01Approach to the Critical Patient/attcp49

Triage priorities

›Limb threat screen

›Open injury

›Gross contamination

›Tendon exposure

›Neurovascular compromise

›Absent or diminished dorsalis pedis pulse

›Absent or diminished posterior tibial pulse

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe motion

›Associated fracture pattern

›Posterior malleolus fracture

›Fibular avulsion at retinaculum insertion

Immediate actions

›Stabilization and analgesia

›Elevation

›Heart level or above

›Avoid dependent position

›Ice

›Skin protection barrier

›Intermittent application

›Pain control plan

›Acetaminophen first line if no contraindication

›NSAID if no contraindication

›Immobilization now

›Short leg splint position

›Neutral dorsiflexion

02History/hx29

Mechanism and timeline

›Injury mechanism

›Forced dorsiflexion with inversion

›Forced dorsiflexion with eversion

›Cutting or pivoting sport

›Timing

›Immediate snapping sensation

›Recurrent snapping with activity

›Prior instability

›Prior ankle sprains

›Prior peroneal subluxation episodes

Symptoms and functional impact

›Pain pattern

›Posterolateral ankle pain

›Pain with push off

›Mechanical symptoms

›Snapping behind lateral malleolus

›Visible tendon translation

›Function

›Weight bearing tolerance

›Return to sport goals

Risk factors and comorbidities

›Anatomic predisposition

›Shallow retromalleolar groove

›Low lying peroneus brevis muscle belly

›Peroneus quartus

›Medication and bleeding risk

›Anticoagulants

03Physical Exam/exam36

Inspection and palpation

›Lateral ankle assessment

›Swelling over posterolateral malleolus

›Ecchymosis over retinaculum region

›Peroneal tendon location

›Tenderness posterior to lateral malleolus

›Palpable tendon bowstringing anterior to malleolus

Provocative maneuvers

›Dynamic subluxation tests

›Active dorsiflexion with eversion against resistance

›Visible or palpable tendon subluxation

›Painful snap

›Circumduction

›Reproducible tendon translation

›Peroneal tendon integrity

›Eversion strength

›Weakness suggests tear

›Pain limited testing common

›Pain with resisted eversion

›Tendinopathy or split tear

›Retinaculum injury

Neurovascular and associated injury exam

›Neurovascular status

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Superficial peroneal nerve sensation

›Ankle stability screen

04Differential Diagnosis/ddx30

Traumatic lateral ankle pain

›Lateral ankle sprain

›ICD 10 S93.401A sprain of unspecified ligament of right ankle initial encounter

›No tendon translation on dynamic testing

›Distal fibula fracture

›ICD 10 S82.64XA fracture of lateral malleolus initial encounter

›Focal bony tenderness and inability to bear weight

›Posterior malleolus fracture

›ICD 10 S82.8 other fractures of lower leg initial encounter

›Posterior ankle pain and swelling

›Talus osteochondral lesion

›ICD 10 M93.27 osteochondritis dissecans ankle

›Deep ankle pain and catching

›Lateral talar process fracture

›ICD 10 S92.1 fracture of talus

›Snowboarder mechanism

Tendon and retinaculum pathology

›Peroneal tendon tear

›ICD 10 S86.31XA injury of peroneal muscle and tendon at lower leg level initial encounter

›Weakness and persistent pain without clear snap

›Peroneal tendinopathy

›ICD 10 M76.71 peroneal tendinitis right leg

›Overuse history and gradual onset

›Superior peroneal retinaculum sprain without dislocation

›ICD 10 S93.499A sprain of unspecified ligament of ankle initial encounter

›Localized retinaculum tenderness

Infections and other mimics

›Cellulitis over lateral ankle

05Laboratory Tests/lt21

When labs matter

›Lab strategy

›No routine labs for isolated closed tendon dislocation

›Targeted labs for operative pathway or systemic illness

Open injury or planned surgery pathway

›Infection and surgery baseline

›Complete blood count for open injury or infection concern

›Leukocytosis supports infection but nonspecific

›Normal white count does not exclude infection

›Basic metabolic panel for dehydration or renal risk

›Creatinine baseline for contrast planning

›Potassium baseline for anesthesia planning

›Bleeding risk

›INR for warfarin use or unknown anticoagulant status

›Elevated INR increases hematoma risk

›Reversal planning if urgent surgery

Compartment or rhabdomyolysis concern

›Muscle injury markers

›Creatine kinase for crush or prolonged immobilization

›Rising values support muscle injury

›Correlate with renal function

›Urinalysis for myoglobinuria surrogate

›Heme positive with few red cells suggests myoglobin

›Not diagnostic alone

06Diagnostic Tests/dt39

Scoring Systems

›Decision aids and classifications

›Ottawa Ankle Rules for fracture screening

›Bone tenderness posterior edge or tip of lateral malleolus

›Bone tenderness posterior edge or tip of medial malleolus

›Inability to bear weight for 4 steps

›Peroneal tendon instability clinical grading

›Acute first episode

›Recurrent or chronic

›Reducible versus fixed displacement

Radiographs

›X ray evaluation

›Standard views

›Ankle 3 view

›Mortise view

›Associated injury screening

›Fibular avulsion at retinaculum insertion

›Posterior malleolus fracture

›Post reduction films if ankle reduction performed

›Tibiotalar congruity

›Mortise symmetry

MRI

›Soft tissue definition

›Indications

›Suspected peroneus brevis split tear

›Persistent pain after immobilization

›Key findings

›Superior peroneal retinaculum disruption

07Disposition/dispo21

ED disposition and follow up

›Discharge with immobilization

›Closed injury

›Pain controlled with oral meds

›Intact neurovascular exam

›Urgent orthopedics follow up

›Suspected acute peroneal tendon dislocation

›Suspected peroneal tendon tear

›Follow up time frame

›3 to 7 days for acute dislocation

›1 to 2 weeks for suspected tear without instability

›Admission or transfer criteria

›Open injury

›Neurovascular compromise

›Unstable fracture or fracture dislocation

›Inability to ambulate safely

Activity restrictions

›Weight bearing status

›Non weight bearing until ortho review for acute dislocation

›Protected weight bearing only if explicitly cleared

›Work and sport restrictions

›No sport or running until cleared

›Driving restriction if right ankle immobilized

08Treatment/t62

Immediate life-saving interventions

›Life threats uncommon in isolated peroneal tendon injury

›Trauma survey for high energy mechanism

›Hemorrhage control for open wounds

›Limb threat response

›If absent pulses after gross deformity

›Immediate reduction if ankle fracture dislocation present

›Immediate vascular surgery or trauma consult

›If compartment syndrome concern

›Immediate compartment pressure measurement if available

›Emergent ortho consult for fasciotomy pathway

Immobilization and Splinting

›Splint selection

›Posterior short leg plus stirrup

›Neutral dorsiflexion

›Eversion bias

›Short leg cast

›Typically orthopedics directed

›Higher stability but swelling risk early

›Immobilization principles

›Swelling phase avoid circumferential cast in ED

›Neurovascular check after splint

›Skin protection over malleoli

Reduction

›Tendon dislocation reduction considerations

›Typical ED management is immobilization rather than repeated tendon manipulation

›If tendon visibly perched anterior to lateral malleolus and very painful

›Gentle manual relocation attempt may be reasonable

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging strategy

›Radiographs acceptable with shielding when needed

›MRI without gadolinium preferred for soft tissue when required

›Analgesia

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›DVT risk

›Elevated baseline VTE risk

›Lower threshold for prophylaxis discussion

Geriatric

›Older adult considerations

›Higher fracture likelihood with low energy mechanism

›Liberal radiographs

›Consider CT if persistent pain with negative X ray

›Fall risk

›Mobility aid assessment

›Home safety planning

›Medication risks

›NSAID renal and GI risk

›Opioid delirium risk

Pediatrics

›Pediatric considerations

›Growth plate injury screening

›Salter Harris patterns around distal fibula

›Low threshold for immobilization if tenderness over physis

›Imaging

10Background/b27

Epidemiology

›Frequency and setting

›Uncommon injury

›Higher prevalence in athletes

›Commonly missed at initial visit

Pathophysiology

›Mechanism

›Superior peroneal retinaculum tear

›Tendon displacement anterior to lateral malleolus

›Injury spectrum

›Retinaculum sprain

›Tendon subluxation

›Complete dislocation

›Peroneus brevis split tear

›Anatomic contributors

›Shallow retromalleolar groove

›Convex fibular groove

›Accessory muscles

Therapeutic Considerations

›Acute management goals

›Prevent recurrent displacement

›Reduce inflammation and pain

›Protect retinaculum healing

›Nonoperative versus operative concepts

›Acute first episode may trial immobilization

›Recurrent instability often needs surgical stabilization

›Rehab principles

›Early swelling control

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Discharge plan

›Splint care

›Keep clean and dry

›Do not insert objects inside

›Swelling control

›Elevation as much as possible for 48 to 72 hours

›Ice over splint if allowed and safe

›Weight bearing

›Non weight bearing until orthopedics review

›Use crutches or walker

›Pain medicines

›Acetaminophen as directed

›NSAID as directed if safe

›Return to ED now for

›Increasing pain not controlled with meds

›New numbness or tingling in foot

›Pale or cool toes

›Increasing tightness in splint

›New weakness of foot or toes

›Fever or drainage from wound

›Follow up

›Orthopedics or sports medicine in 3 to 7 days

›Earlier follow up if symptoms worsen

12References/r14

Evidence and guidelines

›Core references

›Orthopedic sports medicine reviews on peroneal tendon instability and superior peroneal retinaculum injury

›Nonoperative immobilization as initial option for selected acute cases

›Higher recurrence risk with nonoperative care in athletes and recurrent cases

›Imaging references for peroneal tendons

›MRI for tendon tear and retinaculum disruption characterization

›Dynamic ultrasound for real time subluxation confirmation when available

Evidence grading notes

›Evidence interpretation

›Limited high quality randomized trials for acute peroneal tendon dislocation

›Many recommendations based on cohort studies and expert consensus

›Class IIa recommendation for early orthopedic evaluation in suspected acute dislocation based on expert consensus

›ACEP guidance applicability

›No dedicated ACEP guideline for peroneal tendon dislocation

›Procedural sedation guidance follows standard ED sedation policies and society guidelines

Evidence & Review

Evidence & Review