Footnote

[mycrofft]

18 year old was showing off for the girls, playing beach volleyball and diamond softball at a picnic. At the end of the day, this athletic young man ℅ right ankle/distal leg pain, with tenderness; gait favoring the right with short stride and touchdown weight bearing only; and developing swelling near the lateral malleolus. Not able to clearly palpate due to swelling and tenderness. No neural deficits, can cautiously dorsiflex and plantar flex ("wave bye-bye") but no lateral flexion done or tolerated.

This really hurts, the swelling continues until the skin is fairly tense, but without ecchymosis.

So, what do you do? What do you think is happening? Does he need a ride home or just some blue ice and ACE wrap?

(PS: a nice web page I just stumbled onto looking this up more closely):

http://www.rheumatologynetwork.com/biomechanics-report/managing-foot-and-ankle-injuries-athletes

 

[Akulahawk]

I have a good idea where I would start, but the swelling would not make it easy to do what I'd want to do.

 

[mycrofft]

And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!

 

[mycrofft]

Let's say I'm trying to elicit some treatment schemes based upon physical findings…and not from professional trainers!

 

[mycrofft]

And I'm thinking about…fracture versus……

 

[mycrofft]

…..one syllable, sounds like…….

 

[mycrofft]

No, not "sedagive"...

 

[Ewok Jerky]

DDx
*high ankle sprain
*compartment syndrome
*fracture

splint and transport in position of comfort, consider pain control (I am liberal when it comes to pain control). this gentleman needs an ortho workup.

 

[mycrofft]

DDx
*high ankle sprain
*compartment syndrome
*fracture

splint and transport in position of comfort, consider pain control (I am liberal when it comes to pain control). this gentleman needs an ortho workup.

Ice is nice, too. No compression?

But, YES. Treatment even with a fine differential in the field is going to be the same. Spend half an hour doing drawer tests and otherwise imitating Kiefer Sutherland on "24" questioning a terrorist, but when it is time to finally take this pt in, he or she will be in a splint in position of comfort (often 90 degrees) and given pain meds. Or even just sandbagged on the litter.

 

[Brandon O]

Ottawa ankle rules findings?

 

[MrJones]

And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!

What'd he tell you? I'm fixin' to cover my first Spartan Race next month.

 

[Akulahawk]

What'd he tell you? I'm fixin' to cover my first Spartan Race next month.

Mostly he got that there's a lot to sports med... hence why it's a minimum 4 year degree.

 

[Handsome Robb]

Beano took my DDx list.

From the sounds of it he sounds as though he's ambulatory on it. That's what I think when I hear "gait favoring the right".

That makes me think more soft tissue injury than orthopedic but he needs an x-ray. Now if his pain were so intense as to require narcotics and render him non-weight bearing if be thinking some sort of fracture. If it doesn't start resolving in a couple of weeks an MRI might be indicated.

If he has a ride I see no problem with him going POV.

RICE, and a ride to the ED or UC (he meets my ATA protocol so I could triage him to an urgent care, provided we don't give narcs. Once we give narcotic analgesia they have to go to the ED) by his choice of transportation.

 

[mycrofft]

Ottawa ankle rules findings?

Yeah! Right on. Now how to they dovetail with people's specific protocols, and versus distance, in individual cases,to the hospitals in urban and suburban settings?

 

[Akulahawk]

And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!

:glare:

Let's say I'm trying to elicit some treatment schemes based upon physical findings…and not from professional trainers!

DDx
*high ankle sprain
*compartment syndrome
*fracture

splint and transport in position of comfort, consider pain control (I am liberal when it comes to pain control). this gentleman needs an ortho workup.

High ankle sprain, distal fibular fx (or avulsion fx) are on my list as well. Compartment syndrome is a worry, but I would want to correlate that with physical findings... Minor, but very irritated anterior talofib ligament sprain is also possible.

Tx would likely include ice, compression via horseshoe pad and ace wrap, and elevate for quite a while. Medication would be primarily for pain reduction vs anti-inflammatory actions.

Ice is nice, too. No compression?

But, YES. Treatment even with a fine differential in the field is going to be the same. Spend half an hour doing drawer tests and otherwise imitating Kiefer Sutherland on "24" questioning a terrorist, but when it is time to finally take this pt in, he or she will be in a splint in position of comfort (often 90 degrees) and given pain meds. Or even just sandbagged on the litter.

Me spend 1/2 hour doing ligament testing? Please... 3 minutes max.

Transport could very well be POV or ambulance, depending upon stability, need of en-route monitoring, or on-going pain control needs.

 

[Brandon O]

Yeah! Right on. Now how to they dovetail with people's specific protocols, and versus distance, in individual cases,to the hospitals in urban and suburban settings?

Let patient know it's probably not broken, see what they want to do.

 

[mycrofft]

Let patient know it's probably not broken, see what they want to do.

Is your boss listening to this?

 

[mycrofft]

:glare:



High ankle sprain, distal fibular fx (or avulsion fx) are on my list as well. Compartment syndrome is a worry, but I would want to correlate that with physical findings... Minor, but very irritated anterior talofib ligament sprain is also possible.

Tx would likely include ice, compression via horseshoe pad and ace wrap, and elevate for quite a while. Medication would be primarily for pain reduction vs anti-inflammatory actions.

Me spend 1/2 hour doing ligament testing? Please... 3 minutes max.

Transport could very well be POV or ambulance, depending upon stability, need of en-route monitoring, or on-going pain control needs.

Naw.

 

[Akulahawk]

Naw.

Well, that would work... for Maryland... transport straight the RA Cowley STC.

 

[Brandon O]

Is your boss listening to this?

Can't fault you for the truth if you give an honest, full, and accurate description of the risks.

The caveat would be that the Ottawa rule was validated in the ED setting, and applying it on scene may or may not be as accurate. Two good reasons might be that you're not as smart as an ED doc, or that "ability to ambulate since the accident" is one of the rule-ins and you're assessing them much earlier, thus less opportunity to walk. Neither of those seem to apply, since you're very smart, and they ruled out anyway. Still, it hasn't technically been validated for EMS use, unless I missed that study.

A somewhat abbreviated description of all this would be a part of informed consent...