What is the treatment for a probable os trigonum (a bone in the foot) versus a less likely fracture of the posterior talus (a bone in the ankle) in the right ankle, with preserved joint spaces and no radiographically appreciable soft tissue abnormality, following a rolled right ankle injury?

From the Guidelines

For a rolled right ankle with an X-ray showing a possible os trigonum versus a potential posterior talus fracture, I recommend against the RICE protocol and instead suggest functional support and early mobilization, as well as taking over-the-counter pain relievers like ibuprofen 400-600mg every 6-8 hours or acetaminophen 500-1000mg every 6 hours as needed for pain. The most recent and highest quality study, 1, published in the British Journal of Sports Medicine in 2018, advises against the use of RICE as a treatment modality after a lateral ankle sprain and instead recommends functional support, such as the use of a brace, and early mobilization.

Key Points to Consider

• The distinction between an os trigonum and a fracture is crucial for determining proper treatment, which is why specialist evaluation is necessary despite the preserved joint spaces noted on the X-ray 1.
• The patient should be encouraged to start exercise therapy as soon as possible to recover joint functionality, with a focus on proprioception, strength, coordination, and function 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to reduce pain and swelling, but immobilization should not be used in the treatment of a lateral ankle sprain 1.
• Ankle braces or supportive footwear may help during the healing process, and supervised exercises with a focus on proprioception, strength, coordination, and function are advised for sport resumption 1.

Follow-Up and Additional Imaging

Since the X-ray cannot definitively rule out a fracture, follow-up with an orthopedic specialist is essential, especially since the radiologist recommended clinical correlation with the site of pain. They may order additional imaging such as an MRI or CT scan for a more definitive diagnosis, as suggested by 1, which provides guidelines for the use of imaging in acute trauma to the ankle.

Treatment Approach

The treatment approach should prioritize functional rehabilitation over immobilization, with the goal of minimizing work absenteeism and promoting a quick return to normal activities. The use of crutches may be necessary if walking is painful, but the patient should be encouraged to gradually return to normal activities as pain allows.

From the Research

Ankle Injury Treatment

• The patient's x-ray results indicate a probable os trigonum versus a less likely fracture of the posterior talus, with no radiographically appreciable soft tissue abnormality 2.
• Given the lack of evidence-based management strategies for ankle sprains, treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines 2.
• The PRICE (protection, rest, ice, compression, and elevation) treatment can be used to guide the treatment of patients with uncomplicated soft tissue injuries to their upper or lower limbs, including ankle sprains 3.

Recommended Treatment Approach

• The patient's treatment should focus on reducing pain and swelling, and promoting ankle mobility and range of motion 2.
• The use of rest, ice, compression, and elevation (RICE) therapy, or PRICE treatment, can help alleviate symptoms and promote recovery 2, 3.
• Further evaluation and correlation with the site of pain and tenderness are recommended to determine the best course of treatment 2.

Soft Tissue Injury Management

• Nurses should have an understanding of the rationale and evidence base supporting PRICE treatment of soft tissue injuries, including ankle sprains 3.
• Providing accurate information to patients and carers about the management of soft tissue injuries and anticipated recovery time is an important aspect of treatment 3.