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Slide 1-

Injuries of the Lower Extremity: Knee, Ankle and Foot John Burkhardt, MD Clinical Lecturer University of Michigan Departments of Emergency Medicine and Medical Education 1
Slide 2-

First Steps I need a volunteer or two who is willing to move up to the front of the room and help me a demonstration The rest of you come closer and arrange yourselves so you can talk amongst yourselves (No not because my lecture is going to be that boring) 2
Slide 3-

Objectives To provide a review of common lower extremity injuries that present in an Emergency Department setting, focusing on those involving in the knee, ankle and foot To describe the epidemiology of these injuries To review the appropriate history and physical exam maneuvers in order to quickly evaluate and distinguish the different emergent injuries To review the diagnostic examinations available for further evaluation To describe the preliminary management of the in the emergent setting 3
Slide 4-

Basic Anatomy of the Knee Large Hinge Joint Femur Tibia Fibula Patella 4 Kari Stemmen, Wikimedia Commons
Slide 5-

More Basic Anatomy Ligaments Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL) Anterior Cruciate Ligament (ACL) Posterior Cruciate Ligament (PCL) 5 Mysid, Wikimedia Commons
Slide 6-

Articular Cartilage Medial Meniscus Lateral Meniscus 6 Mysid, Wikimedia Commons
Slide 7-

Types of Knee Injuries Injuries to one or more of the ligaments of the knee (ACL, PCL, MCL, and LCL) Injuries to the bony structures (Patellar fractures, femur fractures, tibial fractures) Injuries to the meniscus and articulating surface 7
Slide 8-

Key Pieces of History Fracture High-velocity collision Inability to immediately bear weight "Pop" occurred with injury ACL tear Cut or pivot mechanism of injury Knee "gave way" Inability to continue participation "Pop" felt or heard with injury PCL tear Blow to proximal tibia Less instability than ACL tear Meniscal tear Squat/kneel associated with a twist Clicking Locking Pain with rotational movement Overuse syndrome Occupational or recreational repetitive movement 8
Slide 9-

Epidemiology of Knee Injuries All Knee injuries Subset of Ligamentous injuries Source undetermined 9
Slide 10-

Stepwise evaluation of the injured knee Palpate the knee and determine the areas of maximal tenderness Examine and note the presence and location of any effusion Evaluate the Range of Motion at the Knee Evaluate the movement and stability of the patella Perform specific ligamentous stability testing Perform Meniscal examination Examine for neurovascular compromise 10
Slide 11-

Palpation Superior Patella Pole (Quadriceps Tendonitis) Inferior Patella Pole (Prepatellar Tendonitis) Anterior Patella (Prepatellar Bursitis) 11 bernblue, flickr
Slide 12-

Joint line (Meniscal Injury) Lateral Medial 12 mikebaird, flickr
Slide 13-

Palpation in Adolescents Tibial Tubersoity (Osgood-Schlatter) Femoral or Tibial Epiphysis (Non displaced fracture through the physis) 13
Slide 14-

DDX of Effusions Trauma Ligamentous injury Intra-articular fracture Patellar dislocation Meniscus injury Polyarthritis Reiter's syndrome Juvenile rheumatoid arthritis Rheumatoid arthritis Infection Gonorrhea Lyme disease Tuberculosis Brucellosis Gout Pseudogout (calcium pyrophosphate deposition disease) Osteoarthritis and overuse syndrome Tumor Malignant Hematologic Solid tumor Chondroblastoma Eosinophilic granuloma Giant cell tumor Ewing's sarcoma Osteosarcoma Synovial sarcoma Benign Aneurysmal bone cyst Fibrous cortical defect Fibrous dysplasia Osteochondroma Osteoid osteoma Pigmented villonodular synovitis 14
Slide 15-

Range of Motion The knee should be able to range from hyperextension to 135 degrees of flexion Loss of active extension and inability to maintain passive extension are indicative of quadriceps and patellar tendon 15 tronixstuff, flickr
Slide 16-

Patellar Testing Examine the patella, with ROM testing, feeling for catches and grinding Next test the movement of the patella testing for lateral laxity (Patellar Dislocation 16 openmichigan, YouTube
Slide 17-

ACL testing Anterior Drawer sign Performed at 90 degrees flexion Make sure the quadriceps muscles are relaxed Compare the amount of laxity of movement compared to unaffected side Lachman’s Test Perfromed at 20 to 30 degrees flexion 17 Mak-Ham Lam et al., Wikimedia Commons
Slide 18-

PCL Testing Posterior Drawer sign Gold Standard Performed similarly to Anterior drawer sign Posterior Sag Sign -Observe the lag at maximum muscle relaxation -Compare to unaffected leg 18 openmichigan, YouTube openmichigan, YouTube
Slide 19-

MCL Testing Valgus stressing of the MCL at both 0 and 30 degrees Testing at 30 degrees removes the stabilization provided by the cruciate ligaments 19 openmichigan, YouTube openmichigan, YouTube
Slide 20-

LCL Testing LCL testing similar to MCL testing Varus stress testing Performed at 0 and 30 degrees 20 openmichigan, YouTube
Slide 21-

Meniscal Testing McMurray’s Test to evaluate for Meniscal injury Positive test is “clicking” along joint line along with pain during internal and external rotation 21 openmichigan, YouTube
Slide 22-

Ottawa Knee Rules OK break into groups and lets take 1 minute and list the criteria Hint: There are 5 22
Slide 23-

Ottawa Knee Rules Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex to 90° Inability to bear weight both immediately and in ED 23
Slide 24-

Ottawa Knee Rules: The Numbers In one meta-analysis the decision rule had a sensitivity of 1.0 (95% confidence interval 0.96 to 1.0) in identifying clinically important fractures. In the same study the potential reduction in use of radiography was estimated to be 49% The probability of fracture, if the decision rules were negative, was estimated to be 0% (95% CI 0% to 0.5%) Not worth a patient complaint 24 trekkyandy, flickr
Slide 25-

Imaging Modalities Plain X-Rays CT Ultrasound Bone Scan MRI 25 Source Undetermined
Slide 26-

Plain Films Traditional Standard of Care when concern for fracture Generally A/P and Lateral performed in ER Additional Useful images include a “Sunrise” view 26 Source Undetermined
Slide 27-

Computer Tomography Useful in detecting tibial plateau fracture Usually performed when diagnosis is unclear 27 Source Undetermined
Slide 28-

Ultrasound Often used to examine the musculature of a joint while in use Provides dynamic imaging for examining muscle tears, tendon ruptures, and other soft tissue injuries. 28 Source Undetermined
Slide 29-

Magnetic Resonance Imaging Most useful for examination of meniscal injuries Can be used for evaluating for ligamentous injury ACL has high sensitivity but poor sensitivity in determining complete versus partial tear Very sensitive in PCL 29 Source Undetermined
Slide 30-

Initial Management Or in the other words, after all of that what should we do? 30
Slide 31-

Patellar Fractures If extension is possible without displacement non operative management Initially treated in knee immobilizer Treated long leg cast 4-6 weeks Operative management consists of ORIF 31 Source Undetermined
Slide 32-

Patellar Dislocation Closed reduction may be attempted Gentle extension of the leg with anteriomedial pressure on the lateral aspect of the patella Following reduction patient should be placed in a knee immobilizer for 3-6 weeks 30-50% recurrence rate in properly treated primary dislocations 32 Nadja.robot, flickr
Slide 33-

Distal Femur Fracture Usually secondary to MVC or significant fall After examination, the leg should be splinted If joint incongruity, Othro consult and ORIF Patients are at risk for fat embolus 33 Source Undetermined
Slide 34-

Tibial Plateau Fracture More common in the elderly Usually strong varus force as cause By definition are intrarticular Often with associated ACL or MCL injury (20-25%) Patient should be made non-weight bearing and placed in immobilization either with a long leg cast or immobilizer Patient may require ORIF in more serious or displaced fractures 34 Source Undetermined
Slide 35-

Epiphyseal Fracture Constitute a fracture through an open growth plate Anatomic reduction Ice, elevation, immobilization with a long leg splint Early orthopedic consultation 35 SalterHarris, Wikimedia Commons
Slide 36-

Osteochondritis Dissecans (OCD) Unknown etiology, thought to be related to chronic or acute trauma Occurs mostly in adolescent males Usually seen on plain films In patients with open growth plates, treat with protected weight bearing Poor prognosis if closed If loose piece, may require OR 36 Kristin M Houghton, Wikimedia Commons
Slide 37-

Meniscal Injuries Crescent shaped semilunar fibrocartilaginous structures Diagnosis via MRI after clinical suspicion Unless locking, initial management is NSAIDs, ice, knee immobilization, non weight bearing, and orthopedic referral Ultimate management is determined often secondary to associate ligamentous injury 37 Arthroscopist, Wikimedia Commons
Slide 38-

Ligamentous Injuries ACL injuries PCL injuries MCL injuries LCL injuries 38
Slide 39-

ACL injuries 50% of ACL injuries are associated with meniscal injuries Often associated with bleeding and thus immediate swelling Grade I and II should be managed conservatively with pain meds and range of motion exercises Patient should be made non weight bearing If possible, patient should not be placed in a knee immobilizer if an isolated injury 39
Slide 40-

PCL injuries Hyperflexion and Dashboard injuries when isolated injury Generally managed non-operatively Treated long term with quadriceps strengthening 40 John Collins, Wikimedia Commons
Slide 41-

MCL injuries Often due to a direct blow to the lateral aspect of the knee Should be placed in knee immobilizer and allowed to “scar” down Long term management is generally non operative in isolated injury 41
Slide 42-

LCL injury Less common than others, due to protection provided by other leg Management the same as with MCL Non-operative management Knee immobilization 42
Slide 43-

Tibial Femoral Knee Dislocation Limb Threatening Injury Half of all Dislocations reduce spontaneously 2/3 From MVCs 2 ligament injuries Neurovascular injury 43 Hellerhoff, Wikimedia Commons
Slide 44-

Tibial Femoral Knee Dislocation Longitudinal Reduction should be attempted immediately after documentation of neurovascular status Recheck of neurovascular status post reduction Arteriogram should be performed in any patient not immediately going to the OR if there is any concern of vascular injury Prompt vascular surgery involvement in a must 44
Slide 45-

Demonstration and Review 45
Slide 46-

Ankle Anatomy Bony anatomy Calcaneus/talus (dome) Tibia (medial malleolus) Fibula (lateral malleolus) Composed of 2 joints: True Ankle joint Subtalar joint True ankle joint contains the tibia, fibula, and talus Allows for dorsiflexion and plantar flexion 46 Tibia Fibula Talar Joint Talus EUSKALANATO, flickr
Slide 47-

Ankle Anatomy Subtalar joint consists of the talus and the calcaneus Allows for inversion and eversion 47 Grook Da Oger, Wikimedia Commons eversion inversion Subtalar Function
Slide 48-

Ankle Lateral Ligaments Anterior talofibular Posterior talofibular Calcaneofibular Anterior tibiofibular Posterior tibiofibular 48 Quadell, Wikimedia Commons
Slide 49-

Ankle Medial ligament (Deltoid) 49 Posterior tibiootalar part Anterior tibiootalar part Tibiocalcaneal part Tibionavicular part Pngbot, Wikimedia Commons
Slide 50-

Ankle Ring Integrity of the ring necessary for stability of the ankle Consists of the following: Tibial plafond, Medial malleolus, Deltoid ligaments, Calcaneus, Lateral collateral ligaments Lateral malleolus Syndesmotic ligaments 50 אנדר-ויק Wikimedia Commons
Slide 51-

Ankle Injuries Types of injuries Ankle sprain/Ligamentous injury Ankle fracture/Bony injury Joint Dislocation Neeta Lind, flickr 51
Slide 52-

Ankle Injury Pathophysiology Excessive inversion stress (85%) is the most common cause of ankle injuries for two reasons: Medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert. Deltoid ligament stabilizing the medial aspect is stronger However, given the above when eversion injuries occur there is often substantial damage 52
Slide 53-

Ankle examination Look at the ankle for signs of deformity, redness, or swelling Feel for tender areas, systematically checking: 1. the anterior joint line 2. the lateral gutter and lateral ligaments 3. the syndesmosis 4. the posterior joint line 5. the medial ligament complex 6. the medial gutter Feel for an effusion, synovitis, deformity, bony prominence and loose bodies. Examine for neurovascular compromise 53
Slide 54-

Ankle Joint Testing Drawer and Talar tilt examination techniques are used to assess ankle instability Anterior talofibular ligament Anterior drawer test Calcaneofibular ligament (Talar Tilt) Inversion stress test Deltoid ligament (Talar Tilt) Eversion stress test Use of these techniques in acute injuries an be limited by pain, edema, and muscle spasm 54 Grook Da Oger, Wikimedia Commons
Slide 55-

55 Anterior Drawer Test Talar Tilt Inversion Stress Test openmichigan, YouTube openmichigan, YouTube
Slide 56-

Ottawa Ankle/Foot Rules OK break into groups one more time and lets take 1 minute and list the criteria 56
Slide 57-

Ottawa Ankle Rules X-rays are only required if: There is any pain in the malleolar zone and: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus An inability to bear weight both immediately and in the ED 57 http://www.bmj.com/content/326/7386/417.full
Slide 58-

Ottawa Ankle Rules: The Numbers In a meta-analysis the pooled negative likelihood ratios for the ankle and midfoot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20) Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture Sensitivity of almost 100% Reduce the number of unnecessary radiographs by 3040% 58
Slide 59-

Ankle Sprain Classification Grade 1: Ligament stretching with microscopic tearing but not macroscopic tearing. Little swelling is present Little or no functional loss and no joint instability Able to fully or partially bear weight. Grade 2: Partial tear Moderate-to-severe swelling, ecchymosis Moderate functional loss, and mild-to-moderate joint instability Difficulty bearing weight Grade 3: Complete rupture of the ligament Immediate and severe swelling and ecchymosis Moderate-to-severe instability of the joint Cannot bear weight without experiencing severe pain. 59
Slide 60-

Ankle Ligamentous Injury Types ATFL is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain In forced dorsiflexion, the PTFL can rupture External rotation can disrupt the deep deltoid ligament on the medial side Forced adduction in neutral and dorsiflexed positions can disrupt the Calcaneofibular (CFL) 60 ATFL ATFL PTFL CFL Pngbot, Wikimedia Commons
Slide 61-

Syndesmosis Sprains Account 10% of all ankle sprains and as high as 18% of football players Excessive external rotation of the talus or forced dorsiflexion causes the talus to place pressure on the fibula Results in spreading of the distal syndesmosis as well as damage to anterior or posterior tibiofibular ligament Ankle syndesmosis injury Quibik, Wikimedia Commons
Slide 62-

Ankle Sprain Treatment PRICES Protection Relative rest Ice Compression Elevation Support Good return instructions also a must as always 62
Slide 63-

Ankle Sprain Prognosis Most report full recovery at 2 weeks to 36 months (36-85%) Independent of the initial grade of sprain Most recovery occurs within the first 6 months After 12 months, the risk of recurrent ankle sprain returns to pre-injury levels Re-sprains occur in up to 36% of patients, athletes are at increased risk 63
Slide 64-

Isolated Malleolar Fracture (Unimalleolar) ED Docs describe based off number fractures unimalleolar, bimalleolar, trimalleolar Distal fibula or less common tibial fracture Fractures below the Tibiotalar line (T-t, distal to the tibial plafond) are usually stable 64 http://www.wheelessonline.com/image7/ank120.jpg
Slide 65-

Bimalleolar fracture Involves the lateral and medial malleolus ED Treatment involves fracture reduction and realignment Initial ED management is usually followed by surgical fixation Ortho consult in ED 65 Source Undetermined http://www.georgelianmd.com/cms/ConditionsITreat/AnkleFractures/tabid/117/Default.aspx
Slide 66-

Trimalleolar Fracture Involves the lateral malleolus, medial malleolus, and the distal posterior aspect of the tibia Unstable, loss of lateral control Surgical repair is required Ortho consult in ED 66 http://www.georgelianmd.com/cms/ConditionsITreat/AnkleFractures/tabid/117/Default.aspx
Slide 67-

Ankle Fracture Classifications Danis-Weber classification often used by Ortho Some correlation with need for operative stabilization Lauge-Hansen alternative classification system Type A: Transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus From internal rotation and adduction Usually stable fractures Type B: Oblique fracture of the lateral malleolus with or without rupture of the tibiofibular syndesmosis and medial injury From external rotation May be unstable Type C High fibular fracture with rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus From adduction or abduction with external rotation Usually unstable and require operative repair 67
Slide 68-

Pilon Fracture Fracture of the distal tibial metaphysis combined with disruption of the talar dome. Result of an axial loading mechanism drives the talus into the tibial plafond Foot braced against a floorboard in an auto collision. Skiers coming to an unexpected sudden stop Free fall from heights Fractures often open and can be associated with lumbar spine injuries 68 http://www.georgelianmd.com/cms/ConditionsITreat/AnkleFractures/tabid/117/Default.aspx
Slide 69-

Maisonneuve fracture Proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament Associated with partial or complete disruption of the syndesmosis Important to perform a physical exam or xrays to assess for this in ankle injuries 69 http://www.wheelessonline.com/image7/mason1.jpg
Slide 70-

Tillaux fracture Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis Caused by extreme eversion and lateral rotation Incidence is highest in adolescents because the fracture occurs after the medial aspect of the epiphyseal plate closes but before the lateral 70 http://emedicine.medscape.com/article/824224-clinical#showall
Slide 71-

Ankle Dislocation Associated fractures are the rule rather than the exception with ankle dislocations Neurovascular injury is the principal concern Tented skin may be subject to ischemic necrosis Immediate reduction in the ED is often required 71 OakleyOriginals, flickr
Slide 72-

Demonstration and Review 72
Slide 73-

Foot Anatomy Phalanges proximal, middle, distal Metatarsals Tarsals Calcaneus Talus Navicular Cuboid Cuneiforms Medial/lateral longitudinal and transverse metatarsal arches 73 Medial arch Lateral arch Lisfranc joint Rob Swatski, flickr
Slide 74-

Ottawa Foot Rules X-ray series is indicated if there is any pain in the midfoot zone and any one of the following: Bone tenderness at the base of the fifth metatarsal (for foot injuries) Bone tenderness at the navicular bone (for foot injuries) An inability to bear weight both immediately and in the emergency department for four steps. 74 http://www.bmj.com/content/326/7386/417.full
Slide 75-

Foot Injuries Toe Injuries Metatarsal fracture Jones’ fracture Lisfranc fracture Navicular fracture Calcaneal fracture 75
Slide 76-

Toe fractures Buddy tape the broken toe to an adjacent, uninjured toe Apply a rigid flat-bottom orthopedic shoe Union of fracture segments occurs in 3-8 weeks Symptoms usually improve much earlier Irreducible fractures sometimes require open reduction and internal fixation 76 Padding Buddy-taped toes spaceninja,flickr
Slide 77-

First metatarsal fracture Least commonly fractured metatarsal Bears twice the weight of other metatarsal heads. Treat minimally displaced or nondisplaced fractures with immobilization without weight bearing Displaced fractures usually require open reduction and internal fixation 77 http://www.mdmercy.com/footandankle/conditions/trauma/fractures_metatarsals.html
Slide 78-

Internal metatarsal fracture Nondisplaced and displaced fractures usually heal well, with weight bearing as tolerated, in a cast or rigid flat-bottom orthopedic shoe. Elastic support bandages may be equivalent or superior to casts Must look for Lisfranc Injury as this is a game changer March fracture is a stress fracture of the second or third metatarsal that occurs in joggers. 78
Slide 79-

Jones’ fracture Transverse fracture of the 5th metatarsal Must be at least 15 mm distal to proximal end High rate of malunion As above contact Ortho Pseudo-Jones: avulsion fracture of tuberosity at 5th metatarsal 79 Stress Frx Jones Frx Avulsion Frx Lucien Monfils , Wikimedia Commons
Slide 80-

Lisfranc fracture Site of articulation between the midfoot and forefoot Dislocation at the TMT joint Result of direct blow to the joint or by axial loading along the metatarsal, either with medially or laterally directed rotational forces Fracture at the base of second metatarsal should raise concern for this type on injury Often need weight bearring films to see displacement 80 James Heilman, MD, Wikimedia Commons
Slide 81-

Lisfranc fracture: Xrays 81 http://www.aafp.org/afp/980700ap/burrough.html http://www.aafp.org/afp/980700ap/burrough.html
Slide 82-

Navicular Fracture Avuslsion fracture most common Type 1: coronal fracture with no dislocation Type 2: dorsolateral to plantomedial fracture with medial forefoot displacement Type 3: comminuted fracture with lateral forefoot displacement Most patients are placed in a non–weight-bearing cast for 6 weeks All navicular body fractures with 1 mm or more of displacement require open reduction and internal fixation. 82 http://www.aafp.org/afp/2003/0101/p85.html
Slide 83-

Calcaneal fracture-Bohler’s angle Calcaneus fractures most often occur in males 5:1 Peak age: between 30 and 50 years. Associated injuries (Lumbar spine vertebral compression fractures) Treatment: Operative vs Casting Ortho Consult 83 Thomas Steiner, Wikimedia Commons
Slide 84-

When to call Ortho for foot injuries Talus fractures Calcaneusfractures Navicular fractures, especially if intraarticular Cuboid fractures Lisfranc injuries Metatarsal shaft fractures with > 3 mm displacement or 10 degrees angulation Metatarsal head and neck fractures Jones fractures greggoconnell, flickr 84
Slide 85-

Questions? 85
Slide 86-

Bibliography Alhubaishi, Ahmed: Ankle and Foot, Online Lecture Ameres, Michael J MD: Navicular Fracture,eMedicine Anderson, Ronald and Bruce Anderson: Evaluation of the adult patient with knee pain Up to Date. Com Copyright 2006 Bachmann, Lucas MD, PhD, et al, Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot: systematic review, BMJ VOL 326 22 FEB 2003 Bachmann, Lucas MD, PhD, et al, The Accuracy of the Ottawa Knee Rule To Rule Out Knee Fractures A Systematic Review Ann Intern Med. 2004;140:121-124. Bollen, Steve: Epidemiology of knee injuries: diagnosis and triage Br J Sports Med 2000; 34:227-228 2000 Clark, Mark: Overview of the causes of limp in children, Up to Date. Com Copyright 2006 DeBerardino, Thomas M MD: Medial Collateral Knee Ligament Injury, eMedicine Emparanza, José I. MD, PhD, Validation of the Ottawa Knee Rules Ann Emerg Med. October 2001;38:364-368. Marx: Rosen’s Emergency Medicine: Concepts and Clincal Practice 6th Edition, Copyright 2006 Mosby Inc. Gammons, Matthew MD: Anterior Cruciate Ligament Injury, eMedicine Hergenroeder, Albert C: Causes of Knee pain and injury in the young adult Up to Date. Com Copyright 2006 Ho, Sherwin SW MD: Lateral Collateral Knee Ligament Injury, eMedicine Iskyan, Kara MD: Ankle Fracture in Emergency Medicine, eMedicine Jacobs, Brian A MD: Achilles Tendon Rupture, eMedicine Johnson, Michael W. MAJ, MC, USA Madigan Army Medical Center, Tacoma, Washington: Acute Knee Effusions: A Systematic Approach to Diagnosis American Family Physician April 15th 2000 Kinesiology Online Lecture Keany, James E MD: Ankle Dislocation in Emergency Medicine, eMedicine Malanga, Gerard A MD: Patellar Injury and Dislocation, eMedicine Molis, Marc A MD Talofibular Ligament Injury, eMedicine Peterson, Charles S MD: Posterior Cruciate Ligament Injury, eMedicine Reuss, Bryan L MD: Calcaneofibular Ligament Injury, eMedicine Rupp, Timothy J MD: Athletic Foot Injuries,eMedicine Steele, Phillip M MD: Ankle Fracture in Sports Medicine Treatment & Management, eMedicine Stiell, Ian MD, Derivation of a Decision Rule for the Use Radiography in Acute Knee Injuries Annals of Emergency Medicine OCT 1995 28:4 Stiell, Ian MD, et al, Implementation of the Ottawa Ankle Rules JAMA. 1994;271:827-832 Stiell, Ian MD, Ottawa ankle rules Canadian Family Physician March 1996 Vol 42: Tandeter, Howard B. M.D., Max A. Stevens, M.D. , and Esach Shartzman, M.D. Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering American Family Physician December 1999 Trevino, Saul G MD: Lisfranc Fracture Dislocation, eMedicine Wheeless' Textbook of Orthopaedics: Examination of the Foot and Ankle Young, Craig C MD Ankle Sprain, eMedicine 86