With all injuries, a good clinical history will help you identify the most likely injury. For example, if a patient saying they were running and inverted their ankle stepping down the kerb, then you know it is highly likely that any sprain or fracture will be on the lateral side of the ankle. It’s important to get as much information about exactly how the injury occurred.
- What happened?
- When did it happen?
- What was the mechanism of injury?
- Were they weight bearing immediately after the injury?
- Have they had pain relief?
- What is their pain score?
- Are there any other injuries?
- Are there any videos of the injury?! (its 2018 after all)
With injuries it is good to follow the Look, Feel, Move approach to assessment. Essentially, what can you see when you look at the injury, what can you feel when you palpate the injury, and can they move it / walk on it?
- Is there a gross deformity?
- Is there any swelling
- Is the any bruising / skin discolouration?
- Are there any wounds?
When it comes to Feel, we follow the OTTAWA ankle rules for new injuries. These are extremely accurate for ruling out a fracture and will guide you to whether an X-ray is required or not. On the table below you can see what to palpate and what the limitations of the OTTAWA ankle rules are.
OTTAWA Ankle Rules: Feel & Move
As well the OTTAWA rules it is important to check the neurovascular status distal to the injury for circulation and sensation. It is also very important to assess the joint above and below the injury.
Having a good understanding of the underlying structures that you are palpating will really help you with your assessments. You don’t need to become anatomist, but knowing the layout of a joint, especially of areas that you assess daily, will make your assessment much more accurate. If you combine this knowledge with a really detailed history and an OTTAWA ankle assessment, you’ll most likely know exactly what injury there is without even seeing an X-ray!
If in any doubt about whether to X-ray or not, always ask an ENP or Doctor. It is sometimes beneficial to just give analgesia and let that take effect before re-assessment, or based on the history it may be best to have a full, longer assessment before deciding to X-ray.
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