What is the most appropriate next step in managing a patient with a twisted ankle, moderate edema, ecchymosis, and tenderness, but intact neurovascular function and ability to bear weight?

From the Guidelines

The most appropriate next step in managing a patient with a twisted ankle, moderate edema, ecchymosis, and tenderness, but intact neurovascular function and ability to bear weight, is to use functional support, such as a brace, and start exercise therapy as soon as possible to recover joint functionality. This approach is based on the latest evidence from the British Journal of Sports Medicine, which recommends functional support over immobilization and early exercise therapy to promote healing and prevent stiffness 1.

Key Recommendations

• Functional support is preferred over immobilisation, especially the use of a brace, to provide stability while allowing some movement 1.
• Exercise therapy should be started as soon as possible to recover joint functionality and promote healing 1.
• NSAIDs may be used to reduce pain and swelling, but their use should be limited to the minimum necessary 1.
• RICE is not advised as a treatment modality after a lateral ankle sprain, as it may not provide any additional benefits and may even be harmful 1.

Implementation

1. Apply a functional brace or ankle support for stability.
2. Instruct the patient to perform gentle ankle exercises 3-4 times daily, such as:
   • Ankle circles: 10 rotations each direction
   • Ankle pumps: 10-15 repetitions
   • Alphabet tracing with the foot: 1-2 times
3. Encourage gradual weight-bearing as tolerated.
4. Continue using crutches for support if needed.
5. Consider using NSAIDs to reduce pain and swelling, but only as needed and under medical supervision.

This conservative approach is appropriate because the injury appears to be a mild to moderate ankle sprain without signs of fracture or severe ligament damage, and early mobilization promotes better outcomes in most ankle sprains 1.

From the Research

Assessment and Diagnosis

• The patient's condition, with a twisted ankle, moderate edema, ecchymosis, and tenderness, but intact neurovascular function and ability to bear weight, suggests a potential ankle fracture or sprain 2, 3.
• However, the provided studies do not directly address the management of a patient with these specific symptoms, as they focus on ankle fractures, patient experiences, and the role of CT scans in fracture management 2, 3, 4.

Imaging and Management

• The use of CT scans in malleolar ankle fractures has been shown to change the management plan in a significant number of cases, especially when the fractured fragment includes a posterior malleolus or multiple malleoli are fractured 4.
• Radiographic criteria for defining fracture healing are commonly used, but their validity and reliability are debated, and alternative approaches, such as clinical criteria, may be necessary 5.
• In cases of suspected scaphoid fractures, cast immobilization is often used until further investigations, such as bone scintigraphy or MRI, can confirm the diagnosis 6.

Next Steps

• Given the patient's ability to bear weight and intact neurovascular function, a thorough assessment, including imaging studies, such as X-rays or CT scans, may be necessary to determine the extent of the injury and guide further management 2, 4.
• The patient's symptoms and ability to bear weight suggest that a conservative management approach, including immobilization, pain management, and monitoring, may be appropriate, but further evaluation is needed to confirm this approach 3, 5.