Concept Mapping: Ankle Injury Management in Accident & Emergency Room - Case Study Example

Concept Mapping: Ankle Injury Management in A&E Room Introduction Nursing and other medical professionals are needed to assimilate and understand larger questions and problems of their chosen field. It is important to understand the material so that it is stored in long-term memory and the professional is able to recall whenever needed. Proper understanding of the subject occurs when information is presented in a meaningful and thought provoking way. One of the teaching methods which leads to meaningful learning is concept mapping. "Concept mapping is a technique that allows students to understand the relationships between ideas by creating a visual map of the connections. It allows the student to (1) see the connections between ideas they already have, (2) connect new ideas to knowledge that they already have, and (3) organize ideas in a logical but not rigid structure that allows future information or viewpoints to be included" (Concept mapping, Texas Teaching). In concept mapping, the learner identifies the important concept from the learning material or subject and describes the relationship between those concepts with linking words (Novak et al., 1991, quoted in Fonseca, Extremina & Fonseca, 2004). In the following assignment, I shall discuss a minor patient who presented to the department of Accident & Emergency with ankle injury. The discussion will be based on the concept map projected with data assimilated at the time of entry to the emergency department. Case history The case I have chosen to discuss is about Mr. X, a 22 year old male. The name of the patient and the place will not be disclosed throughout the assignment for the purpose of anonymity and confidentiality. Mr. X walked into A&E minors department limping and in pain from his right ankle- inversion injury to right ankle whilst playing football in the morning. On examination, the right ankle was swollen. There was some bruising seen on the right lateral malleolus. The range of movements at that ankle was decreased and patient had severe pain while mobilizing the joint. The patient could not bear weight on that joint. Tenderness was present but it was difficult to localize due to pain and gross swelling. There were no open wounds or visible deformity. Neurovascular status of the limb appeared normal. The ipsilateral knee and foot appeared normal. Routine history revealed history of bronchial asthma in the past. Other than that the young man had no other health problems or known drug allergies. Ankle injuries Ankle injuries are commonly seen in A& E minors department. Ankle is a joint in the lower limb which is formed by fibula, tibia and talus. Its purpose is to facilitate dorsiflexion and plantar flexion of the foot. Ankle joint actually comprises of the true ankle joint and the subtalar joint (Naradzy, 2006). The true ankle joint is formed by the tibia medially, fibula laterally, and the talus (the floor upon which the tibia and fibula rest). It allows dorsiflexion and plantar flexion or the "up and down" movement at the ankle. The subtalar joint consists of the talus and the calcaneus and allows the foot to be inverted or everted (Naradzy, 2006). The medial bony prominence of the ankle is called the medial malleolus. It is formed by the tibia. The lateral malleolus is formed by the fibula. The stability of the ankle joint is maintained by the arrangement of the bones and also by the various ligaments the surround the joint. The ligaments on the lateral side of the ankle are anterior talo-fibular ligament, calcaneo-fibular ligament and the posterior talo-fibular ligament. The ligament on the medial side is the deltoid ligament (actually a ligament complex). The joint becomes unstable whenever there is a fracture of any of the bones of the joint or when there is sprain. Injury to the ankle occurs when sudden plantar flexion and inversion of the foot occurs (Rimado, 2007). The clinical symptoms depend on the type of injury. The injury may be a sprain or fracture. Ankle sprains are the most common injuries to the ankle and they account for 85% of the injuries in that anatomical region (Rimado, 2007). In sports, they constitute 38-45% of all injuries (Rimado, 2007). Symptoms of sprain include pain, swelling, edema, bruising and ecchymotic patches with or without weight bearing difficulty. Most of the sprains in the ankle are inversion sprains. In inversion sprains, the lateral ligaments are damaged. The reason why inversion sprains are common is because of the bony and soft tissue anatomy of the ankle and the fact that the lateral malleolus extends further inferiorly than the medial malleolus (Rimado, 2007). Other sprains encountered in an ankle injury are syndesmotic sprains and eversion sprains. It is important to diagnose and treat ankle sprains appropriately to prevent symptoms of chronic instability like loss of motion, strength and proprioception (Rimado, 2007). Based on the extent of injury to the ligaments, ankle sprains may be classified in to 3 grades as follows (Rimado 2007): Grade I: There is only a stretch in the ligamentous structures. The degree of swelling is mild and weight bearing is possible. Grade II: There is tearing of the ligamentous structures, but it is incomplete. The degree of swelling is moderate. Weight bearing is accompanied with pain and mild instability is present. Grade III: There is at least one ligamentous structure that is ruptured completely. The swelling is severe. Weight bearing is not possible due to instability. There are tests which determine the degree of instability at the joint. These include anterior drawer test, talar tilt test and squeeze test. In case of fracture at the ankle joint, the bones which may be involved include distal tibia, distal fibula, talus, and calcaneus. Even in fractures, inversion injuries are the commonest. Clinical features include gross deformity, perimalleoloar swelling, bony tenderness, discoloration, ecchymosis and inability to bear weight on the injured foot. There may or may not be open wounds. It is important to assess the neurovascular status of the foot and ankle in any ankle joint injuries. This can be done by checking the presence and quality of the pulses of posterior tibial artery and dorsalis pedis artery. Capillary refill time and hand-held Doppler also give a good idea about vascular status. When there is a neurovascular compromise, the patient complains of cold foot and paresthesias. Mind map for treatment of acute ankle injury: Management on the A&E room Acute management involves analgesics for pain, immobilization, and patient comfort. Mr. X, with right ankle injury was given a bed and asked to relax. Immediate ice application was done to the injured area along with foot-end elevation. These were done to bring down swelling. Ice decreases swelling by decreasing the increased blood flow to the region. I applied ice packs to the area of swelling for 10-15 minutes. The clinical examination pointed to either Grade-3 sprain or fracture. He was given IV fentanyl to produce anxiolytic and analgesic effect. Since the patient had severe swelling with decreased weight bearing capacity pointing towards either a severe sprain or fracture, I requested the casualty doctor to ask for radiographs of the ankle. Radiographic evaluation may not be necessary in all cases of ankle injury (Rimado, 2007). It is recommended only when there is suspicion of fracture. Application of Ottawa rules for ankle injuries minimizes unnecessary radiography. The Ottawa rules state that radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia or an inability to bear weight immediately after the injury and in the emergency department; also, bone tenderness over the navicular bone or base of the fifth metatarsal is an indication for radiographs to rule out fracture of the foot (Wolfe, Uhl & Mccluskey, 2001). If indicated to get an X-ray as per these rules, then anteroposterior, lateral and mortise radiographs (with the foot internally rotated 15-20°) should be obtained after the initial physical examination. Mortise view is important because it eliminates the overlapping shadow of the tibia on the fibula. There is no role for stress-view radiographs in acute ankle injury (Steel, 2006). Clinically, fracture is detected by palpating the posterior edge or tip of the medial or lateral malleolus, navicular or base of the fifth metatarsal bones ((Rimado, 2007). Tenderness along the base of the fifth metatarsal indicates avulsion of the peroneal brevis tendon and pain on palpation and effusion along the talocrural joint line is suggestive of suspicion of an osteochondral talar dome lesion (Wolfe, Uhl & Mccluskey 2001). In Mr. X, due to the severity of pain and effusion, localization of pain was difficult. The X-rays revealed fracture of undisplaced fracture of the right lateral-malleolus. The lateral malleolus fracture is a fracture of the fibula. Distal fibula fractures are the most common fractures to the ankle (Steel, 2006). The Danish-Weber classification system which is based on the level of the fracture in relationship to the joint mortise of the distal fibula can be used to classify ankle fractures so that appropriate primary care management can be instituted. The classification is as follows (Steel, 2006): 1. Type A fractures: These are horizontal avulsion fractures. They are found below the mortise. They are stable and can be treated with closed reduction and casting. 2. Type B fractures: These are spiral fibular fractures that start at the level of the mortise. They usually occur secondary to external rotational forces. They may or may not be stable depending on ligamentous injury or associated fractures on the medial side. 3. Type C fractures: These fractures occur above the level of the mortise. They disrupt the ligamentous attachment between the fibula and the tibia distal to the fracture. They are always unstable and definitely need surgical intervention including open reduction and internal fixation. In Mr. X, the fracture was of type-A. Once the diagnosis was made, treatment was initiated. No other investigations were done. Sophisticated investigations with CT scans or MRI are rarely required. Infact, they should be considered in those who remain symptomatic even after 6 weeks, to rule out talar dome lesions and in those with suspected displaced osteochondral fragment (Wolfe, Uhl, Mccluskey 2001). Before starting the treatment, I further confirmed the neurovascular status of the limb and also the level of pain in the patient. I told Mr. X about the fracture and the initial treatment that would be instituted. Definitive treatment in ankle fracture is based on the level and stability of fracture, patients age and activity goals. It is instituted in 3-4 days. Simple fractures will need only splinting in the emergency room while complicated ones like bimalleolar, trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible open reduction and internal fixation (Naradzay, 2006). Since Mr. Xs fracture was a simple undisplaced one without any open wound, splinting with below-knee backslab was done. I enquired if he was comfortable and if the pain had reduced. Mr. X said he was feeling a lot better and wanted something to drink. In the meantime, I got his prescriptions ready. Discharge advice Mr. X was then discharged home. Before discharging, I checked his limb again and ruled out any signs of neurovascular compromise. The discharge advice included paracetamol for pain, crutches, lower limb injury advice card, crutches usage card and a date to follow- up with the orthopedician. The patient was also advised to take ibuprofen in case the pain did not subside with paracetamol. Non-steroidal anti-inflammatory drugs like ibuprofen, naproxen and ketoprofen are useful pain killers. They act by inhibiting cyclooxygenase activity and prostaglandin synthesis. In those with hypersensitivity or contraindications to NSAIDS, acetaminophen may be used for pain control. A combination of acetaminophen and codeine is useful for moderately severe pain (Norvell, 2006). Some researchers argue that NSAIDs should be avoided because they can impair fracture and ligament healing (Naradzay, 2006). I advised to continue application of ice to the injured region over compressive dressing for 20 minutes every 2-3 hours for the first 24 hours and every 4-6 hours thereafter until casting. I also advised him to take rest and keep the foot-end elevated above the level of heart as much as possible. Rest is a very important aspect in the treatment of ankle injuries because it allows tissue healing (Rimado, 2007). Crutches were provided to reduce weight bearing on the right ankle. I ensured that Mr. X could properly use the crutches before discharge. Type- A Danish- Weber fractures without medial-sided fractures can be treated with a walking cast or stirrup brace and ambulation as tolerated. I explained to him about splint care. I also warned him about possible complications that may arise like neurovascular compromise, compartment syndrome and peroneal nerve injury. I advised him to get in touch with the emergency room immediately in case of severe pain, tingling sensation of the digits, loss of sensation of the digits or any color changes. Compartment syndrome is dangerous because the pressure inside a particular fascial compartment of the leg can cause restriction of blood flow and nerve damage. Absence of pulse, increase pressure, pain, paresthesia and pallor of the distal affected extremity are features of compartment syndrome (Konowalchuk, 2005). Compartment syndrome is an emergency and needs fasciotomy. I fixed an appointment with the orthopedician 3 days later and asked Mr. X to follow up with him. When Mr. X asked what the orthopedician would do, I explained to him that, the orthopedician would put cast immobilization with either a short leg walking cast or walking cast fracture boot once the acute phase is settled. It is important to put the cast to the ankle when the ankle is in neutral position to avoid shortening of the Achilles tendon. Long-term Complications Mr. X was worried as to what complications could arise due to the injury in the long run. Most of the simple ankle injuries especially in the young people heal well. The prognosis for fibular fracture is good. People who smoke, have diabetes, or are elderly are at a higher risk for complications because healing is delayed in these persons (Crist, 2007). However, like in any other fracture, mal-union, delayed union and non-union can occur. Delayed union means that there is not enough bridging callus to achieve clinical stability by 16 weeks (Patel, 2004). Delayed union is due to stripping of the soft tissues in the injury leading to damage to the blood supply of the bone. Inability to unite without additional surgical or nonsurgical intervention by 6-9 months is known as non-union (Patel, 2004). This complication is related to the type and degree of injury, associated bone loss and degree of soft tissue injury. Other than these factors, cigarette smoking, intake of non-steroidal anti-inflammatory drugs, poor nutrition and general poor health of the patient can contribute to delayed healing (Patel, 2004). Non-unions can be hypertrophic, atrophic or normotrophic depending upon the amount of callous formation. In some patients chronic arthritis can also develop. Recovery and return to work Mr. X was worried as to how long it would take for the fracture to heal and when he could resort to normal life and also sports. Most ankle fractures take atleast 4- 8 weeks to heal and may need many months to regain full normalcy. That is why 4-6 weeks of immobilization is necessary (Steel, 2006). The time to return to football is significantly related to the severity of the fracture and there is no correlation with the skill of the player (Shaw et al, 1997). Rehabilitation Mr. X wanted to know what the rehabilitation plan was. I told him that intermittent motion can be commenced after the initial 2 weeks after the swelling has subsided and proper rehabilitation must be started after completing the immobilization period. Physiotherapy and rehabilitation are the most important aspects of management of ankle sprain to facilitate walking without limping or pain. Usually young individuals may not need the help of physiotherapists because the range of motion and strength returns quickly in these people. To enable recovery of muscle function, calf stretching and strengthening exercises, along with range-of-motion activities, especially attainment of dorsiflexion must be done (Steel, 2006). Proprioception and balance training should also be achieved to prevent recurrent ankle injury. In Mr. X, the goal of rehabilitation should be symmetric range of motion and 85% of contralateral strength, since he is interested in returning to sports. Conclusion Ankle injury is the most common injury in sports persons. Of these sprains are the most common. A person visiting A&E department with ankle injury needs to be evaluated as to what is the type of injury. Initial evaluation includes looking for deformity, swelling, tenderness, bruises and weight bearing capacity. Those with suspected fractures will need radiographic evaluation. The fractures can be classified based on the Danish- Weber Classification system and then treated accordingly. Initial treatment for all ankle injuries includes ice application and foot-end elevation. Thereafter, slabs are applied for splinting. Once the initial acute phase is over in 3-4 days, immobilization is done with casting. This is done for 4-6 weeks after which rehabilitation is started with exercise and physiotherapy. References Crist, B.D., 2007.Ankle Fractures. American Academy of Orthopedic Sugeons. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00391 [Accessed 10 May 2008]. Fonseca, A.P., Extremina, C.I., Fonseca, A.F., 2004. Concept Mapping: A Strategy for Meaningful Learning in Medical Microbiology. Conference on Concept Mapping. Available at: http://cmc.ihmc.us/papers/cmc2004-071.pdf [Accessed 10 May 2008]. Konowalchuk, B.K., 2005. Tibial Shaft Fractures. eMedicine from WebMD. Available at: http://www.emedicine.com/orthoped/topic340.htm [Accessed 10 May 2008]. Naradzay, J.F.X., 2006. Fractures, Ankle. eMedicine from Web MD . Available at: http://www.emedicine.com/emerg/TOPIC188.HTM [Accessed 10 May 2008]. Patel, M. 2004. Tibial Nonunions. eMedicine from WebMD. Available at: http://www.emedicine.com/orthoped/topic569.htm [Accessed 10 May 2008]. Rimando, M.P., 2007. Ankle Sprain. eMedicine from WebMD Available at: http://www.emedicine.com/PMR/topic11.htm [Accessed 10 May 2008]. Shaw, A.D., Gustilo, T., Court-Brown, C.M., 1997. Epidemiology and outcome of tibial diaphyseal fractures in footballers. Injury, 28, pp.365-7. Steel, PM, 2006. Ankle Fracture. eMedicine from WebMD. Available at: http://www.emedicine.com/sports/topic4.htm [Accessed 10 May 2008]. Texas Collaborative for Teaching Excellence. Critical Thinking Strategies: Concept Mapping. Available at: http://cord.org/txcollabnursing/onsite_conceptmap.htm [Accessed 10 May 2008]. Wolfe, M.W., Uhl, T.L., Mccluskey, L.C., 2001. Management of Ankle Sprains. American Family Physician Available at: http://www.aafp.org/afp/20010101/93.html [Accessed 10 May 2008]. Read More