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:

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Nursing Notes:

Initials:__________

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