Orthopaedic surgeons on emergency duty are always encountering some unlucky people who are unlucky in the extreme – ankle sprains, which are almost the most common type of orthopaedic emergencies, accounting for about 25% of skeletal muscle system injuries, the vast majority of which are lateral ligament injuries.
RICE principles
As an emergency treatment for ankle sprains, the RICE principles have become classic.
1.Rest (rest): stop walking and let the injured part rest quietly to reduce further damage.
2, Ice (ice): let the temperature of the injured area to reduce the inflammatory response and muscle spasm, relieve pain and inhibit swelling. Each 10-20 minutes, more than 3 times a day, pay attention not to directly apply ice to the affected area, available wet towel wrapped in ice to avoid frostbite. Apply ice only within 48 hours after the injury.
3.Compression：Wrap the injured ankle joint with an elastic bandage and apply appropriate pressure to reduce swelling. Be careful not to apply excessive pressure, otherwise it will increase the swelling and ischemia of the limb far from the wrap.
4. Elevation: Elevate the limb above the heart position to increase venous and lymphatic return, reduce swelling and promote recovery.
Is it enough to have the RICE principle for ankle sprain? Which patients need immobilization? Which patients need surgery? Obviously, RICE is only the principle for emergency management of ankle sprains (within 24-48 hours), so what is the subsequent management?
Grading of ankle sprains
There are usually 3 grades of ankle injury based on the mild to moderate severity of the injury.
Grade 1: There is stretching of the ligaments, only microscopic damage to the ligament fibers and mild pain. Weight bearing is possible as long as it is tolerated; no splinting brace is required; isometric contraction exercises are feasible; full range of joint mobility exercises and muscle strength training can be performed if tolerated.
Grade 2: Partial rupture of ligament fibers, moderate pain and swelling, limited mobility, and possible joint instability. Immobilization with splinting or bracing, physical therapy, and muscle and joint mobility exercises are required.
Grade 3: Complete ligament rupture with significant swelling and pain and joint instability. Braking and rehabilitation are the same as grade 2, but the rehabilitation time is longer and in a few cases surgery is required.
Non-surgical treatment
POLICE principles
In 2012, the British Journal of Sports Medicine recommended replacing the current RICE principles of ankle injury treatment with POLICE: Protect, Optimal loading, Ice, Compression, Elevation, with a strong emphasis on early activity.
It has been suggested that for grade 1 and 2 ankle sprains, joint mobility exercises and gradual weight-bearing after a few days can lead to a faster recovery. In grade 3 ankle sprains (complete ligament tears), there is evidence to support early braking within 10 days of injury, after which ankle motion is initiated. Of course, many scholars still support 2-3 weeks of braking in patients with grade 3 injuries.
General recommendations
Phase 1, RICE principles for 1 week, rest, protection of the ankle joint and reduction of swelling
Phase 2, weeks 2-3, gradual restoration of joint mobility, strength and flexibility.
Phase 3, over the next few weeks to months, gradual return to sports, starting with sports that do not require twisting of the ankle joint and eventually returning to sports.
Medication
The available evidence recommends only NSAIDs to control the pain and inflammatory response.
It is worth mentioning that there is no clear evidence to support all external medications and manipulative rubbing for revision.
Surgical treatment
Only a very small number of patients with grade 3 injuries require surgical treatment after failure through several months of systematic non-surgical treatment. These patients are typically those with severe injuries, significant instability, and high motor demands.
Ankle instability usually presents with a positive anterior drawer test as well as a positive talar tilt test, which can also be demonstrated on orthogonal inversion stress films of the ankle, in addition to MRI to help determine ligament tears.
The stability of the ankle joint can be better determined by a later examination.
The surgical approach can be considered arthroscopic or open reconstruction to repair the ligamentous structures.