CC: I fell off my skateboard a few hours ago and my left leg hurts.

HPI:

20 y/o M w no PMHx, presents to the ED s/p fall x 2 hours. Pt states he was skateboarding on the street  around 12 pm today when he lost control and fell on his but twisting his L ankle. He states a man that was driving by helped him up and dropped him to the ED. He states he able to bear weight on the R leg but is having trouble bearing weight on the L leg due to pain. Pt states pain is only localized to the left ankle, is a throbbing pain, 6/10 in intensity, radiates from his ankle down the left foot, is worse with movement and weight bearing, but better with resting his leg. Pt states “I also have two cuts on the left leg, one on the knee and the other somewhere on the foot but I can’t see how bad they are”. He denies any head trauma, LOC, dizziness (before and after the incident), CP, SOB, fevers, chills, N/V, H/A, visual disturbances.

Differential Diagnosis

Ankle sprain + laceration

Ankle fracture + laceration

Contusion + laceration

Torn ligament + laceration

Injury to Achilles tendon +laceration

Fracture of other bone ( tarsals, metatarsals, etc. )

PMH

None

Past surgical hx

None

Past hospitalizations

None

Medication

None

Allergies

None

Immunization:

Up to date with tetanus shot received last year 2018.

Family history

noncontributory

Social History

Student at university

Does not smoke cigarettes, drink alcohol or use drugs.

Physical Exam

General:

Pt is AOx3, looks stated age, well-nourished, in NAD.

Pt is sitting in wheelchair with leg wrapped up in gauze. Blood noted dripping from left leg.

Vitals

Vitals BP: 120/78, HR: 82, T: 98.3F oral R: 18 Sp02: 98%

Skin: normal in color and warm to touch upper and

lower extremities mild abrasion on L knee, 3 cm laceration noted on dorsal aspect of the L foot. Mild swelling and erythema noted around the later malleolus.

Nails : cap refill<2 sec throughout

Eyes: PERRLA, EOMs full, no nystagmus

Ears: no evidence of lesions/masses/trauma on external ears, no discharge/foreign bodies in external auditory canals AU, TM’s pearly white/intact with light reflex in normal position AU

Neck: FROM, non-tender to palpation

Heart: S1, S2, no murmurs or extra heart sounds on auscultation, no JVD, no carotid bruits.

Lungs: CTA,  normal breath sounds throughout all lung fields, no rhonchi, crackle, or rales.

Abdominal: BS present in all 4 quadrants, Non-tender to soft/deep palpation.

Neuro: A&O x3, no focal neuro deficit, normal strength, no nystagmus, no facial droop, no abnormal speech, Rapid alternating movements and fine finger movements are intact, no lack of coordination of movement on finger-to-nose, Romberg no assessed due to pain, sensation is intact throughout.

Peripheral Vascular:

No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No cyanosis, clubbing/edema noted bilaterally

Extremities:
Upper: pulses 2+ B/L, normal muscle strength, reflexes intact

Lower: B/L DP pulses palpated, normal muscle strength B/L, reflexes intact

Right leg FROM, no pain

Left leg FROM with moderate pain on eversion of the foot. Pain on palpation in L midfoot, and pain in left lateral malleolus. Unable to bear weight on L foot with ambulation.

X-ray – shows fracture of the lateral malleolus.

Assessment:

20 y/o M w no PMHx, presents to the ED with ankle pain s/p fall x 2 hours. Physical exam finds a 3 cm laceration on the left dorsal aspect of the foot requiring a laceration repair. PE findings and x-rays are both consistent with the diagnosis of an ankle fracture (lateral process of the talus)

Plan

Administer Motrin for pain

Perform Laceration repair

Immobilize joint (Posterior Splint)

Provide crutches

Outpatient referral for orthopedics

Patient information:

• Your X-rays show that you have an ankle fracture.
• Initial management of ankle fractures consists of splinting and rest, ice, analgesia, and elevation
• We have applied a splint to immobilize the ankle.
• You are being discharged.
• You can apply ice, elevate you leg above the level of the heart, and use analgesics for pain relief.
• You will need to F/U with orthopedics within one week to be evaluated further.