radER vol. 1.5

Case 1.5

A 38-year-old man was playing basketball when he came down from a rebound and twisted his right ankle.  He complains of pain to his right lower extremity and is unable to bear weight on his ankle.  You provide him an ice pack, pain medication, and obtain the following radiographs.

1.  Name 5 areas that should be examined and documented in the medical record?

2.  Describe the radiographic findings?

3.  Describe the treatment and disposition for this patient?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.  Special Comment is provided by Dr. David Schwartz, Associate Professor of Emergency Medicine at NYU/Bellevue Hospital Center and author of two emergency radiology textbooks.

6 Responses

  1. 1.) assess for pulses, sensation, motor, and stability. Four areas: knee, shin, both ankles, and foot

    2.) there is an avulsion fracture of the medial malleolus, and a fracture of the proximal fibula…There also looks to be a non-displaced area of hypolucency at the lateral malleolus as well. Seems like the kinetic energy was transmitted through the syndesmosis and up to the proximal fibula This seems to be consistent with a Massoneive’s fracture. The mortise looks like it is not widened (under 2 mm), but I would like to see stress views because I am still concerned for possible deltoid disruption. Massoneive fractures are concerning to me because of the high amount of energy that is required to produce them.

    3.) I would think about a long leg cast, elevate leg, and wait for reduced swelling with very close follow-up with orthopaedics for evaluation. But because I was given limited physical exam findings in this presentation, I am concerned of the stability of this ankle. Due to this I’d consult orthopaedics. Without neuropraxia, vascular, or ligamentous disruption, then non-surgical, outpatient therapy is probably the disposition for this patient, but I will leave that to ortho consult since we are fortunate enough to have the service.

  2. 1) Medial and lateral malleolus tenderness, tenderness over the proximal tibia and fibula, dorsalis and posterior tibialis pulses, neurological exam.
    2) Proximal fibula, distal tibia fracture – Maisonneuve fracture
    3) Stable fx: cast, early wt bearing, convert to brace when comfortable

  3. 1) Examine for tenderness above and below joint, tenderness around malleoli, check to see if neurovascularly intact, intactness of skin, function of Achilles tendon, and range of motion of ankle. Also check if able to bear weight.
    2) Nondisplaced fracture of lateral malleolus and fracture of proximal fibula
    3) May obtain ortho consult, but should place in posterior mold splint, non-weight bearning, RICE, and follow-up with orthopedics.

  4. Five Areas to Examine and Document:
    Palpate the tibia, the foot, and the Achilles tendon (Thompson test), Ottawa ankle rules also require examination and documentation of the posterior edge of the lateral malleolus/medial malleolus, base of the fifth metatarsal and navicular bone. Palpation of the talocrural joint line for fracture of the talar dome. Finally, palpate the entire fibula (to r/o a syndesmotic injury — a Maisonneuve fracture). It would probably be best to also document sensation, pulses, cap refill and finally if and when the patient was able to tolerate weight bearing.

    The Radiographs:
    1. Fracture of Distal tibia
    2. Avulsion fracture of tibial malleolus (medial malleolus)
    3. Maisonneuve fracture of distal fibula (fibular neck)
    (I wasn’t able to really evaluate the distal fibula on my computer screen – the picture is too small)

    Treatment and Disposition
    Splinting in the department – posterior short leg with coaptation. Because there is a maleolar injury and a syndesmotic injury – this is an unstable fracture due to the medial ankle disruption. If there is a shift of the mortise or medial ligament disruption, referral to orthopedics for open reduction and internal fixation (ORIF) is required.

  5. 1. calcaneus, medial and lateral malleolus, tibial plateau/proximal fibula, femoral neck/acetabulum, lumbar vertabrae
    2. fx proximal fibula, fx medial malleolus, pilon fx of medial side of tibia
    3. closed reduction, orthopaedic consult, long leg splint-ice-elevation, discharge home non-weight bearing, orthopaedic follow-up

  6. 1. Areas to document on phyiscal exam: Note the position, swelling, and skin integrity of the injured ankle. Assess active and passive plantar and dorsiflexion of the injured ankle. Examine the joint above and below the injury. Palpate the inferior and posterior edge of the medial and lateral malleoli, base of fifth metatarsal, calcaneus, talus, medial and lateral collateral ligaments, achilles tendon, and the whole length of the tibia and fibula. Check neurovascular status including the dorsalis pedis and posterior tibial pulses, capillary refill, and sensory and motor function.
    2. Radiographic findings: Avulsion fracture at the tip of the medial malleous, oblique fracture of the shaft of the proximal fibular. Possible avulsion fracture of the distal tibia.
    3. Treatment: Patient has a Maissonneuve Fracture. ED management includes a posterior mold and stirrup splint and remain NWB of the right lower extremity. Emergent orthopedic consultation is not required if the patient is NVI and minimal displacement is present. Patient needs to follow-up in the orthopedic clinic within the next 2-7 days.

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