What is the initial evaluation and management of a patient presenting with ankle swelling?

From the Guidelines

The initial evaluation of a patient presenting with ankle swelling should begin with a thorough history and physical examination, followed by radiographs if the patient meets the Ottawa Ankle Rules (OAR) criteria, as this approach has been shown to have high sensitivity for detecting ankle fractures 1. When evaluating ankle swelling, it is essential to consider the patient's history, including trauma, duration of symptoms, pain characteristics, and associated symptoms like fever or joint pain. A physical examination should assess the ankle for warmth, redness, tenderness, range of motion, and check for pitting edema.

Key Considerations

• Bilateral swelling often suggests systemic causes like heart failure or kidney disease, while unilateral swelling may indicate local pathology.
• Basic diagnostic tests include complete blood count, comprehensive metabolic panel, and urinalysis.
• Imaging studies such as X-rays, including anteroposterior, lateral, and mortise views, can rule out fractures and should be performed if the patient meets the OAR criteria 1.
• Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability.

Management

• Management depends on the cause but generally includes RICE therapy (Rest, Ice, Compression, Elevation) for acute injuries.
• Compression with elastic bandages or compression stockings helps reduce swelling, while elevation above heart level promotes fluid drainage.
• Non-steroidal anti-inflammatory drugs like ibuprofen can reduce pain and inflammation.
• Diuretics such as furosemide may be prescribed for edema from heart or kidney disease.
• Patients should be advised to limit salt intake and maintain mobility as appropriate.

Special Considerations

• Severe cases or those with concerning features like significant pain, inability to bear weight, or signs of infection require urgent medical attention for more specialized treatment.
• Special scenarios that warrant special mention and additional views include axial Harris-Beath view for suspected calcaneal fractures, Broden view for lateral process fracture of the talus, and bicycle spoke injuries in children 1.

From the Research

Initial Evaluation of Ankle Swelling

• The initial evaluation of a patient presenting with ankle swelling requires a multifaceted approach, including clinical assessment, evaluation of pre-test probability, and objective diagnostic testing 2.
• A thorough physical examination should be performed, including inspection, palpation, range of motion, and special tests when applicable 3.
• The pre-test probability of deep vein thrombosis (DVT) can be assessed using a clinical decision rule, which stratifies DVT into "unlikely" or "likely" 2.

Diagnostic Testing for DVT

• If DVT is "unlikely", a D-dimer test can be performed to rule out DVT 2.
• If the D-dimer level is increased, or if DVT is "likely", compression ultrasound (CUS) should be performed to confirm the diagnosis 4, 2.
• CUS is a non-invasive, readily available, and highly accurate diagnostic tool for DVT, with a sensitivity and specificity of over 90% and 100%, respectively, for proximal DVT 4.

Laboratory Tests for DVT

• Complete blood cell count (CBC) parameters, including red blood cell indices, white blood cell subtypes, and platelet indices, may be useful in predicting DVT 5, 6.
• Certain CBC parameters, such as neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and red blood cell distribution width, have been identified as independent risk factors for DVT 5, 6.
• However, the predictive value of these parameters is still being researched, and more studies are needed to confirm their utility in clinical practice 5, 6.

Management of DVT

• If DVT is confirmed, anticoagulation is indicated to control symptoms, prevent progression, and reduce the risk of post-thrombotic syndrome and pulmonary embolism 2.
• Direct oral anticoagulants (DOACs) are the preferred treatment for DVT, as they are at least as effective, safer, and more convenient than warfarin 2.
• However, DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy 2.