Date
[Ankle Sprain Template]
S: Date & Time of Injury: ______________________________
[ + -- ] Previous history of ankle injury (If previous Hx, when ____________________ )
[ + -- ] Able to bear weight immediately after the injury.
[ + -- ] Rapid onset of swelling after injury.
[ + -- ] Audible sound or a sensation of popping, snapping, or cracking.
Type of Injury (circle one): Inversion, Eversion, Dorsiflexion, Plantar Flexion, Unknown
[pic]
# 1: Bilat. Posterior Ankles
[pic]
# 2: Bilat Anterior Ankles
|Indications for X-rays before Stress Tests: |
|(1) Immediate significant swelling. (2) Obvious deformity. |
|(3) Inability to bear weight. (4) Pain mainly over bone. |
O: [ + -- ] Anterior Drawer Sign (tests ant. Talofibular ligament, ant. Capsule, and calcaneofibular band).
[ + -- ] Inversion (Talar Tilt) Test (tests calcaneofibular ligament).
[ + -- ] Eversion Test
[pic]# 3: Lat. Right Ankle
[pic]# 4: Lat. Left Ankle
[ + -- ] Transverse Test (tests inferior tibiofibular ligament and interosseous membrean or with a fracture).
[ + -- ] Fibular Compression (“Squeeze”) Test
[ + -- ] Thompson’s (Squeeze Calf) Test
Pulses: [ + -- ] Tibialis posterior; [ + -- ] Dorsalis pedis.
Sensory Test: [ + -- ] Sural n.; [ + -- ] Peroneal n.
Skin: [ + -- ] Ecchymosis; [ + -- ] Swelling (mild - moderate - severe)
[ + -- ] Weight Bearing: [+ -- ] limp
Tenderness:
ROM:
[pic]
# 5: Xray R. Ant. Ankle
[pic]
# 6: Xray L. Ant. Ankle
DTR’s:
|Ottawa Rules for Ankle X-rays (for Guidance Only) |
|1. An Ankle Series is only necessary if there pain near the malleoli and any of these findings: |
|a. Inability to bear weight both immediately and in emergency department (four steps) |
|OR |
|b. Bone tenderness at the posterior edge or tip of either malleolus. |
|2. A Foot X-ray Series is only necessary if there is pain in the midfoot and any of these findings: |
|a. Inability to bear weight both immediately and in emergency department (four steps). |
|b. Bone tenderness at the navicular or the base of the 5th metatarsal. |
A: ( Right – Left ) Ankle Sprain [Class: I II III ]
Other Dx’s:
P: ( Rest: (Crutches; (Other: _______________________________
( Ice: Apply 20-25 minutes, taken off for an hour, and re-applied x 24-48o
( Compression: (Ace Wrap (Caution dangers of too tight wrap)
Elevation
NSAID’s: (Motrin _____mg 1-pill ____x daily #_____/___; (Naprosyn ______mg 1-pill _______x daily #_____/___.
(Posterior Splint
(Referral: (Physical Therapy for: ____________________; (Orthopedic Referral for: _______________________________.
(Return to Clinic: ______ days for reevaluation.
(Other:
-----------------------
Nursing Notes:
Initials:__________
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