9.12 Ligament Sprains 
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(Including Joint Capsule Injuries)
agk's Library of Common Simple Emergencies

Presentation
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A joint is distorted beyond its normal 
anatomical limits (as when an ankle is inverted 
or a shoulder is dislocated and reduced) The 
patient may complain of a snapping or popping 
noise at the time of injury, immediate 
swelling, and loss of function (suggestive of 
second- or third-degree sprain or a fracture); 
or he may corne in hours to days following the 
injury, complaining of gradually increasing 
swelling and resulting pain and stiffness 
(suggestive of a first- or second-degree sprain 
and development of a traumatic effusion).

What to do:
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- Obtain a detailed history of the mechanism of 
    injury, and examine the joint for struct- 
    ural integrity, function, and point 
    tenderness. Use the uninjured limb as a 
    control.
- Obtain x rays (these can be deferred if 
    necessary).
- With first-degree and second-degree sprains, 
    gently immobilize the joint using an 
    elastic bandage alone, or in combination 
    with a cotton roll and/or plaster splint, 
    as discomfort demands.
- Consider prescribing anti-inflammatory pain 
    medication when the patient complains of 
    pain at rest and provide crutches when 
    discomfort will not allow weight bearing.
- If there is a fracture or ligament tear with 
    instability, the limb is usually best 
    immobilized in a splint or cast. Splint 
    ankles at 90 degrees, wrists in extension, 
    fingers at slight flexion.
- Instruct the patient in rest, elevation, and 
    application of ice (10-20 minutes each 
    hour) for the first 24 hours.
- Explain to the patient that swelling in acute 
    musculoskeletal injuries usually increases 
    for the first 24 hours, and then decreases 
    over the next 2-4 days (longer if the 
    treatment above is not employed) and that 
    some swelling and discomfort may persist 
    for several weeks and at times for several 
    months.
- Explain the possibility of occult injuries, 
    the necessity for followups, and the slow 
    healing of injured ligaments (usually 6 
    months until full strength is regained).

What not to do:
---------------

- Do not obtain x-rays before the history or 
    physical examination. Films of the wrong 
    spot can be very misleading. For example, 
    physicians have been steered away from the 
    diagnosis of an avulsion fracture of the 
    base of the fifth metatarsal by the 
    presence of normal ankle films.
- Do not base the diagnosis on x-rays. They 
    should be used as confirmatory evidence.

Discussion
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Ligamentous injuries are classified as first- 
degree, (minimal stretching); second-degree (a 
partial tear with functional loss and bleeding 
but still holding); and third-degree (complete 
tear with ligamentous instability, often 
requiring a cast). A tense joint effusion will 
limit the physical examination (and is one 
reason to require re-evaluation after the 
swelling has decreased) but also suggests less 
than a third degree ligamentous injury, which 
is normally accompanied by a tear of the joint 
capsule.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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