eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Ankle Injury, Soft Tissue: Treatment & Medication
Updated: Sep 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
For patient comfort, all ankle injuries should be placed in a splint prior to transport to the ED.
Emergency Department Care
- First-degree sprains or mild second-degree sprains
- Rest, ice, and elevation
- Compression dressing, posterior splint, or commercially available air stirrup splint
- Initial cessation of weight bearing
- Consider referral to physical therapy for early range of motion exercise and wobble board training after recovery to reduce the number of recurrent injuries and to prevent functional instability.
- Severe second- or third-degree sprains
- Rest, ice, and elevation
- Plaster or fiberglass posterior splint in the ED
- New evidence suggests that, for severe sprains, a short, 10-day period of immobilization in a below-the-knee cast was the most effective strategy for promoting proper ligament healing and a quicker recovery than an Aircast brace, a Bledsoe boot, or tubular compression bandage.26 At 3 months after the injury, the below-the-knee cast performed significantly better than the tubular compression bandage in terms of pain, activities of daily living, and quality of life indices. The Aircast brace was better than the tubular compression bandage in ankle-related quality of life and mental health. At 9 months, however, there was no difference between the 4 treatment modalities.
- Orthopedic or sports physician referral is indicated. Most patients require physical therapy to prevent functional loss.
Consultations
- Obtain orthopedic consultation for severe sprains, suspected peroneal tendon subluxation, or associated fractures.
- Emergent orthopedic evaluation rarely is required. Office follow-up in a week usually suffices.
Medication
The goals of therapy are to reduce pain and to prevent complications.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
With analgesic and anti-inflammatory properties, NSAIDs are the ideal agents for treating ankle injuries. Acetaminophen with or without an opiate analgesic may be added to NSAID therapy (or used as a substitute).
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain, if no contraindications exist. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, resulting in the inhibition of prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
Used for the relief of mild to moderate pain and inflammation.
Administer small doses initially to patients with small body size, elderly patients, and those with renal or liver disease.
Doses higher than 75 mg do not increase its therapeutic effects. Administer high doses with caution, and closely observe patients for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that are beneficial for patients who have sustained injuries.
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1,000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d acetaminophen
Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d; single dose should not exceed 10 mg of hydrocodone bitartrate
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
More on Ankle Injury, Soft Tissue |
| Overview: Ankle Injury, Soft Tissue |
| Differential Diagnoses & Workup: Ankle Injury, Soft Tissue |
 Treatment & Medication: Ankle Injury, Soft Tissue |
| Follow-up: Ankle Injury, Soft Tissue |
| Multimedia: Ankle Injury, Soft Tissue |
| References |
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Further Reading
Keywords
ankle injury, soft tissue ankle injury, soft-tissue ankle injury, ankle sprain, sprained ligament, twisted ankle, Ottawa ankle rules, sports-related ankle injury, ankle injuries, anterior talofibular ligament rupture, ATFL rupture, recurrent ankle sprain, calcaneofibular ligament rupture, CFL rupture, posterior talofibular ligament rupture, PTFL rupture, distal tibiofibular syndesmotic rupture, superior peroneal retinaculum rupture, ankle ligaments, inversion ankle injury
