Immediate care of people with non life threatening problems - Essay Example

Assignment: Concept mapping: Ankle Injury Introduction Assimilation of knowledge in medical profession needs lot of learning and memorization. Until and unless the medical professional understands, the learning cannot be fruitful. There are many strategies used to understand concepts in medical profession. One of the strategies is cognitive or concept mapping. This strategy involves principles of educational psychology (All & Havens, 1997) where mind maps are used to allow flow of information. It allows the students to see connections between ideas they already have and connect new ideas to knowledge that they already have (Concept mapping, Texas Teaching; Fonseca, Extremina & Fonseca, 2004). Case history The topic I shall be discussing under this assignment is 'ankle injury'. I have chosen the case of Mr. Y, a 35 year old man who came to the A&E with left ankle injury following foot ball match on the previous day. He walked into the room limping. Mr.Y sustained injury to the left ankle while playing football. The type of injury was 'inversion'. Soon after the injury, ice was applied to that area for few minutes, after which Mr.Y went home and took a pain killer and slept. Since, in the following morning there was no pain relief noted, he came to the A&E for further advice and management. Mr.Y suffered from no other medical illness. His past history and family history were not significant. He was not a smoker. The pain killer he took was ibuprofen. On examination, the left ankle appeared moderately swollen with some ecchymotic patches over the lateral malleolus area. The range of movements of the joint was minimized. Mr. Y could not bear his weight on the left ankle. Though the joint area was painful and tender, the tenderness could not be localized to a single point. Palpation ruled out the possibility of any fractures. There was no evidence of neurovascular compromise either. Discussion Ankle injuries are common injuries encountered in sports personnel, especially football players. They account for 38-45% of all injuries in sports (Rimando, 2007). These injuries occur when sudden plantar flexion and inversion of the foot occurs. Ankle joint functions to allow the body to adapt to uneven terrain during ambulation. When there is failure to compensate for uneven footing, ankle injury occurs (Young, 2008). Other risk factors for ankle sprains include flat feet, high arched feet, previous history of ankle sprain or ankle injury (PDRhealth, n.d.). Rarely, ankle injury may occur due to excessive eversion and dorsiflexion. This leads to damage to the medial ligament complex (Wolfe, Uhl & Mccluskey, 2001). Most of the ankle injuries are sprains (almost 75%). The most often damaged ligaments are the lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments (Ankle sprain, emedicine health). Of these, the anterior talofibular ligament is easily injured and posterior talofibular ligament is rarely injured (Wolfe, Uhl, Mccluskey, 2001). There are tests which can give a clue as to what ligament is injured. The anterior drawer test assesses the integrity of the anterior talofibular ligament and the inversion stress assesses the calcaneofibular ligament. Injury to both the anterior talofibular ligament and the calcaneofibular ligament leads to instability of the joint (Wolfe, Uhl & Mccluskey, 2001). Fractures are less common and may involve lower end of fibula or tibia, or calneus or talus (Naradzay, 2006 & Steel, 2006) Figure-1: Injury to ankle Ankle sprains may be complicated or uncomplicated. Complicated ones are those which require surgical management and uncomplicated ones heal non-operatively. The sprains may also be classified as 3 grades (COSM, 2005). Grade-1: There is partial tear of the ligament. There is microscopic tearing of collagen fibers (AAOS, 2005). The patient presents with mild tenderness or swelling. There is no functional loss and the patient is able to ambulate and bear weight on the injured ankle. Grade-2: There is incomplete tear of the ligament accompanied by some degree of functional loss. The patient suffers from moderate pain and swelling, some degree of ecchymosis, tenderness, pain during weight bearing and ambulation with mild-to-moderate instability. Grade-3: The ligament injured is completely torn with loss of integrity. The patient is unable to bear weight on the injured ankle or ambulate. Clinical stress examination shows mechanical instability. Figure-2: Clinical features of ankle injury After Mr. Y was examined, it was difficult to rule out fracture. This is because; he could not bear weight on the injured ankle. Hence a radiographic evaluation was asked for. X-rays ruled out fracture. After that a diagnosis of grade- 3 ankle eversion sprain was made in Mr.Y and than treated accordingly. The diagnosis of ankle sprains is mainly based on clinical examination. Gross deformity is rare in ankle sprains, although severe swelling can give an impression of deformity. It is important to thoroughly evaluate for fractures. The entire length of tibia and fibula must be palpated for tenderness. Tenderness along the base of the fifth metatarsal may indicate an avulsion of the peroneal brevis tendon. In osteochondral talar dome lesion, there will be palpable pain and effusion along the talocrural joint line (Wolfe, Uhl, Mccluskey, 2001). In syndesmosis sprain, swelling may be absent. There will be distal tibiofibular joint tenderness. A "squeeze test," may be performed to confirm syndesmosis sprain (Wolfe, Uhl, Mccluskey, 2001). Peroneal tendon disorders must be part of the differential diagnosis after ankle sprain in the professional athlete (van Zoest, Janssen & Tseng, 2007). When to ask for radiographic evaluation is an important aspect of assessing ankle injury. This question arises because, most of the ankle injuries are sprains and unnecessary radiography not only imposes a health threat but also adds to the cost of health care. Ottawa ankle rules can be applied to ascertain whether radiography is essential in any ankle injury (Stiell et al, 1994). The Ottawa rules state that "radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia or an inability to bear weight immediately after the injury and in the emergency department (or physician's office)" (Wolfe, Uhl & Mccluskey, 2001). Also, bone tenderness over the navicular bone or base of the fifth metatarsal is an indication of fracture requiring evaluation with radiography. In a study by Stiell et al (1994), the researchers reported that implementation of Ottawa rules reduces unnecessary radiography, decreased waiting time for patients and lowered diagnostic costs. They also concluded that the rules have a sensitivity of 100 percent for the detection of malleolar fractures and a sensitivity of 100 percent for the detection of mid-foot fractures. Once radiographic evaluation is indicated, radiographs must be taken in antero-posterior, lateral and mortise views. Mortise view is nothing but an antero-posterior view obtained with the leg internally rotated 15 to 20 degrees. In this view, the X-ray beam is nearly perpendicular to the inter-malleolar line, thus eliminating the overlapping shadow of the tibia on the fibula. There is no role for stress-view radiographs in acute ankle injury (Steel, 2006). Do other radiographic tests have any role in the management of sprains? Most ankle strains recover without any problem and do not need further investigations. However, in sprains that remain symptomatic for more than six weeks, talar dome lesions must be suspected which are detectable by computed tomographic (CT) scanning or magnetic resonance imaging (MRI). These investigations are also indicated in ankle injuries involving crepitus, catching, or locking to rule out displaced osteochondral fragment (Wolfe, Uhl, Mccluskey, 2001). Mr. Y was given treatment in the accident and emergency room itself. After the initial ice application and foot end elevation, compression bandage was applied. Most ankle sprains do not need referral to orthopedician. The initial goals in the management are to prevent swelling and maintain range of motion. The first steps in the management include 'RICE' (i.e., rest, ice, compression and elevation). Ice application reduces hyperemia and helps in healing. The crushed ice must be put in a plastic bag and applied to the medial and lateral ankle over a thin layer of cloth. If ice is not available, the foot and ankle may be immersed in cold water. Cooling must be done for 20 minutes every two to three hours for the first 48 hours, or until edema and inflammation have stabilized (Wolfe, Uhl & Mccluskey, 2001). Duing ice therapy, one must remember not to ice the injured area for more than 20 minutes because it can actually cause tissue damage (Cluett, 2008). Also, ice must not be applied directly. It must be put in a cloth or ice bag and then applied (Stoppler, 2007). Simultaneously, exercises must be initiated to facilitate lymphatic drainage and also to maintain range of motion. How far cryotherapy is useful in reducing swelling and pain in acute stains is as yet a much debated topic. There is a need for more quality trials to establish its usefulness (Hubbard & Denegar, 2004). Figure-3: Management of ankle sprain Compression with elastic bandage must be done to milk edema fluid away from the injured tissues. Compression with bandage must be started just proximal to the toes and extended above the level of maximal calf circumference. The patient must be advised to rest with the injured leg elevated about 15 to 20 cm above the level of the heart. Foot- end elevation facilitates venous and lymphatic drainage and assists wound healing. This must be done until the swelling resolves (Wolfe, Uhl & Mccluskey, 2001). How far compression with cyclical bandage is effective is not known. Wilson & Cooke (1998) argue that since ankle has a 90 degree curve, the bandage will tend to produce an anterior compressive band, with elastication being insufficient to prevent inversion and eversion of the ankle. Along with these, pain relief is an important aspect in the management of ankle sprain. Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics can be used. Of these, NSAIDs are the most popular. Anti-inflammatory medications will be necessary to reduce swelling and pain (Rimando, 2007). Since weight bearing during the initial period is painful, crutches must be advised to the patient until weight bearing is possible (Rimando, 2007). Weight bearing must be done only as much as tolerated (Rimando, 2007). Nutrition and general health of the patient can contribute to healing (Patel, 2004). After the initial evaluation and treatment, Mr.Y was discharged home with an advice to continue ice application for 2 more days, foot-end elevation, compression bandage and painkillers as needed. He was asked to come back if there was no improvement in symptoms or he developed any new symptoms like neurovascular compromise, joint instability or foot deformity. Otherwise, the follow up was scheduled for after 3 weeks. In most of the cases, follow up may not be necessary until and unless swelling continues or there is persistent pain even after 2 weeks. In the mean time he was asked to take as much rest as possible, but at the same time maintain some ambulation. He was advised to bear weight only as much tolerated and not to exercise ambitiously. He was given a pair of crutches and taught how to use them properly. Most sprains do not need splinting. However, if early rehabilitation is desired, plastic ankle-foot orthosis or simple plaster posterior splint may be applied for immobilization. Air-filled or gel-filled ankle braces may also be used (Wolfe, Uhl, Mccluskey, 2001). No splinting was done for Mr. Y. Infact, splints and non-weight bearing are not recommended in ankle sprains because as these result in increased swelling, pain and risk of sympathetic dystrophy (MAMC, 2007). Surgical intervention is not necessary in most of the cases. It is indicated when fibulo-calcaneal ligament is torn or when there is an unstable fracture (Rimando, 2007). Mr. Y was concerned about return to work, sports and normal activities. He was also worried about the possible complications that may arise due to sprain. Return to work depends on the degree of injury to the ligament. It may take some weeks for the patient to resume to active walking and further more time to running and sports. Return to work also depends on rehabilitation. van Rijn et al (2008), did a wide research on the clinical course of ankle sprains. they concluded that " After 1 year of follow-up, a high percentage of patients still experienced pain and subjective instability, while within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain. From 36% up to 85% of the patients reported full recovery within a period of 3 years". Rehabilitation is the most important aspect of management of ankle strain. This is because prolonged immobilization and improper rehabilitation leads to decreased range of motion, persistent pain and swelling, and chronic joint instability (Wolfe, Uhl, Mccluskey, 2001) and delays recovery and return to work. In his study on Military personnel, Weinstein (1993) reported that improper rehabilitation in ankle strains delayed return to duty for several months. The time to return to football is significantly related to the severity of the injury and there is no correlation with the skill of the player (Shaw et al, 1997). Return to sports must occur only when there is full range of motion, have near- normal strength, good balance, and no pain or swelling with exercise or activity (AOSSM sports tips, 2008). Figure-4: Functional rehabilitation Rehabilitation starts immediately after the acute phase, from the 4th day, and may last up to 2 weeks (Rimando, 2007). The components of rehabilitation include: 1. Range-of-motion rehabilitation: Range-of-motion can be improved with Achilles tendon stretch with and without weight bearing. Alphabet exercises wherein the ankle is moved in multiple planes of motion by drawing letters of alphabet also increases range of motion. 2. Progressive muscle-strengthening exercises: Isometric exercises where in resistance is provided by immovable object increases muscle strength. The exercises must be done in plantar flexion, dorsiflexion, inversion and eversion movements. Similar movements must also be done for isotonic exercises but resistance must be provided by rubber tubing or weights. Toe curls, marble picks, toe rises, heel walks and toe walks are other exercises which can be advised to strengthen muscles. 3. Proprioceptive training: This training is done for the recovery of balance and postural control. This is important to prevent recurrent ankle injury. There are many devices developed to facilitate proprioceptive training. These include devices like circular wobble board. Walking on different surfaces also can be used for proprioception training. 4. Activity-specific training: This can be done by gradually resuming to regular work. Walk-jog and Jog-run in forward and backward directions are useful. Those who want to return to sports will need additional athletic therapy supervised by a certified athletic trainer or sports physical therapist. In early period of return to activity, it is recommended to use stabilizing orthotic device or tape which may be gradually weaned. Functional rehabilitation must be started only once joint stability has been achieved. In grades 1 & 2 of ankle injury, rehabilitation can be started immediately because the joint stability is not affected in the injury (Wolfe, Uhl, Mccluskey, 2001). Since ankle sprains are very common among athletes, it is useful to advise them regarding prevention to prevent unnecessary morbidity and medical expenditure. The prevention strategies include use of ankle braces and advocation of multifaceted ankle sprain prevention programmes (Osborne & Rizzo, 2003). How far these are useful is still debatable. Conclusion Ankle injuries are very common in sports persons. Of these, sprain to the lateral ligament is the commonest. Most sprains can be managed in the A& E with application of ice, foot-end elevation, compression and pain alleviation. Sprains usually heal without surgical intervention. Rehabilitation is the most important aspect of sprain management to prevent joint stiffness and chronic instability. No recovery within 4 weeks is an indication for thorough evaluation and to look for fractures. References All, A.C., Havens, R.L. (1997), Cognitive/concept mapping: a teaching strategy for nursing. Journal of Advanced Nursing 25 (6), pp.1210–1219. American academy of orthopedic Surgeons. (AAOS). Sprained Ankle. (2005). Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00150 [Cited on May 17 2007] Ankle sprain. (2005). emedicinehealth. Available at: http://www.emedicinehealth.com/ankle_sprain/article_em.htm [Cited 19 may 2008] Cluett, J. (2008). Ankle sprain treatment. About.com: Orthopedics. Available at: http://orthopedics.about.com/cs/sprainsstrains/a/anklesprain_2.htm [Cited on May 17 2007] Crist, B.D., 2007.Ankle Fractures. American Academy of Orthopedic Sugeons. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00391 [Accessed 10 May 2008]. Fonseca, A.P., Extremina, C.I., Fonseca, A.F., 2004. Concept Mapping: A Strategy for Meaningful Learning in Medical Microbiology. Conference on Concept Mapping. Available at: http://cmc.ihmc.us/papers/cmc2004-071.pdf [Accessed 10 May 2008]. Hubbard, T.J., Denegar, C.R. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury? J Athl Train., 39(3), pp.278-279. Madigan Army Medical Center. (MAMC) (2007). Ankle Sprain: Phyiscal therapy. Available at: http://www.mamc.amedd.army.mil/Referral/guidelines/pt_ankle.htm [Cited May 20, 2008] Naradzay, J.F.X., 2006. Fractures, Ankle. eMedicine from Web MD . Available at: http://www.emedicine.com/emerg/TOPIC188.HTM [Accessed 10 May 2008]. Osborne, M.D., Rizzo, T.D. Jr. (2003). Prevention and treatment of ankle sprain in athletes. Sports Med., 33(15), pp.1145-50. Patel, M. 2004. Tibial Nonunions. eMedicine from WebMD. Available at: http://www.emedicine.com/orthoped/topic569.htm [Accessed 10 May 2008]. PDRhealth. Ankle strain.(n.d). Available at: http://www.pdrhealth.com/disease/disease-mono.aspx?contentFileName=BHG01RH19.xml&contentName=Ankle+Sprain&contentId=08§ionMonograph=ht1[Cited on May 17 2007] Rimando, M.P., 2007. Ankle Sprain. eMedicine from WebMD Available at: http://www.emedicine.com/PMR/topic11.htm [Cited on 10 May 2008]. Shaw, A.D., Gustilo, T., Court-Brown, C.M., 1997. Epidemiology and outcome of tibial diaphyseal fractures in footballers. Injury, 28, pp.365-7. Steel, P.M., 2006. Ankle Fracture. eMedicine from WebMD. Available at: http://www.emedicine.com/sports/topic4.htm [Cited on 10 May 2008]. Stiell, I.G., McKnight, R.D., Greenberg, G.H., McDowell, I., Nair, R.C., Wells, G.A., et al (1994). Implementation of the Ottawa ankle rules. JAMA, 271, pp.827-32. Stoppler, M.C. (2007). Ankle Sprain Treatment. WebMD. Available at: http://firstaid.webmd.com/ankle_sprain_treatment_firstaid.htm [Cited on 20th may, 2008]. Texas Collaborative for Teaching Excellence. Critical Thinking Strategies: Concept Mapping. Available at: http://cord.org/txcollabnursing/onsite_conceptmap.htm [Accessed 10 May 2008] The Center for Orthopedics and Sports Medicine. (COSM). (2005). Ankle Sprain. Available at http://www.arthroscopy.com/sp09005.htm [Cited on 19 May 2008] van Rijn et al (2008). What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med.,121(4), pp.324-331.e6. Review. van Zoest, W., Janssen, R.P.A., & Tseng, C.M.E.S. (2007). An uncommon ankle sprain. British Journal of Sports Medicine, 41, 849-850. Available at: http://bjsm.bmj.com/cgi/content/abstract/41/11/849 [Cited on May 17 2007] Weinstein, M.L. (1993). An ankle protocol for second-degree ankle sprains. Mil Med, 158, pp.771-4. Wilson, S., & Cooke, M. (1998). Double bandaging of sprained ankles. BMJ, 317, 1722-3 Wolfe, M.W., Uhl,.T.L. & Mccluskey, L.C. (2001). American Family Physician, http://www.aafp.org/afp/20010101/93.html [Accessed 17 May 2008] Young, C.,C. (2005). Ankle Sprain. eMedicine from WebMD Available at: http://www.emedicine.com/SPORTS/topic6.htm [Accessed 17 May 2008] Young, C.C., 2008. Ankle Sprain. eMedicine from WebMD Available at: http://www.emedicine.com/sports/topic6.htm [Accessed 17 May 2008] AOSSM sports tips (2008). Ankle sprains: How to speed your recovery? Available at: http://www.sportsmed.org/secure/reveal/admin/uploads/documents/ST%20Ankle%20Sprains%2008.pdf Read More