What to do with the Swollen Ankle

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What to do with the Swollen Ankle

• Rochelle M Nolte, MD
• CDR USPHS

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Objectives

• Describe an approach to the patient with a
  swollen ankle
• Establish a differential diagnosis for the
  patient with a swollen ankle
• Understand the use of diagnostic laboratory and
  imaging studies in the patient with a swollen
  ankle

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Whats the initial goal?

• Formulate a differential diagnosis that
• Leads to an accurate diagnosis and timely therapy
• Avoids excessive diagnostic testing and
  unnecessary treatment

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Whats the initial approach?

• Anatomic localization of complaint
• Articular v. non-articular
• Determine nature of pathologic process
• Inflammatory v. non-inflammatory
• Determine extent of involvement
• Mono v. polyarticular. Focal v. widespread
• Determine chronicity
• Acute v. chronic

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Articular v. non-articular

• Articular structures
• Synovium
• Synovial fluid
• Articular cartilage
• Intraarticular ligaments
• Joint capsule
• Juxtaarticular bone

• Non-articular
• Extraarticular ligaments
• Tendons
• Bursae
• Muscle
• Fascia
• Bone
• Nerve
• Overlying skin

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Articular Disorders

• Deep or diffuse pain
• Limited ROM (active and passive)
• Swelling (effusion or synovial proliferation)
• Crepitation
• Instability
• Locking
• Deformity (bony enlargement, subluxation)

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Non-articular Disorders

• Painful on active ROM, not passive ROM
• Point tenderness remote from joint capsule
• Seldom have crepitus, instability, or deformity

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Inflammatory v. Non-inflammatory

• Inflammatory
• Infectious
• N. gonorrhea
• M tuberculosis
• Crystal-induced
• Gout, pseudogout
• Immune-related
• SLE, RA
• Reactive
• Rheumatic fever, Reiters
• Idiopathic

• Non-inflammatory
• Trauma
• Rotator cuff tear
• Ineffective repair
• Osteoarthritis
• Neoplasm
• Pigmented villonodular synovitis
• Pain amplification
• Fibromyalgia

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Inflammatory

• Four cardinal signs
• Erythema, warmth, pain, swelling
• Systemic symptoms
• Fatigue, fever, weight loss, prolonged morning
  stiffness
• Laboratory evidence of inflammation
• ESR, CRP, thrombocytosis, anemia of chronic
  disease, hypoalbuminemia

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Acute v. Chronic

• Typically lt6 weeks acute gt 6 wks chronic
• Acute infectious, crystal-induced, reactive
• Chronic non-inflammatory, immunologic
• Chronology
• Onset
• Evolution
• Duration

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Chronology

• Onset
• Abrupt
• Septic arthritis
• Gout
• Indolent
• Osteoarthritis
• Rheumatoid arthritis
• Fibromyalgia

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Chronology

• Evolution
• Chronic
• Osteoarthritis
• Intermittent
• Gout
• Migratory
• Gonococcal or viral arthritis
• Additive
• Reiters syndrome or rheumatoid arthritis

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Chronology

• Duration
• Less than 6 weeks
• Acute arthritis (infections, gout, CPPD,
  Reiters)
• Initial presentation of chronic arthritis
• Trauma, fracture
• Greater than 6 weeks
• Inflammatory (indolent infection, psoriatic, JRA,
  RA, SLE, scleroderma, polymyositis)
• Non-inflammatory (OA, Charcot arthritis,
  osteonecrosis)
• Bursitis, tendinitis, fibromyalgia, PMR

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Distribution

• Monoarticular (one joint)
• Oligoarticular or pauciarticular (2-4 joints)
• Polyarticular (more than 4 joints)

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History and ROS

• Precipitating events
• Trauma, drug, illness
• Rheumatic ROS
• Fever, rash, myalgias, weakness
• Eye sx (Behcets, sarcoidosis, Reiters)
• GI sx (scleroderma, inflammatory bowel dz)
• GU sx (Reiters, goncoccemia)
• Nervous system (Lyme disease, vasculitis)

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History

• If traumatic, mechanism of injury (MOI)
• Inversion sprains account for 85 of injuries
• Ability to bear weight
• When did injury occur
• Age of patient and skeletal maturity
• History of prior injuries
• Complicating illnesses
• Medications

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Physical Exam

• Goals of PE
• ID the structures involved
• ID nature of underlying pathology
• ID extent and functional consequences
• ID any systemic or extra-articular signs

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Physical Exam

• Observe for obvious deformity or erythema
• Determine location of swelling/ecchymosis
• Palpate for focal tenderness or warmth
• Observe patient walking
• Neurovascular status
• Squeeze and rotary tests
• Evaluation of tendons with resisted ROM
• Passive ROM tests

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Laboratory Evaluation

• VAST MAJORITY OF MUSCULOSKELETAL DISORDERS CAN BE
  EASILY DIAGNOSED BY A COMPLETE HISTORY AND
  PHYSICAL.

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Laboratory Evaluation

• Serology (RF, ANA, complement levels, Lyme Abs,
  C-ANCA, ASO)
• Poor predictive value with low pre-test
  probability
• Should only be used for high clinical suspicion
• Uric acid
• Only helpful when gout has been diagnosed and
  therapy is being contemplated

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Laboratory Evaluation

• VAST MAJORITY OF MUSCULOSKELETAL DISORDERS CAN BE
  EASILY DIAGNOSED BY A COMPLETE HISTORY AND
  PHYSICAL.

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Laboratory Evaluation

• Synovial fluid aspiration
• Indicated in setting of acute monoarthritis of
  unknown etiology
• Evaluate for
• Appearance, viscosity, cell count
• Cultures of fluid if infection is suspected
• Other tests (glucose, protein, LDH, etc) of
  little diagnostic value

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Laboratory Evaluation

• Synovial fluid aspiration
• Is effusion hemorrhagic?
• Trauma or mechanical derangement
• Coagulopathy
• Neuropathic arthropathy
• Is WBC gt2000? (inflammatory or septic)
• Is WBC gt50,000? (septic)
• Are crystals present? (gout or CPPD)

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Diagnostic Imaging

• When are x-rays indicated?
• History of trauma (more on Ottawa rules later)
• Suspected chronic infection
• Progressive disability
• Monoarticular involvement
• When considering therapeutic alterations
• When a baseline assessment is needed for a
  chronic process

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Diagnostic Imaging

• Ottawa Ankle rules (SOR A/Level I)
• AP, lateral, and mortise views indicated for
  acute trauma if
• Patient had inability to bear weight immediately
  after injury
• Point tenderness over medial malleolus, posterior
  edge or inferior tip of lateral malleolus, talus,
  or calcaneus
• Inability to ambulate for four steps in the ER

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Diagnostic Imaging

• Ultrasound
• Useful in detection of soft tissue abnormalities
• Operator dependent
• Radionuclide scintigraphy (bone scan)
• Very sensitive but poorly specific means of
  detecting inflammatory or metabolic alterations

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Diagnostic Imaging

• Computed tomography (CT)
• Useful for identifying
• Osteoid osteoma
• Tarsal coalition
• Osteomyelitis
• Intraarticular osteochondral fragments
• Advanced osteonecrosis
• Obscure fractures

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Diagnostic Imaging

• Magnetic resonance imaging (MRI)
• Multiplanar images
• Fine anatomic detail
• Contrast resolution
• Lack of ionizing radiation
• Can visualized bone marrow and soft tissue
  periarticular structures
• Indicated when it will provide necessary
  information that can not be o/w obtained

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Diagnostic Imaging

• MRI
• More sensitive than CT in diagnosis of soft
  tissue injuries, intraarticular derangements, and
  synovitis
• Can image
• Fascia, vessels, nerves, muscles, cartilage,
  ligaments, tendons, pannus, synovial effusions,
  and bone marrow

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ACR Appropriateness Criteria

• American College of Radiology
• Expert Panel of Musculoskeletal Imaging
• Rates appropriateness of study from 1-9
• 1 (least appropriate) to 9 (most appropriate)
• Panel reviews criteria annually and updates prn
  depending on new evidence
• There have been no studies specifically
  addressing the value of radiographs in chronic
  ankle pain

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ACR Appropriateness Criteria

• Best initial study for chronic ankle pain
• AP, lateral, and mortise x-ray (9)
• R/O arthritis, infection, fracture, neoplasm
• Suspected Osteochondral injury (nl x-rays)
• MRI (9) (SOR B/Level II)
• In 30 patients, MRI detected all osteochondral
  lesions and had high accuracy in determining
  stability (x-rays, CT, and bone scan all missed
  lesions)

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ACR Appropriateness Criteria

• Suspected tendinopathy with normal x-rays
• MRI (9) (SOR B/ Level II)
• MRI more accurate in identifying and staging
  severity of tendon injury than CT
• MRI was more accurate in predicting patient
  outcome after tendon reconstruction than
  intraoperative staging

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ACR Appropriateness Criteria

• Suspected ankle impingement syndrome
• MRI (8) (SOR C/Level II)
• Studies inconsistent---some find overlap in MRI
  findings of symptomatic patients and controls
• MRA (8)
• Has been found to be accurate in assessing
  impingement with the advantage of joint capsule
  distension by intra-articular contrast injection

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ACR Appropriateness Criteria

• DJD by radiograph (operative candidate)
• MRI (6)
• Up to the surgeon
• Pain of uncertain etiology with normal x-ray
• MRI (6)
• If patient truly needs an imaging study, MRI is
  probably the most appropriate
• Consider diagnostic injection

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ACR Appropriateness Criteria

• Suspected ankle instability
• MRI (3)
• US (2)
• CT (2)
• Stress view x-rays (2)
• Bone scan (2)
• Arthrography (2)
• CTA or MRA (2)

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Treatment

• Ultimately depends on correct diagnosis..
• Initial goals of acute treatment
• Avoid exacerbating factors or activities
• PRICEMM
• Protection (from abnormal motion/re-injury)
• Relative rest
• Ice
• Compression
• Elevation
• Modalities (as appropriate based on diagnosis)
• Medications (as appropriate based on diagnosis)

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Treatment

• Long-term treatment will depend on accurate
  diagnosis from history and physical (with
  supporting imaging as appropriate)

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Summary

• VAST MAJORITY OF MUSCULOSKELETAL DISORDERS CAN BE
  EASILY DIAGNOSED BY A COMPLETE HISTORY AND
  PHYSICAL.

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Summary

• Start with a full and accurate history of the
  swollen ankle not excluding non-traumatic
  etiology of swelling until history definitely
  excludes
• Perform a careful physical exam of the involved
  structures to narrow the differential diagnosis
• Order diagnostic imaging as appropriate based on
  working diagnosis
• Provide treatment as appropriate

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Thanks for coming

• Questions?