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This
week’s Residency Insight is a challenging case study presentation which was
submitted by Fausto Ramos at the Bon Secours Residency Program in New Jersey.
HPI
57 year old male
presented to the ER with a painful, edematous R ankle with recent worsening
symptoms. The patient walked into the ER using crutches and stated that 4
weeks ago he twisted his R ankle on an uneven sidewalk. At the time of the
injury, he went to a local hospital, and was was admitted with a diagnosis
of cellulitis. Treatment then included 7 weeks of IV antibiotics, crutches,
and NWB. The patient
denies F/C/N/V/SOB.
PMH:
DM
PSH:
denies
Medications:
Glucophage, Glucotrol
Allergies:
NKDA
Social Hx:
neg ETOH, neg tobacco, neg IVDA.
Family Hx:
CAD (grandmother), Asthma (Mother), COPD (Father)
Physical Exam
Vascular: palpable
pulses on DP and PT. CFT 1 sec x 10. + edema, + erythema surrounding entire
R ankle and foot.
Neurological:
vibratory, protective sensations diminished b/l.
Dermatological: No
break in skin. Some ecchymosis and hyperpigmented lesions noted R foot and
ankle.
Orthopedic: Pain on
palpation of R medial and lateral malleoli. Pain on palpation of ATFL.
Pain with active/passive R ankle ROM which is limited due to guarding. Pain
on palpation over metatarsal shafts 1-3 R foot. R ankle appears grossly
dislocated.
Musculoskeletal: muscle
power decreased on the R ankle and foot due to guarding and pain.
X-Rays
Diagnosis: Ankle fracture
with dislocation. 1st metatarsal base displaced fracture.
Treatment: Due
to the chronic nature of the deformity, a closed reduction was not attempted.
The patient was admitted and an ankle fusion was attempted as well an ORIF of
the metatarsal base with bone graft, CC fusion and STJ fusion.
POST-OP X-RAYS
The approach taken here is quite aggressive
and somewhat controversial. Please email me at
jsteinberg@podiatry.com
with your comments / critiques / thoughts
about this case. An interesting surprise occurred after this surgery was
performed. Next week we will present that surprise, the final result and
also publish some of your feedback.
If you have
something you would like to suggest for a topic for a future Residency Insight, please email it to me
at
jsteinberg@podiatry.com
John S. Steinberg, DPM
Editor, PRESENT Send in YOUR most
interesting clinical case for others to learn from.
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