AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Ankle fractures refer to fractures of the distal tibia, distal fibula, talus, and calcaneus.

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint.

The true ankle joint contains the tibia (medial wall), fibula (lateral wall), and talus (the floor upon which the tibia and fibula rest). The true ankle joint allows dorsiflexion and plantar flexion or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward the ceiling via the true ankle joint.

The subtalar joint consists of the talus and the calcaneus. The subtalar joint allows the foot to be inverted or everted, that is, the sole of the foot can be made to face inward (inverted) or face outward (everted) through the subtalar joint.

During evaluation of ankle fractures, the mechanism of injury (eg, eversion, inversion, dorsiflexion, plantar flexion), associated injuries (eg, vascular, ligamentous, capsular), the need for immobilization (eg, application of a splint), and the need for referral to a specialist for further treatment or evaluation (eg, additional immobilization, surgery, or rehabilitation) are all important components of care.

For more information on fractures, see Medscape’s Fracture Resource Center.

For related CME activities, see CME - Calcium Supplementation May Reduce Fracture Risk and CME - More Evidence of Increased Fractures With Thiazolidinediones.

Pathophysiology

The primary motion of the ankle at the true ankle joint (tibiotalar joint) is plantarflexion and dorsiflexion.

Inversion and eversion occur at the subtalar joint.

Excessive inversion stress is the most common cause of ankle injuries for 2 anatomic reasons. First, the medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert. Second, the deltoid ligament stabilizing the medial aspect of the ankle joint offers stronger support than the thinner lateral ligaments. As a result, the ankle is more stable and resistant to eversion injury than inversion injury. However, when eversion injury occurs, there is often substantial damage to bony and ligamentous supporting structures and loss of joint stability.

Posterior malleolar fractures are usually associated with other fractures and/or ligamentous disruption. They are commonly associated with fibular fractures and are often unstable.

Transverse malleolar fractures usually represent an avulsion-type injury. 

Vertical malleolar fractures result from talar impaction.

Frequency

United States

Of all the ankle injuries evaluated in the ED, only 15% are ankle fractures. The frequency of ankle fractures has been increasing for the past 20 years, and the rate is approximately 187 in 100,000 person-years.

Mortality/Morbidity

• Patients with unrecognized or undertreated open ankle fractures are at high risk of infection including local infection, osteomyelitis, and sepsis. Gas gangrene is the most serious infectious complication. It can be both limb and life threatening.
• Vascular supply to the ankle and foot may become compromised by development of a compartment syndrome or direct injury to blood vessels from bone fragments.
• Talus fractures, those commonly occurring in snowboarding trauma, can cause osteoarthritis and subtalar joint degeneration.
• A calcaneal fracture may compromise inversion and eversion of the ankle. Surgical complications and prolonged rehabilitation are common with calcaneal fractures.
• Older patients with ankle fractures experience more long-term complications than younger patients.

Race

No race predilection is noted.

Sex

The male-to-female ratio is 2:1. Most patients younger than 50 years are male, while most older than 50 years are female.

Age

• Pediatric ankle bones are susceptible to medial malleolar and transitional fractures of the distal tibia.
• As the population ages, ankle fractures are becoming more common. An increase in fall risk and osteoporosis are risk factors.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• All injured patients should be evaluated for more extensive and serious trauma depending on the circumstances.
• Knowledge of the trauma, such as the direction of torque force applied to the ankle and the foot's position, helps predict the nature and severity of an ankle injury. Although patients tend to recall the event, they often cannot depict the exact manner in which their injury occurred.
• History of prior trauma to the affected ankle may cause antecedent laxity, instability, or radiographic abnormalities misinterpreted as an acute event.
• Chronic medical condition, such as diabetes, peripheral vascular disease, and metabolic bone disease, may affect examination findings and treatment plans.
• Chronic medication use is an important part of the history and has implications for management. For example, long-term use of corticosteroids may provoke premature osteoporosis, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) may mitigate the degree of swelling normally expected with fractures.

Physical

Because an ankle fracture often presents with symptoms similar to those of an ankle sprain, a complete and thorough examination of the involved extremity is needed to avoid misdiagnosis and prevent unnecessary radiographs.

• Indicators suggesting fracture include gross deformity, swelling (especially perimalleolar), bony tenderness, discoloration, and ecchymosis. Inability to bear weight on the injured foot also indicates a fracture.
• Corroborate any visible deformity by gently manipulating the affected area.
• Inspect carefully for the presence of open wounds close to the injured ankle.
• Assess the neurovascular status of the foot and ankle. Compare findings to the unaffected extremity.
• • Check presence and quality of pulse of the posterior tibial artery. A hand-held Doppler can be useful to document arterial patency.
  • Check presence and quality of pulse of dorsalis pedis artery. Note that the dorsalis pedis is congenitally absent in as many as 10-15% of the population.
  • Document the time for capillary refill.
• Palpate for focal bony tenderness, especially along the medial and lateral malleoli and posterior aspect of the joint. If possible, palpate the most tender area last.
• Assess passive and active range of motion of the ankle joint, noting limitations. During the immediate acute phase, most patients' ankles are too tender to cooperate with stress testing of the joint.
• Examine the ipsilateral knee and foot, particularly documenting the condition of the proximal fibula and proximal fifth metatarsal.

Causes

• Multiple classification schemes are used for ankle fractures. The Lauge-Hansen system categorizes ankle fractures based on the position of the foot and the forces acting on it at the time of injury, while the Danis-Weber system relies on the level of fibular fracture. Neither classification scheme has been proven to be prognostic, so emergency medicine physicians usually label ankle fractures according to the number of fractures in the ankle (unimalleolar, bimalleolar, trimalleolar).
• Danis-Weber classification: These fractures are classified according to location of the fracture and appearance of the fibular component. To some degree, Weber classification correlates with need for operative stabilization. Orthopedic surgeons frequently use this classification system. 
• • Type A depicts a transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus. These result from internal rotation and adduction. These are usually stable fractures.
  • Type B describes an oblique fracture of the lateral malleolus with or without rupture of the tibiofibular syndesmosis and medial injury (either medial malleolus fracture or deltoid rupture). These result from external rotation. These may be unstable.
  • Type C designates a high fibular fracture with rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus. Usually, syndesmotic injury is more extensive than in type B. These result from adduction or abduction with external rotation. These are usually unstable and require operative repair.
• Fracture eponyms
• • Pilon fracture
  • • A pilon fracture designates a fracture of the distal tibial metaphysis combined with disruption of the talar dome. An axial loading mechanism drives the talus into the tibial plafond (the distal articular surface of the tibia). A common method of trauma is a foot braced against a floorboard in an auto collision. Skiers coming to an unexpected sudden stop and victims of free fall from heights also may sustain pilon fractures. Incidence of pilon fractures ranges from 1-10% of all tibial fractures.
    • Establish vascular and integument integrity. Pilon fractures are often open. Skin sloughing is not uncommon. Subsequent edema, fracture blisters, and skin necrosis from the original injury may convert closed fractures to open injuries.
    • Depending on the trauma, associated injuries include spinal compression fractures (especially of L1) and ipsilateral or contralateral fractures of the os calcis, tibial plateau, pelvis, or acetabulum.
    • As pilon fractures are often comminuted and open, there is often significant long-term disability. 
  • Maisonneuve fracture
  • • A Maisonneuve fracture is defined as a proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Maisonneuve fractures are associated with partial or complete disruption of the syndesmosis.
    • Treatment of Maisonneuve fractures depends on stability of the ankle mortise.
  • Tillaux fracture
  • • A Tillaux fracture describes a Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis caused by extreme eversion and lateral rotation of the ankle. Incidence is highest in adolescents, usually those aged 12-14 years, because the fracture occurs after the medial aspect of the epiphyseal plate of the tibia closes but before the lateral aspect arrests.
    • Distinguish a Tillaux fracture from a triplane fracture. Triplane fracture is a combination of a SH II and III fracture and is more likely than a Tillaux fracture to require open reduction and internal fixation.
  • Pott fracture: Bimalleolar fractures, termed Pott fractures, involve at least 2 elements of the ankle ring. These fractures should be considered unstable and require urgent orthopedic attention.
  • Cotton fracture: A trimalleolar, or Cotton, fracture involves the medial, lateral, and posterior malleoli. These fractures are considered unstable and require urgent orthopedic attention.
  • Snowboarder's fracture
  • • With the popularity of snowboarding in the late adolescent and young adult population, it is likely the emergency physician will come across a fracture of the lateral process of the talus, the so-called snowboarding ankle fracture.
    • A combination of dorsiflexion and inversion of the ankle produces the lateral talar fracture.
    • A high index of suspicion should be used in snowboarders who complain of lateral ankle pain with a normal-appearing ankle radiograph. Computed tomography imaging is often required to diagnose a talus fracture.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Tibia-fibular diastasis
Incisura fracture
Achilles tendon rupture
Achilles tendonitis
Charcot-Marie-Tooth disease

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• No laboratory studies are necessary in patients with isolated ankle fracture when caused by a plausible mechanism. However, repeated ankle fracture or a fracture caused by simple, low force trauma can require investigation for osteoporosis, Charcot-Marie-Tooth disease, arthritis, connective tissue disease, or peripheral vascular disease.

Imaging Studies

• Routinely obtaining radiographs following an ankle injury is not cost-effective because fewer than 15% of affected patients have fractures. Patients without fractures are identified reliably from the physical examination. Ottawa ankle rules provide practical guidelines to select patients for radiographic studies.
• Indications for ankle radiographs in patients with acute ankle pain include pain in the ankle region plus one of the following:
• • Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus
  • Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus
  • Inability to bear weight both immediately and in the ED (defined as 4 steps)
  • Confounding variables to the Ottawa rules are (1) younger than 18 years, (2) underlying neurologic deficit affecting lower limb(s), (3) altered mental status, and (4) multisystem trauma.
• Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral, and mortise views). In the mortise view, the foot is rotated approximately 15° internally, allowing better visualization of the ankle mortise. Check radiograph for headset sign (ie, tibia sits atop the talus resembling a headpiece on a receiver). Normally, the space between the cradle and the handle should be equal. Lack of symmetry suggests injury. Stress views help assess ankle joint stability but usually are deferred during the initial ED evaluation.
• • The ankle joint usually adheres to the ring axiom (eg, a fracture in one part of the ring often is associated with a second injury). Always look for an associated medial malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is seen. A vertical fracture of the medial malleolus is also associated with either a lateral malleolar fracture or rupture of the lateral ligaments.
  • Accessory ossicles appear frequently adjacent to the medial and lateral malleoli and may mimic fractures. Clinical correlation is important. Accessory ossicles demonstrate well-corticated margins, whereas fracture fragments exhibit less-defined borders.
• CT scan and MRI
• • CT and MRI imaging studies may be part of outpatient management where imaging features by the other modalities are equivocal.
  • Advanced imaging is most useful to diagnose talar dome and triplane fractures, distinguish pilon from trimalleolar fractures, and differentiate an accessory ossicle from an avulsion fracture. Occasionally, these tests are used to assess the complexity of the fracture and any associated ligamentous and intra-articular injuries.
• A bone scan rarely is indicated emergently. It may be useful for diagnosing and localizing stress fractures, infections, and neoplastic lesions.

Other Tests

• Stress radiographs assess the ankle during stress testing; however, results of this test generally do not affect immediate ED management.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

• Patients with ankle injuries must be evaluated for further trauma.
• For an isolated ankle injury, confirm neurovascular status of the concerned limb, decrease pain, and prevent further damage. 
• • Cover open fractures with wet sterile gauze.
  • Stabilize the suspected fracture site with a pillow splint, air splint, or bulky Jones dressing before transporting patient. Try to immobilize the ankle in a neutral position if possible but avoid excessive handling. Immobilization helps decrease pain, bleeding, and damage to surrounding soft tissue.
  • Prehospital reduction of a fracture is not advised unless neurovascular compromise is evident (eg, presence of a cool, dusky foot) and a significantly prolonged transport time is anticipated.

Emergency Department Care

• First, patients should be evaluated for multisystem trauma.
• Once additional trauma is excluded, an ankle fracture should be identified as stable or unstable. Unstable fractures include any fracture-dislocation, any bimalleolar or trimalleolar fracture, or any lateral malleolar fracture with significant talar shift.
• If neurovascular status of the extremity is compromised, the fracture should be reduced as soon as possible and reduction should be maintained during the healing period with a cast, external fixator, or open reduction and internal fixation (ORIF). 
• Open fractures should be guarded from further contamination by covering wounds with a wet, sterile dressing secured by loosely wrapped dry sterile gauze. 
• • Confirm a current tetanus immunization, administering tetanus immunoglobulin when patients lack immunity and harbor a grossly contaminated wound.
  • Consider antibiotic prophylaxis, administering cefazolin for mild to moderately contaminated wounds and adding an aminoglycoside for highly contaminated wounds. Administer vancomycin and gentamicin if the patient is allergic to penicillin.
  • Leave fracture blisters intact. Once ruptured, blisters are more likely to become contaminated by skin flora.
• Unless neurovascular compromise exists, reduction is best deferred to the orthopedic consultant when an unstable ankle fracture is diagnosed.
• Closed reduction is accomplished as follows (refer to Dislocation, Ankle for specific techniques):
• • The orthopedic consultant typically reduces ankle fractures. Ankle dislocations are reduced easily, and physicians treating a new fracture should be skilled in their initial management; however, immediate reduction of a dislocation may not be required unless blood flow to the foot is compromised.
  • Provide either local anesthesia with a hematoma block or procedural sedation.
  • Closed reduction is best achieved by manipulating the limb to reverse the direction of the original deforming forces. For example, a fracture-dislocation resulting from abductive stress requires pushing the affected site in an adduct direction to restore. Applying a concurrent distracting force often assists reduction attempts.
• Simple, uncomplicated lateral malleolar fractures usually can be splinted in the ED, followed by arrangement of timely orthopedic follow-up care. Bimalleolar, trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible ORIF.
• Provide analgesics liberally.
• Splinting and casting
• • Ankle splints are commercially available or may be constructed by sandwiching 10-12 layers of plaster between 4 sheets of cotton padding.
  • Posterior splint: Stable injuries can be treated initially with a posterior splint. Ask the patient to lie prone with the knee bent to a 90-degree angle when applying a posterior splint. Extend the splint from the metatarsal heads along the posterior surface of the leg to the level of the fibular head. Maintain the ankle at a 90-degree angle and mold the splint in the malleolar region.
  • Sugar tong/short leg stirrup splint: An alternative to the posterior splint is a sugar tong or short leg stirrup splint. Using 4- or 6-inch plaster, pass the splint under the plantar aspect of the foot, between the calcaneus and metatarsal heads. Secure in place with an elastic wrap.
  • Splinting of a fracture with bulky padding (eg, Jones dressing) is indicated when immobilization and compression are needed but swelling is expected to progress. In very unstable ankle fractures, apply a bivalve cast. A normal cast is bivalved by cutting completely through the casting material on the medial and lateral aspects longitudinally to avoid extremity compression. Next, the bivalved cast is overwrapped with an elastic bandage to stabilize the fracture site, while still allowing for swelling and expansion.

Consultations

• Request orthopedic consultation for the following conditions:
• • Displaced medial, lateral, or posterior malleolar fracture
  • Medial malleolar fracture with lateral ligament damage
  • Lateral malleolar fracture with deltoid ligament damage
  • Fibula fracture at or proximal to the tibiotalar joint line (eg, Danis-Weber classification type C)
  • All bimalleolar fractures
  • All trimalleolar fractures
  • All intra-articular fractures
  • All open fractures
  • All pilon fractures
• Consult a vascular surgeon when vascular flow to the ankle or foot is compromised. In a fracture with vascular compromise, angiography may be necessary.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Provide sufficient analgesia to patients sustaining an ankle fracture. A variety of medications can be used, ranging from oral acetaminophen to parenteral narcotics. For procedural sedation, agents include short-acting sedative-hypnotics and opiate analgesics, usually in combination. In addition, administer tetanus prophylaxis for open fractures.

Drug Category: Narcotic/analgesics

Pain control is essential to quality patient care. Ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Sedating properties of narcotics benefit patients who have sustained fractures.

Drug Category: Anxiolytic/hypnotics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow administration of a smaller analgesic dose to achieve the same effect.

Drug Category: Antidotes

In procedural sedation, a benzodiazepine antagonist may be needed to reverse the sedation and respiratory depression resulting from benzodiazepines and narcotics.

An opioid antagonist also can be used to reverse oversedation in a patient manifesting significant respiratory depression.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the clinical setting.

Drug Category: Toxoids

These agents are used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Drug Category: Immunoglobulins

Administer tetanus immune globulin to patients who may not have been immunized against Clostridium tetani products.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Admission criteria
• • Open fracture
  • Unstable fracture requiring urgent operative stabilization
  • Presence of or potential for neurovascular compromise (eg severely comminuted pilon fracture causing a compartment syndrome)

Further Outpatient Care

• Discharge instructions should include elevation of the affected leg, application of ice, and non-weight bearing on the injured joint.
• Ice packs can be applied to areas of swelling for 10-15 minutes every 3-4 hours while awake for the first 24-48 hours. Ice works through splints.
• Advise patients to refrain from bearing weight on the ankle until seen by orthopedist. Provide crutches and instructions on their proper use. Ensure proper use of the crutches before discharge from the ED.
• All patients with ankle fractures should receive follow-up instructions for consultation with a specialist (eg orthopedist, podiatrist). Many fractures, with the exception of most unimalleolar fractures, will eventually require ORIF.
• Patients with gait disorders or other reasons that caused the ankle fracture must be assessed for a safe discharge to home. The ankle fracture might have a low morbidity, but concomitant inability to attend to activities of daily living due to conditions, such as ataxia or peripheral neuropathy, may warrant mobilization of additional support services or admission.
• Provide written and oral information on cast and/or splint care and ensure that the patient understands which symptoms warrant immediate physician notification and/or return to the ED.
• With increased immobilization, patients are at higher risk for deep vein thrombosis (DVT).

In/Out Patient Meds

• Oral analgesics should be used liberally as long as they do not interfere with other medication or the patient's ability to ambulate. The emergency physician might consider prescribing a narcotic because controversy exists whether NSAIDs impair fracture and ligament healing.

Transfer

• Indications for transferring the patient with an ankle fracture include the patient's or consultant requests for a transfer, inability of the treating facility to sufficiently to treat the ankle fracture (eg, requirement for ORIF in facility without operating room).
• Provide adequate stabilization prior to the transport.
• Discuss the type of immobilization with the accepting physicians. It may be a simple "pillow" type splint or more complex sterile dressing and combination posterior and stirrup splint.
• Be sure to document the neurovascular status of the leg and foot prior to and following the immobilization.

Deterrence/Prevention

• Encourage the patient to undergo rehabilitation to regain strength of the ankle joint.
• Orthotics and proper shoe gear may help prevent future injury.

Complications

• Nonunion of the fracture site requires orthopedic referral for operative repair.
• Malunion of the fracture site occurs more frequently than nonunion and potentially proceeds to degenerative changes of the joint. Chronic persistent symptoms such as pain, weakness, and instability of the ankle may develop. Refer such patients to an orthopedist for evaluation and possible surgical revision.
• Traumatic arthritis complicates 20-40% of ankle fractures. Generally, the more severe the fracture, the greater the likelihood of posttraumatic arthritis; comminuted pilon fractures are most at risk. Older patients have an increased risk of arthritic complications.
• Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle fractures. Clinical features include complex pain, muscle atrophy, cyanosis, and edema. The term Sudeck atrophy is reserved for RSD-like conditions accompanied by a characteristic radiographic appearance (ie, spotty rarefaction), as opposed to the ground-glass appearance seen with disuse atrophy of bone.
• Osteochondral fractures of the talar surface can easily go unrecognized and if left untreated may result in chronic pain, locking, and swelling. If suspected, arrange appropriate orthopedic follow-up care.
• In children, ankle fractures involving the growth plate may cause chronic deformity with disturbance of growth of the limb.

Prognosis

• The prognosis can be improved with prompt, accurate diagnosis and appropriate treatment and referral.
• Complex open fractures with substantial soft-tissue damage have a worse prognosis than isolated closed ankle fractures.
• Isolated, nondisplaced lateral malleolus fracture, the most common ankle fracture, has a favorable prognosis and heals unremarkably.
• Aggressive rehabilitation helps reduce the majority of morbidity associated with ankle fractures.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Ankle Fracture.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to find fractures accounts for 20% of malpractice claims against emergency physicians. Causes include inadequate examinations, acceptance of inadequate films, lack of real-time radiology consultation, failure to promptly treat or consult when evidence of vascular compromise exists, failure to explain limits of initial radiographic interpretation, failure to immobilize and prevent further injury, and failure to arrange follow-up care.
• Subtle fractures (eg, osteochondral lesions) may go undiagnosed because they are unrecognized on initial radiographs. When suspicion for a fracture remains high despite seemingly normal radiographs, splint the extremity, have the patient refrain from weight bearing, and arrange timely orthopedic referral.
• Failure to provide clear and concise aftercare and follow-up instructions to all patients discharged from the ED is dangerous. Give details of splint or cast care and list symptoms that warrant immediate physician notification and/or return to the ED.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Jul 15, 2008