A Reflective Analysis on the Assessment and Management for an Ankle Injury - Essay Example

A Reflective Analysis on the Assessment and Management for ankle injury Introduction Experience at a urgent care centre (UCC) can be very challenging and at the same time a great opportunity for learning due to the different nature of injuries one encounters. Injuries are classified as major or minor depending on the condition of the patient and the underlying causes. The ankle joint is one of the most important joint in human bodies, as it enables mobility and independence. However it is also one of the most often contused joints in the body especially when it comes to sports people (Walker,2007, p.216). This analysis was carried out by a trainee nurse practitioner. The aim was not only to see the patient receiving the most suitable treatment for his condition, but also to consider such matters as how could he have been treated somewhat differently for an optimal outcome and how can similar injuries be prevented in the future. When considering this patient’s case reflectively the Gibbs model was chosen (1988). This well established model was chosen because it follows logically , and includes such things as evaluation and analysis, and also allows for the fact that the problem might recur, as is common in ankle injuries. The practitioner as they reflect, learn while doing. A patient in his early 20s walked in at the UCC with a contused left ankle. He said that he acquired the injury while playing soccer and the swelling and reaction present indicated that he was in great pain. The patient responded to questions in order to identify the cause of the injury, and the next cause of action. An ankle injury occurs when there is overstretching of ligaments beyond their ability, therefore causing a tearing (Stephens, Pait, & Sheehan, 2003). Following the OTTAWA ankle rules, not all ankle springs require XRAY, especially where there are no suspected fractures (McKeag & Moeller, 2007, p. 502). However, the clinician did make an exemption in this case because there was a swelling on the left ankle and the condition would not allow palpation of the bone. It was felt that if the patient had not continued playing at the initial stage when he first injured the ankle then there would not have been such swelling and the pain he was experiencing. Ankle sprain results from two situations; The inversion injury whereby the ankle turns inside as the ankle inverse and an injury due to external rotation (Buttaro, Trybulski, & Bailey, 2013 p.887). In order to determine the extent of the injury, which is a categorization the injury in a particular grade, a health practitioner carries out further assessment. There are different types of ankle injury, which a person may suffer, with lateral ankle sprain being the most common. This type of injury results from strain due to rotation of the leg inversely twisting the leg. The others types of ankle sprains include syndesmotic and medial ankle sprains (Dhillon, Dhatt & Boer, 2012, p.90). Another name for syndesmotic sprain is high ankle sprain, which causes excessive softness of the bone that lie above the mortise. Medial on the contrary affects the deltoid ligament because of aversion. According to Gengenbach and Hyde (2007, p. 799), there are three stages of ankle injuries. The grade 1 springs, which is minor injury that requires minimal or no treatment at all. The time span for patients with this spring is usually two weeks or less. The other stage is the grade 2 sprains, which mostly involves the fracture of the ligament and requires surgical treatment. However, avoidance of surgery is possible in this case if there is one by one-strict follow up on the specific management procedures. Lastly, the third stage grade sprain, which is usually very severe and the patient cannot move. The medical practitioner did careful assessment on the patients since patients with ankle sprains requires careful assessment in order to avoid missing some of the information. This would follow NICE guidelines (2012). Similar guidelines can be found in the British Journal of Sports Medicine , as in an article by Kerkhoffs et al ( 2012). This helps in establishing the exact type of sprain the patient has in order to offer appropriate treatment and management (Porter & Schon, 2008). I feel continuous assessment on the patient was paramount so as to rule out completely any further damage despite the fact that the radiographic analysis showed no fractures. The analysis by browner (2009, p. 2570) indicates that radiographic analysis may not indicate any fractures of bones causing medical practitioners to rule serious injuries and conclude a lateral collateral injuries. However, the patient may try to use his injured limb too early and this could cause more damage or a fracture so I feel that serious analysis is paramount in order to make a conclusive diagnosis. Evaluation of the situation The patient gave a full description of the occurrences leading to the ankle injury. He even described the kind of job he did so that the medical officer could have an overview of what caused the injury. However, the patient did not mention whether the condition was a recurrent one. With ankle injury, history of whether it was a recurrent condition is vital when diagnosing the right type of ankle spring although on its own injury history cannot conclusively be a basis for diagnosis (Goroll & Mulley, 2011). Because the history is so important I would ensure on another occasion that this question was answered, and would alos ensure the patient received guidance eas to how repeat injury could be prevented, as described by Purcell et al ( 2009) . Due to the nature of the jump as the patient described, the most common possibility was sprain of the ankle ligament, since there was no contact with any other object. Despite the fact that the swelling was around the ligament area, assessment of the whole leg is also very important to ensure that no further damage is present on the leg (Lynch, 2002). In order to establish the intensity of the sprain, a medical officer does the grading but it is mostly subjective on the medical practitioner since several literatures describes the grading differently. The grading in this case constituted the observation that showed the swelling on the left ankle including the description of the pain that the patient gave. To certify completely that the injury was grade one, the patient also underwent the radiographic analysis. In other cases, many people misconceive the concept of ankle sprain with a misunderstanding that they heal automatically and nothing that a medical practitioner can do to help to treat the sprain. This explains why there are high cases of repeat ankle sprain cases due to the initial lack of treatment (Bravarian, 2011). Following a failure to seek medical treatment for ankle sprains, a severe tearing of the ligament may take place, which is a more serious condition than the initial ankle sprain. OTTAWA Ankle rules ( MD + Calc 2015) The rules helps in diagnosing ankle injuries without putting the patient through unnecessary radiographic examination but at the same time ensuring that no fractures goes unnoticed (Harrison et al., 2009, p. 158). When the areas around the malleoli are swollen and there is an inability to sustain weight, as well as the tenderness of the bones, then this indicates the need for an X-ray. Similarly, when there is a swelling around the ligaments and the ankle is painful, an X-ray is also necessary in order to rule out any fractures that might be present. Following these OTTAWA guidelines ( MD + Calc 2015) , there was a need for an X-ray since the patient’s ankle was swollen and painful. Reasons for the swelling and pain After the patient’s injury, he continued playing for up to thirty minutes, which exerted more pressure on the ankle, so causing even further damage. He should have stopped playing in order to reduce the movement of the ankle and reduce the weight on the sprain ankle (Nyska & Mann, 2002). The prescription to take adequate rest for the first few weeks was appropriate, so as to ensure that the ankle heals and there after the patient should gradually resume activities. Another reason that could have been a cause for the ankle injury was the kind of job that the patient did. The patient’s job involved carrying heavy loads and other kind of manual job, which could have been very damaging. Carrying heavy load exerts pressure on the leg especially at the ankle weakening the ligament. This could have been a contributory factor to the injury, because if the patient went to play football and it was not his regular routine , and with his routine work then damage of the lateral ligament could have been possible. He should have been asked if he warmed up before playing, and if not this should have been encouraged. The clinician further advised the patient on preventative action, rest, ice, compression and elevation (PRICE, Patient 2015) . PRICE Protection of joint is very beneficial, together with the administration of analgesia, as well as anti-inflammatory medication in order to reduce the swelling (Baravarian, 2011). Above all other treatment options the patient should ensure the foot does not suffer another injury in order to avoid further complications. Rest is also a crucial aspect when treating sprains in order to minimize the weight on the ankle and the use of clutches can be very beneficial. Application of ice is very helpful is very crucial when dealing with ankle sprains. The patient should apply the ice while covering it with another material because direct contact of ice with the skin can damage the skin (Stephens, Pait, & Sheehan, 2003). Compression involves pressing the ankle in order to reduce the oedema and a bandage is very helpful for compression. The patient should stay with bandage until the swelling has greatly minimized and the bandage should not be too tight to ensure that there is enough supply of oxygen in the leg (Health Xchange, 2014). To further help in the swelling the elevation of the foot is necessary and the foot should be well above the knee. Many critics argue that PRICE is a traditional method in treating ankle sprains and some of its concepts contradict with the advice of the same doctors who advise patients to follow it. Rest for instance is paramount according to PRICE but at the same time, exercise is necessary in order to restore the mobility of the ankle and for quick recovery and that, rest should happen only for a short while immediately after the trauma (Harrison, 2014). They argued that PRICE did not follow the current guideline and modern science but rather POLICE should replace is that is Protection, Optimal loading, Ice, Compression and Elevation. After the analysis on the patient, the results portrayed a grade 1 injury with the confirmation after the radiographic examination. This treatment option was appropriate since the patient had no visible fractures. However, the refusal of the patient to use clutches could be detrimental to the recovery process he could add weight to the ankle therefore slowing the pace of swelling reduction. For the pain and reduction of oedema the administration of oral analgesia Paracetamol 1 gram every 4 hours as needed and Ibuprofen was appropriate, as this is a non-steroid anti-inflammatory drug. ( Drugs.com 2015), as well as elevation of the limb for a few hours . The patient would require warning that he should only take a maximum of four grams of Paracetamol in 24 hours ( Drugs.com, 2015). . Conclusion The use of OTTAWA ( MD + Calc 2015) in diagnosing the ankle injury was appropriate in order to determine the extent of the injury and to decide whether the injury required the radiographic examination. The medical specialist adhered to these rules strictly and that is why the patient had to undergo the X-ray in order to rule out the presence of any bone fractures (Berquist, 2011, p. 73). Similarly, the use of PRICE guidelines ( Carmichael Clinic, 2015) were relevant for the management of the ankle sprain to ensure that the patient recuperated fast, if he followed the advice given . However, on reflection the use of POLICE, that is a regime of protection, optimal loading, ice, compression, and elevation (Harrison 2014, could have achieved faster results, including the ability of the patient to move his ankle again. This patient wants to get on with his life, including getting back to his work and his sport , and I feel that POLICE is a suitable regime in such a situation. The medical practitioners should have put more emphasis on the use crutches immediately after the trauma, waiting for the swelling to subside first , and then this gentleman could gradually do ankle exercises to avoid the ankle becoming too stiff. There should have been a recommendation of a review after one week. This was necessary to check the progress the ankle in order to assess whether the patient was following the management program given to him. Otherwise, the diagnosis and treatment was adequate, and if the patient followed the guidelines in the correct manner, then in a maximum of two weeks, his ankle should be fully operational. Past evidence of ankle injury on its own cannot be a basis for conclusive diagnosis and treatment, but a combination of several methods of assessment, as was done in this case, by using observation, examination and X-ray, is best in order to ensure maximum accuracy. Future Action In future, there should be a consideration of the review of the guidelines for treating ankle sprain to include the POLICE management guidelines ( Harrison 2014). This will enable the restoration of movement faster than when using PRICE ( Carmichael Clinic 2015) since they will minimize the amount of rest suggested and replace it with optimal loading, for faster mobility. Additionally, medical researchers should look more into the OTTAWA rules ( MD + Calc 2015) so as to standardize them and enable them talk in one voice and eliminate the confusion that exist in their use. The use of these rules have been proven to reduce the number of X-rays on ankle sprain, but an improvement to them is necessary in order to reduce this number even further. Future patients should attend reviews at least once week but not only when they detect a problem, in order to monitor their healing progress and ensure that are they not defaulting upon the recommended management programme. Also they should be advised, when undertaking sports to warm up properly and to use tape as described by Purcell et al ( 2009) in order to minimise the possibility of repeated injury. Conclusion Ankle sprains are common injuries especially to people who participate in sport and even though this is the case, training about protection is an important means of reducing the number of the cases. It must be stressed to those with ankle injuries the importance of following the suggested management programme in order to ensure full recovery. Awareness about ankle sprain generally is also important since many perceive the injury as a minor one and that treatment is not necessary. This is because even though the injury is common for those who undertake sports, another person can also suffer the injury. Failure to treat ankle sprain properly can lead to chronic ligament tearing with recurrent episodes in the future, as described by Fong et al ( 2009). Ankle sprain with a proper diagnosis and management programme takes only a few weeks to heal. References Baravarian, B. 2011. Foot and ankle athletic injuries. Philadelphia: Saunders Berquist, T.H. 2011. Imaging of the foot and ankle.3rd ed. Philadelphia: Wolters/Lippincott Williams & Wilkins Health Buttaro, T.M., Trybulski, J. and Bailey,P.P. 2013. Primary care: a collaborative practice. St Louis, Mo: Elsavier/Mosby Carmichael Clinic, 2014, Acute Soft Tissue Injury, Available at http://www.carmichael-physio.co.uk/soft-tissue.pdf [Accessed 2nd April 2015] Drugs.com, 2015, Ibrufapen, Available at http://www.drugs.com/ibuprofen.html [Accessed 22nd April 2015) Drugs.com, 2015, Paracetamol, Available at http://www.drugs.com/paracetamol.html [Accessed 22nd April 2015] Fong, D., Chan, Y., Mok, K., Yung, P., and Chan, K., 2009, Understanding acute ankle ligamentous sprain injury in sports, Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology, 1:14, Available from http://www.biomedcentral.com/1758-2555/1/14, [ Accessed 22nd April 2015] Gibbs, G. 1988, Learning by doing, from Using Gibb’s Reflective Cycle , Available at http://www.kcl.ac.uk/campuslife/services/disability/service/using-gibbs-reflective-cycle-in-coursework.pdf [Accessed 22nd April; 2015] Harrison, L. 2014, Should POLICE Replace RICE as the Ankle Therapy of Choice?, MedScape.multispeciality, Available from http://www.medscape.com/viewarticle/823217, [Accessed 22nd April 2015] Kerkoffs ,G. , van den Bekerom, M. 2, Elders, L. , van Beek, P., Hullegie, W. , Bloemers, G. , de Heus, E. , Loogman, M. , Rosenbrand, K., 9, Kuipers, T., Hoogstraten, J., Dekker, R., ten Duis, H., van Dijk, C., van Tulder, M.., van der Wees, P. and de Bie, R., 2012, Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline, British Journal of Sports Medicine , 46, pp 854-860, Available at http://bjsm.bmj.com/content/46/12/854.long [Accessed 22nd April 2014] Lynch, S.A. 2002. Assessment of the Injured Ankle in the Athlete. Journal of athletic training .34 (4): pp 406-412. McKeag, D. and Moeller, J.L. 2007. ACSM’s primary care sports medicine.2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins. MD + Calc, 2015, Ottowa Ankle Rule, Available at http://www.mdcalc.com/ottawa-ankle-rule/ [ Accessed 22nd April 2015] NICE, 2012, Clinical Knowledge Summaries, Sprains and Strains, Available at http://cks.nice.org.uk/sprains-and-strains#!scenario [ Accessed 22nd April 2015] Nyska, M. and Mann, G. 2002. The unstable ankle. Champaign,III: Human Kinetics Patient, 2015, Ankle Injuries, Available from http://www.patient.co.uk/health/ankle-injuries-leaflet, [Accessed 22nd April 2015] Purcell, S. , Schuckman B., Docherty, C. , Schrader, J., Poppy W., 2009, Differences in ankle range of motion before and after exercise in 2 tape conditions., American Journal of Sports Medicine, .Feb;37(2):383-9, Pub Med Available at http://www.ncbi.nlm.nih.gov/pubmed/19088055 [ Accessed 22nd April 2015] Stephens, J.T., Pait, T.G. and Sheehan, J. 2003. Golf forever : the spine and more : a health guide to playing the game. Las Vegas, Nev: Stephens Press Further Reading Browner, B.D. 2009. Skeletal trauma: basic science, management, and reconstruction.4th ed.Philadelphia, PA: Saunders/Elsavier Comac, I. and Gray,D. 2012. Essentials of physical health in psychiatry.London: Royal College of Psychiatrists Publication DeLisa,,J.., Gans, B. and Walsh, N., 2004. Physical and rehabilitation medicine: Principle and practice. 4th ed. Philadelphia, pa; London: Lippincott Williams & Wilkins Dhillon,M. Dhatt, S. and Boer, P.. 2012. First aid and emergency management in orthopedic injuries .London: Jaypee Brother Medical pub Domino,F.., Baldor, R.. , Golding, J. and Grimes, J.. 2014. The 5-minute clinical consult premium 2015. Philadelphia : Wolters Kluwer Health Gengenbach, M.. and Hyde, T. . 2007. Conservative management of sports injuries.2nd ed. Sudbury; Toronto: Jones and Bartlett Publishers Goroll,A. and Mulley, A.. 2011. Primary Care Medicine: Office Evaluation and Management of the Adult Patient.6th ed. Philadelphia, PA : Lipincott Williams & Wilkins Harrison,J., Kulkarni,K. , Baguneid, M. and Prendergast,B. 2009. Oxford Handbook of Key Clinical Evidence. Oxford; New York: Oxford University press. Health Xchange, 2014.Yahoo! News Singapore. How RICE can heal your sprained ankle, [online], Available at: https://sg.news.yahoo.com/rice-heal-sprained-ankle-135342453.html [Accessed 21 April 2015] Howse, J. and McCormack, M. 2009. Anatomy, dance technique & injury prevention.4th ed. London: Methuen Drama. Porter D.. and Schon, L. 2008. Baxters the Foot and Ankle in Sport .Philadelphia, PA: Elsevier health sciences Read More