Most people wouldn’t be surprised that the ankle injuries are some of the more common things that ruin a good hiking trip. Drs. Townes and Hung wrote a very interesting article about Rescue teams in Yosemite Park and the injuries they deployed to. Clearly, treating an ankle injury is a required skill for anyone who cares for people in the wilderness.
Upon seeing a companion or patient with an ankle injury, a few things should be done. First, ensure they are safe and out of immediate danger and you won’t be at risk when you stop and help them. I also use this time to re-check my ABC’s (airway, breathing, circulation). When it come to looking at the ankle, there are a few very important exams that need to be done.
First, feel the pulses of the foot. The Dorsalis Pedis and Posterior Tibial are the two pulses in the foot. The Posterior Tibial pulse should be fairly strong, while the Dorsalis Pedis may be faint and sometimes hard to find. You are doing this to ensure there is good blood flow to the foot and it it not at risk of tissue damage due to a ruptured artery, from the injury. Color of the foot (nice and pink) can tell alot about perfusion of the foot, as well. A grey or white and cold foot is a very bad sign and is a true emergency needing an orthopedic doctor. Capillary refill is another method to check vascular status of the limb.
Neurological status of the foot can be checked by ensuring there is movement of the toes and that sensation is intact, by asking how touching the foot feels. These several simple tests can tell you if the underlying nerves and blood vessels of the foot were damaged in the injury. If something on these exams is abnormal, this should be looked at quickly as possible, by an orthopedic doctor.
A really amazing set of rules can be used to assess the severity of the injury and the need for an x-ray. The Ottawa Ankle Rules are very good and commonly used in emergency departments to aid with the decision to get an x-ray, or not.
According to Ottawa Ankle rules, X-rays are only required if there is bony pain in the malleolar or midfoot area, and any one of the following:
*Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
*Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
*Bone tenderness at the base of the fifth metatarsal (for foot injuries).
*Bone tenderness at the navicular bone (for foot injuries).
*An inability to bear weight both immediately and in the emergency department for four steps.
Certain groups are excluded, in particular children (under the age of 18), pregnant women, and those with diminished ability to follow the test (for example due to head injury or intoxication).
These rules are found to be accurate in about 85-87% of the time, meaning the rate of missing an ankle fracture is only 13%, if these rules are used correctly.
Splinting an ankle injury is the subject of much debate and everybody has their favorite method. A very easy and effective method is using a SAM splint in a “stirrup” configuration. The makers of SAM Splints have a very good video (free on their website) about how to construct these.
Pain control can usually be achieved with ibuprofen or even tylenol. Ensure there are no allergies or contraindication to using these types of pain control.
A great resource on management of ankle sprains can be found here:
http://www.fpnotebook.com/Ortho/Ankle/AnklSprnMngmnt.htm