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Soft tissue injury or potential fracture??
So is it a soft tissue injury or potential fracture? A sprained ankle can be a tricky one to navigate. Check out our guide to assessing severity when onboard a ship.
In the medical world, we use a tool called the Ottowa Ankle Rules to decide whether an x-ray is needed for an ankle injury. The tool was developed to meet a need for a rapid and accurate way to assess severity and avoid unnecessary x-rays. Of course if there’s a bone sticking out, or some dodgy looking deformity, then your decision may be a quick one!
Ankle sprains are a common injury in the general population and certainly not uncommon onboard vessels of all kinds. According to NICE Guidelines, lateral ankle sprains are the most prevalent form of musculoskeletal injury in physically active populations and an Australian study found that up to 70% of people reported having an ankle injury during their lifetime. Other studies indicate a higher incidence in females compared to males and that the risk is greater the younger you are.
Historically, ankle injuries are seen frequently in emergency departments, but only 15% have significant fractures. The Ottowa Ankle Rules were developed as a tool for identifying ankle and mid-foot fractures. Less than 1.7% of patients presenting with no symptoms are likely to be suffering a fracture. This figure reduces the sooner after the injury that the assessment can be made.
So how do the Ottowa Ankle Rules work and is it possible for an onboard medic to use them? Let’s start with a diagram…
This diagram shows the key areas of the foot and ankle that the rules apply to. Don’t worry about the big words, we’ll keep it simple! This short video might help too:
There are 5 components to test to assess whether your patient is positive for the Ottowa Ankle Rules. Always make sure you palpate areas thoroughly.
- Find the lateral (outside) malleolus at points A or B. Is there bony tenderness on palpation of 6 cm above the tip of the lateral malleolus?
- Find the medial (inside) malleolus at points A or B. Is there bony tenderness on palpation of the 6 cm above the tip of the medial malleolus?
- Is there bony tenderness at the base of the 5th metatarsal?
- Is there bony tenderness at the navicular bone?
- Was the patient unable to bear weight immediately after the injury and for 4 steps during your assessment?
If there is pain in the malleolar zone, or the mid foot zone, or if the patient ticks the box for any of the above points, an ankle and/or foot x-ray is indicated.
Certain patient groups are excluded, for instance someone who happens to be intoxicated, if there is another reason that they lack ability to follow the test, or if the patient is pregnant.
If you, or in conjunction with your Telemedicine provider, decide that your patient does need an x-ray, you will need to follow your vessel procedures for disembarkation or medevac, depending on your circumstances and location.
But how would you treat an ankle injury if a fracture isn’t suspected?
On medical courses over the years, you’re likely to have come across mnemonics such as RICE, PRICE and POLICE in relation to the management of acute soft tissue injuries. We’ve listed them in full at the end of the blog for information.
But hey, we’re now moving on to
PEACE and LOVE! Far out man!
The aim of PEACE and LOVE, is to optimise recovery and healing as part of the soft tissue injury management from the first point of care. It takes into consideration some important factors to aid recovery, but also highlights the potentially harmful effects of using anti-inflammatory medication as part of the process. Wowsa! So does this mean that taking anti-inflammatories isn’t the right thing to do any more? Let’s look into this PEACE and LOVE a bit more…
P - PROTECT
- Unload or restrict movement for the first 1-3 days.
- This reduces bleeding.
- It prevents distension of any injured fibres.
- It reduces the risk of aggravating the injury.
- Minimise rest - prolonged rest actually compromises the tissue strength and quality.
- Let the patient's level of pain guide the removal of protection and gradual reloading.
E - ELEVATE
- Elevate the injured limb higher than the heart. This helps to keep interstitial (in the spaces between the cells) fluid flowing out of the injured tissue. Although the evidence of its benefit is poor, there’s a low risk to benefit ratio and it may help some patients.
A - AVOID ANTI-INFLAMMATORY MODALITIES (medications and treatments)
- Anti-inflammatory medications may negatively impact long term healing, so don’t use them! This is because the inflammatory process actually supports optimal soft tissue regeneration. Using medications to inhibit this process can impair the healing process.
- Avoid ice. The benefit of ice is mainly for pain relief and although it's used widely, there’s little high quality evidence to support its use in healing soft tissue injuries. Ice could also disrupt inflammation, the restoration of blood flow to the injured area and formation of new blood vessels. It can delay the infiltration of neutrophils and macrophages to fight infection, and potentially increase immature microfibres, resulting in impaired tissue regeneration.
C - COMPRESS
- Joint swelling and internal bleeding may be limited by external compression such as taping or bandaging. But, it must allow full range of movement at the joint.
E - EDUCATE
- Contrary to popular belief, there are many benefits to an active rather than passive approach to recovery.
- Many passive therapies (e.g. electrotherapy, manual therapy, acupuncture) have minimal effects on pain and function compared to an active approach.
- Load management will avoid over treatment. Over treatment can increase the likelihood of injections and surgery.
- Dependence on therapies such as physiotherapy can actually contribute to persistent symptoms.
- Set realistic expectations about recovery times.
L - LOAD
- Evidence shows that an active approach with movement and exercises is beneficial, so normal activities should start as soon as symptoms allow.
- To provide optimal loading without increasing pain is indicated. It promotes repair and builds tissue tolerance and the capacity of tendons, muscles and ligaments.
O - OPTIMISM
- Our brains can play a significant role in rehabilitation interventions. Research shows that these factors may explain differences in symptoms and limitations better than the degree of injury.
- Barriers to recovery include many psychological factors, such as catastrophisation, depression and fear.
- Pessimistic patient expectations can negatively influence the outcomes and prognosis of an injury.
- It’s important to stay realistic and encourage optimism to improve chances of optimal recovery.
V - VASCULARISATION
- Cardiovascular physical activity is needed to manage musculoskeletal injuries.
- While more research is needed, evidence suggests that pain free cardiovascular activity increases blood flow to injuries and is a motivation booster.
- Benefits of early mobilisation and aerobic exercise improves function and work status and reduces the need for pain relief.
E - EXERCISE
- Evidence shows that exercise therapy can reduce the risk of a recurring injury.
- Exercise can restore mobility, strength and proprioception (sense of self-movement, force and body position) after an injury.
- Avoiding pain can help to promote optimal repair initially, and pain can be used as a guide to progress the difficulty of exercises gradually.
This short film might help to explain it too:
https://www.youtube.com/watch?v=HGTabgG7GIU&t=1s
So what does PEACE and LOVE mean onboard. Nope, it’s not a cue to smoke weed and hug each other while wearing flowers in our hair!
What it does mean is that crew with ankle injuries where a fracture isn’t suspected, can take pain relief (but not anti-inflammatories), use compression and elevation initially and keep the joint moving gently. As the pain allows, they should be encouraged to start to weight bear and exercise the joint.
Of course if you’re managing a crew member with a musculoskeletal injury and you aren’t sure what to do, please remember to contact your telemedicine provider.
Previous mnemonics used in the treatment of soft tissue injuries:
RICE - Rest, Ice, Compression, Elevation.
PRICE - Protect, Rest, Ice, Compression, Elevation.
POLICE - Protection, Optimal Loading, Rest, Ice, Compression, Elevation.
Resources used for this blog:
https://cks.nice.org.uk/topics/sprains-strains/background-information/prevalence/
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In this month's blog, as aching hearts aren’t just related to Valentines Day, we’re taking a look at chest pain! Chest pain is a common reason for calls for an ambulance or to shoreside, and frequently it’s not actually due to cardiac (heart) issues. But you will often hear Paramedics tell their patients that they have done the right thing; they would genuinely prefer to get to a patient and find the chest pain is a minor issue, than it being cardiac, and too late! Last year, we wrote this blog about 20 causes of chest pain (plus a bonus one!). Some of the conditions described are acute (sudden onset), some are chronic (long term), some need urgent attention, others not so much. But we should always take chest pain seriously and make sure a full assessment is done at the earliest opportunity to rule out anything life threatening. Typical symptoms of cardiac chest pain and/or a heart attack are:
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Reflection is an essential part of medicine and our regular followers will know that every year, we like to take a look back and assess where we started and how far we’ve come over the last 12 months. So, please join us on our whirlwind recap of 2024 as we get ready for a fabulous 2025… In 2024 we increased the number of STCW training clients to 4 organisations in 6 locations. We delivered STCW training at all levels to over 250 students. We delivered bespoke training to over 75 students onboard Superyachts and cruise ships. We delivered first aid at work or oxygen training to over 40 students, on land and on ships.
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All the guest blogs! When we started adding blogs to our website back in early 2021, we did a little feature on each of our instructors of the time. They’re quite a fascinating bunch and the series proved quite popular amongst our followers. In addition to our amazing instructors, we work with some utterly incredible human beings all over the world, and the idea of sharing their stories grew and developed into what eventually became a monthly guest blog. It’s been interesting to find out more about how medical care at sea or in remote locations features in their work, and to discover a few fun facts along the way. This month, we thought that it might be a fun idea to give you a chance to go back into the archives and review all the guest blogs over the last few years! Maybe even let us know which your favourite one is?
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Welcome to our September blog, and as we all start (in the UK at least!) to think about adding a few layers for warmth, we’d like to talk about getting naked! Well, to be more specific, getting bra’s off. Fact: Women are dying because bystanders are less likely to carry out CPR on women than men. Research shows that women are 27% less likely to receive CPR than men and if a defibrillator is used, their chance of survival is affected by bra’s being left on. Most of us have never had the chance to train using a female manikin. The #BraOffDefibOn campaign aims to address the inequality in CPR for women and we’re supporting it.