What is the assessment and treatment for a 9-year-old female with an ankle injury one week ago, presenting with bruising, intact range of motion, and minimal pain with manipulation?

Assessment and Treatment of Ankle Injury in a 9-Year-Old Female

The 9-year-old female with an ankle injury from one week ago presenting with bruising, intact range of motion, and minimal pain with manipulation most likely has a grade I ankle sprain that should be treated with functional rehabilitation including cold therapy, compression, and progressive exercise therapy.

Assessment

Clinical Evaluation

• The presentation of bruising with intact range of motion and minimal pain with manipulation suggests a mild ankle sprain (Grade I) 1
• The Ottawa Ankle Rules (OAR) can help determine if radiographs are necessary 1:
  • Since the patient has minimal pain with manipulation and intact range of motion, she likely does not meet OAR criteria for imaging
  • OAR criteria include: inability to bear weight immediately after injury OR point tenderness over the malleoli, talus, or calcaneus

Imaging Considerations

• Radiographs are generally not indicated in this case since:
  • The patient has intact range of motion
  • There is minimal pain with manipulation
  • The injury occurred one week ago with apparent improvement 1
• If the patient were unable to bear weight or had point tenderness over the malleoli, radiographs (anteroposterior, lateral, and mortise views) would be indicated 1

Treatment Plan

Immediate Management

1. Cold therapy (ice application):

   • Apply ice for 15-20 minutes, 3-4 times daily 1, 2
   • Use ice wrapped in a damp cloth to prevent cold injury
   • Limit application to 20-30 minutes per session 1

2. Compression:

   • Apply a compression wrap or semi-rigid support 1
   • Ensure the compression wrap doesn't compromise circulation 1
   • Semi-rigid or lace-up supports are superior to elastic bandages 2

3. Pain management:

   • NSAIDs may be used if needed for pain and inflammation 2
   • Use appropriate pediatric dosing

Rehabilitation Protocol

1. Early functional rehabilitation (begin immediately):

   • Encourage normal walking as tolerated 1
   • Avoid activities that cause pain 1
   • Begin ankle range of motion exercises 2:
     • Ankle circles
     • Alphabet drawing with toes
     • Gentle towel stretches for dorsiflexion

2. Progressive strengthening (begin within 48-72 hours):

   • Resistance band exercises in all directions 2
   • Heel raises (progressing from bilateral to unilateral) 2
   • Balance and proprioception exercises 1, 2:
     • Single-leg stance with eyes open, progressing to eyes closed
     • Balance board exercises when appropriate

Return to Activity

• Allow return to light activities when pain-free walking is achieved 2
• Progress to sports-specific activities when full range of motion and strength are restored 2
• Consider a semi-rigid ankle support for sports activities for at least 6 weeks 3

Follow-up and Monitoring

• Reassess in 1-2 weeks if symptoms persist or worsen
• Monitor for signs of chronic ankle instability, which occurs in approximately 20% of ankle sprains 4
• Consider referral to physical therapy if recovery is delayed or incomplete

Common Pitfalls to Avoid

• Excessive immobilization: This can lead to joint stiffness, muscle atrophy, and loss of proprioception 1, 2
• Delayed mobilization: Begin exercises within 48-72 hours to promote healing 2
• Inadequate support: Using only elastic bandages rather than semi-rigid or lace-up supports 2
• Overlooking proprioception training: Balance exercises are crucial to prevent recurrence 2
• Using heat on acute injuries: This can increase swelling and inflammation 2

By following this treatment approach, most pediatric ankle sprains will resolve completely with full return to activities within 3-4 weeks 1, 2.