Persistent disability associated with ankle sprains: a prospective examination of an athletic population

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.     

Subtalar arthrography in acute injuries of the calcaneofibular ligament

We treated 43 acute tears of the calcaneofibular ligament by operation in 43 patients after subtalar arthrography. There were 22 men and 21 women with a mean age of 22.3 years (14 to 61). Anteroposterior (AP), lateral and oblique views were obtained with the foot in 45 degrees of internal rotation and the ankle in the neutral position. Any communication or leakage to the ankle, tendon sheaths, subcutaneous tissue and sinus tarsi was recorded. We examined an oblique view of the microrecess along the interosseous ligament and an AP view of the lateral recess just under the distal end of the fibula. We also studied a control group of 27 patients with isolated injuries of the anterior talofibular ligament without rupture of the calcaneofibular ligament. The findings in the two groups were significantly different when examined for leakage to the ankle (p=0.0002), to the peroneal tendon sheaths (p=0.0347) and to the subcutaneous tissue (p=0.0222), absence of the microrecess (p=0.0055) and presence of the lateral recess (p=0.0012). Many ankle sprains which involve tearing of the calcaneofibular ligament are accompanied by injuries of the subtalar joint. Combined injuries of the anterior talofibular ligament and calcaneofibular ligament, and isolated injury of the anterior talofibular ligament should be differentiated.     

Radiosurgery

On the night of May 15/16, 1996, the largest parachute assault of United States (US) and United Kingdom (UK) airborne forces in 52 years occurred at Fort Bragg, North Carolina. This paper describes the injuries sustained in that operation. A total of 4,754 (US, N = 3,066; UK, N = 1,688) aircraft exits were made, causing a total of 137 (US, N = 73; UK, N = 64) injuries in 117 personnel (US = 68; UK = 49). There were 15 hospital admissions (US = 8; UK = 7; p = 0.37) and no fatalities. The combined exit injury incidence was 24.6 injured soldiers per 1,000 exits. The US exit injury rate was 22 injured per 1,000 aircraft exits and the UK rate was 29 injured soldiers per 1,000 aircraft exits. This difference was not statistically significant (p = 0.25). Lower extremity sprains, strains, and fractures accounted for the majority of injuries in US and UK forces. UK soldiers sustained significantly more of these potentially incapacitating injuries than US troops, 16.1 per 1,000 exits versus 9.1 per 1,000 exits, respectively (chi 2 = 4.07; p = 0.043; relative risk [RR] = 1.70; 95% confidence interval [CI] = 1.01, 2.86). The UK forces sustained significantly more closed head injuries than US forces, 7.1 per 1,000 exits versus 2.3 per 1,000 exits, respectively (chi 2 = 6.4; p = 0.011; RR = 3.13; 95% CI = 1.23, 7.93). The UK forces also had significantly more soldiers with multiple injuries than US forces (RR = 9.15; 95% CI = 2.5, 39.7). Factors that may have influenced differences in injury incidence include differences in weight of personal equipment and possible differences between the drop zones.     

Effect of chronic hypoxemia on the regulation of nitric-oxide synthase in the fetal sheep brain

We undertook a prospective study to determine the type and distribution of foot and ankle snowboarding injuries. Reports of 3213 snowboarding injuries were collected from 12 Colorado ski resorts between 1988 and 1995. Of these, 491 (15.3%) were ankle injuries and 58 (1.8%) were foot injuries. Ankle injuries included 216 (44%) fractures and 255 (52%) sprains. Thirty-three (57%) of the foot injuries were fractures and 16 (28%) were sprains. The remaining injuries were soft tissue injuries, contusions, or abrasions. There was no significant correlation between boot type (soft, hybrid, or hard) and overall foot or ankle injury rate. There were significantly fewer ankle sprains in patients wearing hybrid boots and fewer fractures of the lateral process of the talus in patients wearing soft boots. An unexpectedly high number of fractures of the lateral process of the talus were noted. These 74 fractures represented 2.3% of all snowboarding injuries, 15% of all ankle injuries, and 34% of the ankle fractures. Many of these fractures are not visible on plain radiographs and require computed tomography imaging to be diagnosed. Diagnosis of this fracture pattern is paramount; the physician should be very suspicious of anterolateral ankle pain in the snowboarder, where subtle fractures that may require surgical intervention can be confused with anterior talofibular ligament sprains.     

Nursing and the law. 6. Clinical responsibility

Surveillance for parachute-related injuries was conducted at Fort Bragg, North Carolina, between May 1993 and December 1994. During this 20-month period, lower-extremity injuries (27% of all injuries), axial skeletal (back and neck) strains and sprains (19.3%), and closed head injuries (18.4%) were the leading causes of injury. The incidence of injuries requiring emergency care was 8/1,000 jumps. This rate is well within the jump injury planning estimate, suggesting that airborne training and operations are conducted in a safe and effective manner at Fort Bragg.     

Lateral ankle sprains and instability problems

The lateral ankle complex is the most frequently injured single structure in athletes, consisting of 38% to 45% of all injuries. One-sixth of all sports injury loss time is from ankle sprains. In North America, ankle inversion sprains are considered "de rigeur" for basketball participation.     

Sports injuries in the game of hurling. A one-year prospective study

A prospective study of hurling injuries was conducted over the 8 months of one season on 74 players. These athletes averaged 4.30 +/- 2.58 hours per week of training and 1.15 +/- 0.21 hours per week of matches. Mean time of injury was 1.20 +/- 2.53 days in the hospital, 20.34 +/- 19.25 days off sport, and 13.34 +/- 17.25 days of restricted activity. Together this injury time amounts to 14.3% of the season. There were 92 match- and 43 training-related injuries, giving 342.47 injuries per 10,000 hours of matches and 43.83 injuries per 10,000 hours of training. Overall, there were 369.9 days of injury per 1000 hours of participation. The most common type of injury was muscle strain (24.4% of the 135 total injuries). The hamstrings was the most common site of strain, accounting for 41% of these injuries. Contusions comprised 16.3% of the injuries and sprains comprised 15.6%. The most frequently injured sites were the finger (13%), hamstrings (12%), back (11%), head (9%), and knee and ankle (9%). Forty-one percent of the injuries were attributed to foul play. The results of the study suggest that the incidence of injuries in hurling is high and may be attributed to poor conditioning, poor protection, and lack of enforcement of the rules.     

Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis

PURPOSE: Five hundred fourteen consecutive patients with an isolated upper or lower extremity penetrating injury were entered into a prospective study designed to refine the indications for diagnostic arteriography. METHODS: Twenty-two (4%) patients with limb-threatening ischemia who required immediate operation and 23 (4%) who refused arteriography were excluded from subsequent analyses. The remaining 469 patients were classified as being at high, intermediate, or low risk for an arterial injury. RESULTS: Two hundred thirteen patients who were at low risk were observed for 24 hours, discharged, and monitored as outpatients. No delayed complications of an arterial injury developed in any patient in this group. The intermediate-risk group of 151 patients and the high-risk group of 105 patients underwent arteriography. Seventy-seven injuries were identified; 24 were major (limb-threatening) and 53 were minor. Fourteen major injuries required operative repair or transcatheter embolization; the remaining 10 nonocclusive major injuries were observed without sequelae. CONCLUSIONS: By step-down logistic regression only pulse deficit (p < 0.01) and an ankle/brachial or wrist/brachial index less than 1.00 in the injured extremity (p < 0.03) were found to be significant predictors of an arterial injury. The presence of either of these two clinical variables successfully predicted all major arterial injuries. This prospective study supports the proposition that arteriography that is limited only to those patients who have either a pulse deficit or minimum ankle/brachial or wrist/brachial index less than 1.00 successfully detects all significant arterial injuries.     

Evaluation and diagnosis of ankle injuries

The evaluation of ankle injuries is a common challenge for family physicians. Diagnosis is made by using knowledge of the anatomy and function of the ankle joint to aid in taking an adequate history and performing an appropriate physical examination. The patient should be questioned about the mechanism of injury, previous injury, disability, treatment and pain. The ankle should be evaluated for ecchymosis, swelling, areas of tenderness and laxity. These measures help to determine what, if any, additional diagnostic procedures may be needed. Most ankle sprains are lateral, affecting the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Other injuries include medial ankle sprains affecting the deltoid ligament, trauma to the Achilles and peroneal tendons, tarsal tunnel syndrome, fractures, syndesmotic sprains, synovial impingement and chronic instability. Criteria for radiographic evaluation include inability to bear weight initially or when examined, and tenderness over the medial or lateral malleolus. Accurate diagnosis is critical for appropriate treatment and minimizing functional disability.     

Handball injuries. An epidemiological and socioeconomic study

A total of 570 injuries in handball players were prospectively registered in a well-defined geographical area of 124,321 inhabitants. The incidence of handball injuries was 46/10,000 inhabitants/year and in females (61/10,000/year) double that for males (31/10,000/year). Sixty-two percent of the injuries were distortions and sprains and 12% were fractures. A total of 7% were hospitalised and the loss of income because of sick leave was in total $3870. Sixty-eight percent of the injured handball players did not play for more than one week. Surprisingly, 8% of the minor injuries resulted in a risk leave of more than six days. Five percent of these injured quit a tournament of training after sustaining a handball injury.     

Bladder tumor markers: need, nature and application. 2. Tumor and tumor-associated antigens

Three hundred and forty-five Touch football players were retrospectively surveyed to determine the nature and incidence of injuries sustained over a one year period. The definition of injury was that it prevented playing or training for at least one week. A total of 177 injuries were sustained by 117 players who participated in a total of 1043 hours of playing and training each week. The injury rate was 4.85/1000 hours of playing or training which was less than in other football codes. This rate was significantly more (p < 0.05) among males and no relationship was evident based on representative or training status. 71% of injuries were to the lower limb. 23% of all injuries involved the ankle. Less than 3% of injuries affected the head or neck. 54% of injuries were considered mild in that they only prevented playing or training for less than two weeks. Only 17% of injuries were stated to have been caused by contact with another player. This study found that the injury rate in Touch was much less than in other football codes.     

How often do women in the emergency department without intimate violence injuries return with such injuries?

OBJECTIVE: To determine the rate at which a group of women visiting the ED for reasons other than intimate violence return to the ED at a later time for intimate-violence-related injuries. METHODS: Retrospective cohort study of a group of women with intimate-violence-related injuries on an index visit and a matched comparison group. Return visit rates to the ED for intimate violence injuries over the next 5 years were then compared. RESULTS: The 95 women in each group were followed an average of 57 months. The return rates in the positive index case group and matched comparison group, respectively, for any reason were 74.9% vs 77.9% (p = 0.463) and for intimate violence injuries were 29.5% vs 18.9% (p = 0.118). CONCLUSION: Women in the ED without intimate violence injuries often return to the ED later with such injuries. This suggests the ED may play an important role in identifying women at risk for future intimate-violence-related injury.     

Epidemiological study of sequelae of injuries in adolescents

BACKGROUND: In all industrialized countries, injuries constitute the primary public health problem during adolescence; study of long-term outcome of injuries to adolescents remains poor. POPULATION AND METHODS: A longitudinal epidemiological study performed on 8,140 students in 17 secondary schools in Paris and the Department of the C?te-d'Or followed the development over one year of 777 adolescents who had injuries in 1990. All injuries, both within and outside school, were included if they fulfilled the following criteria: school absence or excused from vocational training exceeding or equal to 2 days, or excused from physical education classes for at least 14 days. RESULTS: One year after the injury, 13% of the adolescents were still bothered by their injury, especially those who were older and the girls. Among described impairments, musculo-skeletal problems (88% of cases) were the major difficulty. These impairments were primarily in the lower limbs (53%). Unaesthetic scars were found in 17% of cases, and a psychological impact was found in 16.5% of the adolescents. The presence of sequelae was related to the type of initial lesion (present in 24% of head injuries and in 16% of cases affecting the lower limbs). The most serious difficulties were caused by dislocations, serious sprains and fractures. One year after the injury, sequelae were serious in 10% of those adolescents still experiencing problems; they had some impact on the daily life of the adolescents in 36% of cases, that is, 5% of all adolescents experiencing an injury. These sequelae were responsible for a high level of consumption of medical services. CONCLUSIONS: Although observed sequelae were relatively minor, the high frequency of injuries during adolescence, as well as their high economic costs, justify the most appropriate care available for victims of injuries, even those which appear benign. In addition, longitudinal studies should be prepared using adapted tools (scales for the evaluation of the gravity of injury sequelae).     

Spectrum of roller-blading injuries

We studied 32 patients who presented to the Accident and Emergency Department of Toa Payoh Hospital with injuries sustained while roller-blading (in-line roller skating). This sporting activity carries risk of injuries, often fractures, due to 3 principal mechanisms of injury. The first and main mechanism of injury is that of a forward fall with the arms outstretched as a protective gesture. This is associated with fractures of the distal radius in the majority of cases, although other injuries to the upper limb can occur. The second important mechanism is that of a backward fall with resulting injury to the back of the head. Lastly, the patient may fall sideways, often together with a twisting force to the lower limbs, resulting in ankle sprains and meniscus injuries to the knee. The vast majority of patients are young teenagers who are beginners and had not been properly clad in protective gear. Roller-blading therefore carries a very real risk of sporting injury.     

The hazard of spatial disorientation during helicopter flight using night vision devices

INTRODUCTION: Night Vision Devices (NVDs) provide an enormous advantage to the operational effectiveness of military helicopter flying by permitting flight throughout the night. However, compared with daytime flight, many of the depth perception and orientational cues are severely degraded. These degraded cues predispose aviators to spatial disorientation (SD), which is a serious drawback of these devices. METHODS: As part of an overall analysis of Army helicopter accidents to assess the impact of SD on military flying, we scrutinized the class A-C mishap reports involving night-aided flight from 1987 to 1995. The accidents were classified according to the role of SD by three independent assessors, with the SD group further analyzed to determine associated factors and possible countermeasures. RESULTS: Almost 43% of all SD-related accidents in this series occurred during flight using NVDs, whereas only 13% of non-SD accidents involved NVDs. An examination of the SD accident rates per 100,000 flying hours revealed a significant difference between the rate for day flying and the rate for flight using NVDs (mean rate for daytime flight = 1.66, mean rate for NVD flight = 9.00, p < 0.001). The most important factors associated with these accidents were related to equipment limitations, distraction from the task, and training or procedural inadequacies. CONCLUSIONS: SD remains an important source of attrition of Army aircraft. The more than fivefold increase in risk associated with NVD flight is of serious concern. The associated factors and suggested countermeasures should be urgently addressed.     

Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group

OBJECTIVE: To assess the feasibility and impact of introducing the Ottawa ankle rules to a large number of physicians in a wide variety of hospital and community settings over a prolonged period of time. DESIGN: Multicentre before and after controlled clinical trial. SETTING: Emergency departments of eight teaching and community hospitals in Canadian communities (population 10,000 to 3,000,000). SUBJECTS: All 12,777 adults (6288 control, 6489 intervention) seen with acute ankle injuries during two 12 month periods before and after the intervention. INTERVENTION: More than 200 physicians of varying experience were taught to order radiography according to the Ottawa ankle rules. MAIN OUTCOME MEASURES: Referral for ankle and foot radiography. RESULTS: There were significant reductions in use of ankle radiography at all eight hospitals and within a priori subgroups: for all hospitals combined 82.8% control v 60.9% intervention(P < 0.001); for community hospitals 86.7% v 61.7%; (P < 0.001); for teaching hospitals 77.9% v 59.9%; (P < 0.001); for emergency physicians 82.1% v 61.6%; (P < 0.001); for family physicians 84.3% v 60.1%; (P < 0.001); and for housestaff 82.3% v 60.1%; (P < 0.001). Compared with patients without fracture who had radiography during the intervention period those who had no radiography spent less time in the emergency department (54.0 v 86.9 minutes; P < 0.001) and had lower medical charges ($70.20 v $161.60; P < 0.001). There was no difference in the rate of fractures diagnosed after discharge from the emergency department (0.5 v 0.4%). CONCLUSIONS: Introduction of the Ottawa ankle rules proved to be feasible in a large variety of hospital and community settings. Use of the rules over a prolonged period of time by many physicians of varying experience led to a decrease in ankle radiography, waiting times, and costs without an increased rate of missed fractures. The multiphase methodological approach used to develop and implement these rules may be applied to other clinical problems.     

A meta-analytic review of the preventive treatment of recurrences of febrile seizures

OBJECTIVE: To assess the efficacy of various medications in the prevention of recurrent febrile seizures. STUDY DESIGN: A meta-analysis of all published randomized, placebo-controlled trials of the preventive treatment of febrile seizures published in English; 45 articles were found, but only 9 trials were randomized and placebo-controlled--4 using phenobarbital; 3, diazepam; 1, pyridoxine; and 1, phenytoin. In one of the phenobarbital trials, valproate was also compared with placebo. RESULTS: The risk of recurrences was significantly lower in children receiving continuous phenobarbital therapy than placebo (odds ratio 0.54, 95% confidence intervals 0.33 to 0.90, p = 0.017). The odds ratio for recurrences in the valproate group was 0.09, 95% CI 0.01 to 0.78, p = 0.011. No difference in the risk was found for recurrences between children receiving intermittent diazepam and placebo (odds ratio 0.81, 95% CI 0.54 to 1.22, p = 0.31). The risk for recurrences in children receiving pyridoxine or phenytoin did not differ from the risk among children receiving placebo. Four children would have to be treated with valproate (95% CI 2 to 11) or eight children would have to be treated with phenobarbital (95% CI 5 to 27), continuously, to prevent one febrile seizure. CONCLUSIONS: Because both agents found to be effective in prevention of recurrent febrile seizures have known adverse effects, prophylaxis of febrile seizures cannot be recommended.     

Oligoribonucleotides containing 8-oxo-7,8-dihydroguanosine and 8-oxo-7,8-dihydro-2''-O-methylguanosine: synthesis and base pairing properties

OBJECTIVE: To test whether a rigid or a flexible ankle orthosis affects postural sway in single-limb stance as quantified by stabilometry. DESIGN: Crossover trial. SETTING: University laboratory. PARTICIPANTS: Twenty-two athletes with functional ankle instability (consecutive sample of patients with recurrent ankle sprains but without mechanical instability) and 22 healthy athletes (control group of volunteers matched to age, height, weight, physical activity). INTERVENTIONS: Stabilometry in single-limb stance on a force platform. Participants were tested on each leg with and without a rigid or a flexible ankle orthosis. The order of test conditions was randomized. MAIN OUTCOME MEASURES: Sway velocities, sway pattern, and sway area as calculated from center of pressure movements. The two groups were compared by Mann-Whitney test, and the different orthoses within each group were compared by Wilcoxon test, paired samples (type I error 5%, Bonferroni adjustment). RESULTS: In athletes with functional ankle instability, both a rigid and a flexible ankle orthosis significantly reduced mediolateral sway velocity. A flexible ankle orthosis also changed sway pattern significantly, by reducing the percentage of linear movements of less than 5 degrees per .01 sec. CONCLUSIONS: In athletes with functional ankle instability, ankle orthoses reduce mediolateral sway velocity, possibly because of improved mediolateral proprioception.