury occur? (ii) Did swelling occur immediately or gradually? (iii) Is there a history of any previous injury to that limb? and (iv) Does the patient have a history of any other medical problems—osseous, neurologic, or muscular disease? A history of fever, rash, or other joint involvement, in combination with a history of minimal or no trauma, suggests nontraumatic diagnoses such as septic joint, arthritis, or collagen vascular disease Physical Examination General Inspection Look for obvious deformities, open wounds, loss of anatomic landmarks, local swelling, and ecchymosis If an obvious deformity is present, keep manipulation of the extremity to a minimum and assess neurovascular status promptly Any break in the skin may communicate with the joint space or constitute an open fracture The need for antibiotic coverage should be evaluated immediately Neurovascular Evaluation