Sprain/strain

• Investigations:

  • Use Ottawa rules to guide if X-ray is required, but not if:
  • Patient under 18
  • Patient is confused/intoxicated
  • Polytrauma
  • Diminished sensation in affected area (known neurological deficit)
  • Gross swelling making palpation impossible
  • Pregnant patients
• Send to ED if concerns about:

  • Fracture or dislocation (Ottawa rules)
  • Damage to nerves or circulation
  • Wound penetrating the joint
  • Serious complications e.g. hemarthrosis, large intramuscular haematoma, compartment syndrome
  • Severe e.g. tender rupture or large tear of muscle belly
• If no indication to send to ED (PRICE):

  • Protection from further injury
  • Rest - 48-72 hours
  • Ice - 15-20 mins every 2-3 hours for first 48-72 hours
  • Compression - elasticated tubular bandage - remove before going to sleep
  • Elevation until swelling controlled
• Analgesia:

  • Paracetamol and NSAID gel 1st line
  • Oral NSAID if required
  • Short term codeine as add on may be considered
• Advice on return to normal activity:

  • Give information leaflet
  • Mobilization as soon as tolerated without excessive pain
  • To prevent reinjury advice e.g. warm up and cool down, use proper sporting equipment, wearing appropriate shoes
• When to refer:

  • Consider physio referral if ongoing symptoms and not improving as expected
  • Review or refer to orthopaedics if lack of expected improvement or worsening symptoms
• Ankle Ottawa rules:

  Pain in malleolar zone and one of the following:

  • Inability to bear weight (4 steps)
  • Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of lateral malleolus
  • Bone tenderness along distal 6cm of the posterior edge of the tibia or medial malleolus
• Foot Ottawa rules:

  Pain in the midfoot zone and one of the following:

  • Inability to bear weight (4 steps)
  • Bone tenderness at the base of the 5th metatarsal
  • Bone tenderness of the navicular bone
• Knee Ottawa rules:

  If one or more of the following:

  • Age 55 yrs or more
  • Inability to bear weight (4 steps)
  • Tenderness at head of fibula (lateral knee)
  • Isolated tenderness of patella
  • Inability to flex the knee to 90 degrees
• Wrist Ottawa rules:

  • Pain or tenderness over the scaphoid bone
  • Palpate at the base of anatomical snuff box and scaphoid tubercle (base of thumb on palmar side)