Saturday, June 11, 2011

Ankle Fracture or Sprain?

 Hello. New patients call me Dr. Herrera, but I prefer being called Doc Raldy or Doc Ralds instead. I’m a board-certified orthopedic surgeon with fellowship training both locally and abroad, specifically in Australia.  Some patients think I am still quite young to be a surgeon. In their mind, they visualize surgeons to be serious, imposing men with gray-hair or receding hairlines (Though the latter already applies to me).   

Some people say I look 20 years old.  (At least that’s what people tell me when I treat them out.)  But I’m not that young either.  My first computer monitor wasn’t colored.  It wasn’t even black and white.  It was green and black.  As a kid, Voltes V was my favorite robot, Walkman was the ipod, and Super Mario was the only popular video game.  We were called bagets back when bagets was still a word.  

Recently, a patient of mine, made me think of how we sometimes try to recapture the invincibility of our youth.  She was a well-dressed, witty lady about my mother’s age.  She told me she played sports once in a while.  How often? Oh about as often as a total solar eclipse.  

She was looking forward to joining a badminton game, and had all the essentials ready.  Pink outfit, pink shoes and pink badminton racket.  (You guessed her favorite color, right?)  She was further motivated to play because her badminton partner said that their opponents were paralyzed patients strapped in wheelchairs who can only move their necks and hold the badminton racket with their chins and shoulders, or something to that effect.  

But halfway through the game, she realized that she wasn’t playing in the Special Olympics, and months without practice was catching up on her.  They lost the game and, literally, to add injury to insult, she twisted her ankle.  As she was trying to hit the shuttle cock, she missed it, stepped on it and rolled over the court several times until she reached the other court.  


Ok, I’m being exag here.  Just want to make you smile a little bit.  But seriously now, she was in pain and pretty much unsure whether she fractured her ankle or not.   It took her several days to decide to see a doctor.

So, we come now to the orthopedic topic for this blog.  Sprain or fracture?  How can you tell if your ankle needs an orthopedic consult or simple home care?

What is a sprain?  A sprain is defined as stretching or tear of a ligament around a joint.  A fracture means a soft tissue injury complicated by a break in the bone. For the layman, it can simply mean a broken bone.

Even for trained medical personnel, such as nurses, emergency room doctors and general practitioners (GPs), differentiating between ankle sprains and fractures can be challenging.  A majority of ankle injuries are sprains, however, subtle fractures may sometimes present mild symptoms.  On the contrary, severe sprains can mimic fracture injuries. 

If you injured your ankle, here are five questions you need to answer to help differentiate sprains from fractures:

Can you step on your injured ankle without causing pain?  If you cannot apply weight on it at all, the ankle is probably broken.  If you can still walk, or limp, it’s most likely a sprain, but can also be a subtle or undisplaced fracture, and will need further tests.

Did your ankle make a sound when you obtained the injury?  A cracking noise could signal a fracture, whereas a popping noise is associated with a sprain.
   How does your ankle look?  If it looks twisted or deformed, with a bump or a protuberance, your ankle may be fractured, or even dislocated.  A fracture is likely if there is obvious deformity.

   How severe is the pain? Severe pain is associated with a fracture, whereas slight pain-- better described as discomfort-- is associated with a sprain.  However, of all symptoms, pain is the most unreliable measure since people have different degrees/ tolerance to pain.

Can you move your ankle?  If the joint is painful when you try to move it, it is most likely a sprain; if it cannot move at all, it is almost surely broken.

In Canada, a system was developed to help in differentiating ankle sprains from fractures.  They found that out of a large number of patients who had x-rays taken after ankle injuries or with ankle pain, only 15% of them actually had fractures.  To minimize unnecessary, costly and time-consuming x-rays, the following Ottawa Ankle Rule was suggested:  A fracture is likely and ankle x-rays are only required if there is pain in the ankle zone and any one of the following signs are present: (please bear with the technical jargon as it was designed for doctors and medical personnel)  
·         Bone tenderness along the distal 6 cm of the posterior edge of the tibia or the tip of the medial malleolus, OR
·         Bone tenderness along the distal 6 cm of the posterior edge of the fibula or the tip of the lateral malleolus, OR
·         Inability to bear weight both immediately and in the emergency department for four steps.

If the symptoms of your injury point to a fracture, you must immediately seek medical attention.  Waiting too long can result in more pain and discomfort. For example, if the bone was broken and healed in the wrong position, the orthopedic surgeon may have to re-break it to set it correctly, and the outcome may not be as good.

Another obvious reason to seek immediate medical attention would be if the ankle bones break through the skin. In such cases, called open fractures, infection is most likely and dangerous.

As soon as you injure your ankle, or any joint for that matter, pack it in ice.  What are other first aid treatment can you do for joint injuries?  Watch out for my next blog.  In the meantime, stay safe!

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