Ankle Injury
                                ============
þ Ankle Dislocations
 - try flexing the knee a bit before reducing.
 
þ Ottawa Rules
  - for adults only.
  - radiographs of ankle are needed only if pain in the malleolar region and
    (1) tenderness in the distal 6 cm of posterolateral medial or lateral
        malleolus OR
    (2) inability to bear weight both immediately after injury AND in the ED.
  - Radiographs of foot necessary after ankle injury only if pain in midfoot,
    and
    (1) tenderness over the cuboid or base of fifth metatarsal or
    (2) inability to bear weight.
 - These criteria are 100% sensitive for detecting clinically significant
   fractures (>3 mm) in this study of 2342 patients.
   [Stiell IG, et al. Implementation of the Ottawa ankle rules. JAMA
   1994;271:827-832.]
   [Stiell IG, McKnight RD, Greenberg GH, et al: Interobserver agreement in
   the examination of acute injury patients. Am J Emerg Med 1992;10:14-17.]
   [Stiell IG, Greenberg GH, McKnight RD, et al: A study to develop clinical
   decisions rules for the use of radiography in acute ankle injuries. Ann
   Emerg Med 1992;21:384-390.]
   [Stiell IG, McDowell I, Nair RC, et al: Use of radiography in acute ankle
   injuries: physicians attitudes and practice. Can Med Assoc J
   1992;147-1671-1678.]
   [Stiell IG, et al: Decision rules for the use of radiography in acute ankle
   injury. JAMA 1993;269:1127.]
   Abstract: <O-AnkleA.TXT -use of r>
   [Stiell IG, et al: Implementation of the Ottawa ankle rules. JAMA
   1994;271:827.]

þ Detecting Occult Ankle Fractures
 - can see effusion on lateral view of ankle, and use similarly to the
   "sail sign" of an elbow effusion.  Big effusions were 85% associated
   with occult fracture, in those with clinically severe ankle injury.
   Big effusion, according to this article, is 5 mm or more.  Anterior
   effusion of > 5 mm is 83% sensitive, 59% specific for occult fracture;
   posterior effusion of > 5 mm is 67% sensitive and 91% specific.
   [Ho K, Connell DG, Janzen DL, Grunfeld A, Clark TIW. Using tomography to
   diagnoses occult ankle fractures. Ann Emerg Med May 1996;27:600-605.]

þ Peroneal Tendon Dislocation:
 - Classic history is "A patient is skiing and falls over the tip of the ski,
   hyperdorsiflexing the foot.  He states it felt like something "slipped out
   of place".  There is tenderness and ecchymosis laterally extending 6 inches
   proximally from the lateral malleolus."