What is the initial management for a patient presenting to the emergency room (ER) with a sprain, considering potential complications and comorbidities such as bleeding disorders or anticoagulant use?

Management of Sprains in the Emergency Department

Apply the POLICE protocol (Protection, Optimal Loading, Ice, Compression, Elevation) rather than traditional RICE, as it provides significantly faster and more effective recovery in ankle sprains. 1

Immediate Assessment and Initial Management

Primary Intervention

• Apply local compression immediately to control swelling and limit bleeding from soft tissue injury 2
• Protect the injured joint with appropriate bracing or immobilization to prevent further damage 1
• Apply ice safely for no more than 10 minutes at a time, maximum 4 times daily—avoid prolonged ice immersion which can impair healing by limiting blood flow 2, 1
• Elevate the affected extremity above heart level to reduce swelling 1
• Initiate optimal loading early (gentle, pain-guided movement) rather than complete rest, as this promotes faster functional recovery 1

Critical Distinction: POLICE vs RICE

The POLICE protocol demonstrates superior outcomes compared to traditional RICE. At 14 days post-injury, patients treated with POLICE showed median improvement of 34.5 points on ankle function scores versus 24 points with RICE, and 42 points versus 31 points on disability indices 1. The key difference is replacing "Rest" with "Optimal Loading"—early, controlled movement within pain tolerance rather than complete immobilization.

Special Considerations for High-Risk Patients

Patients on Anticoagulation or Antiplatelet Therapy

• Obtain urgent coagulation studies (aPTT, PT/INR, anti-Xa if on DOACs) if significant swelling or expanding hematoma develops 3
• For patients on warfarin with expanding hematoma: Consider temporary suspension and 5 mg vitamin K IV 3
• For patients on DOACs: Temporary suspension is generally sufficient unless life-threatening bleeding occurs 3
• Monitor closely for compartment syndrome or progressive hematoma formation, which occurs more frequently in anticoagulated patients 3

Elderly or Frail Patients

• Assess fall risk and functional status immediately, as ankle injuries significantly increase subsequent fall risk 2, 3
• Avoid opioids as first-line analgesia due to increased risk of falls, delirium, and mortality in elderly patients 2, 3
• Implement multimodal analgesia including acetaminophen, topical NSAIDs (if no contraindications), and consider regional nerve blocks if available 2

Pain Management Algorithm

First-Line (All Patients)

• Acetaminophen as baseline analgesia 2
• Topical NSAIDs applied directly to injury site 2
• Ice application (10 minutes maximum, 4 times daily) 2
• Immobilization with ankle brace 4

Second-Line (Moderate-Severe Pain)

• Oral NSAIDs (ibuprofen, naproxen) for patients without contraindications, carefully weighing GI/renal risks especially in elderly 2
• Regional nerve blocks if skills available and patient not anticoagulated 2, 3

Third-Line (Breakthrough Pain Only)

• Tramadol or opioids at lowest effective dose for shortest duration, particularly avoiding in elderly 2

Imaging Considerations

Standard Ankle Sprain

• Clinical decision rules (Ottawa Ankle Rules) determine need for radiography 5
• Ultrasound may be considered to assess degree of ligament injury if available 6

Patients on Anticoagulation with ANY Trauma

• Lower threshold for imaging even with seemingly minor mechanisms 5
• Consider repeat imaging at 24 hours if initial swelling progresses or pain worsens, as anticoagulated patients have 3-fold higher risk of hemorrhage progression 5

Thromboembolic Prophylaxis

Initiation Timing

• Begin LMWH or UFH as soon as bleeding risk is controlled in moderate-to-high risk patients (elderly, immobilized, multiple comorbidities) 2
• Adjust dosing for renal function and weight 2, 3
• If pharmacological prophylaxis contraindicated: Use mechanical prophylaxis with intermittent pneumatic compression 2

Duration

• Continue until patient is fully mobile 2
• Combine with early mobilization as tolerated by pain 3

Discharge Planning and Follow-Up

Mandatory Discharge Instructions

• Prescribe standardized rehabilitation protocol emphasizing early optimal loading rather than prolonged rest 4, 1
• Provide written instructions on progressive weight-bearing and range-of-motion exercises 4
• Schedule follow-up at 1-2 weeks to assess functional recovery 1
• For anticoagulated patients: Provide specific instructions on signs of delayed hemorrhage and when to return immediately 5

Rehabilitation Prescription

• Early therapeutic exercise (within first week) combined with intermittent ice applications shows promise for faster recovery 6
• Progressive weight-bearing as tolerated, avoiding complete immobilization 1
• Functional exercises targeting proprioception and strength to prevent recurrence 4

Common Pitfalls to Avoid

• Prolonged ice application (>10 minutes) or continuous ice immersion impairs healing by limiting blood flow 2
• Complete rest/immobilization delays recovery compared to early optimal loading 1
• Routine opioid prescription especially in elderly patients increases fall risk and complications 2, 3
• Failing to initiate thromboprophylaxis in immobilized or high-risk patients 2
• Inadequate rehabilitation prescription or lack of specific exercise instructions increases recurrence risk 4
• Underestimating bleeding risk in anticoagulated patients with seemingly minor sprains 5, 3
• Discontinuing anticoagulation unnecessarily without considering thromboembolic risk 5