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Case of the week Sept 4
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Case of the week Sept 4 - September 4, 2007 12:16:35 PM
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Dr.Wagner
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18 year old female falls from a horse. Upon standing she complains of foot and ankle pain and swelling. It is painful to walk, but she is able to limp somewhat. She presents to you after having "negative xrays" at the Med Check facility in her rural community.
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RE: Case of the week Sept 4 - September 4, 2007 12:41:35 PM
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JCOY
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Some fractures cannot be visualized(x-ray) immediately,------they become "visible" on x-ray only after callus formation begins(1-3 wks). So- with that in mind- fracture can not be ruled out, and to treat it "as if a fracture" would be prudent, IMO, for the time being, and follow-up with another image study in 1-2 weeks.
< Message edited by JCOY -- September 4, 2007 1:01:09 PM >
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RE: Case of the week Sept 4 - September 4, 2007 3:19:28 PM
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FLAOrthoPT
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what about hip and back What about putting weight through the joint in non weight bearing, that is sending a longitudinal force through the foot while supine, what views were the X-rays? Did they rule outtalar dome fracture in the plantar flexed view? I'd say if no real symptoms other than pain with gait, I'd splint, give some crutches for NWB for 2 weeks, and re-assess, maybe a bone scan or CT scan later if still hurts with wb.
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RE: Case of the week Sept 4 - September 4, 2007 9:08:11 PM
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jma
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The x-rays were negative for fractures? Besides the swelling, was there ecchimosis as well. How much weight could the female put on the affected foot? Has she been given an assistive device to walk on or an ankle air brace?
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RE: Case of the week Sept 4 - September 5, 2007 12:49:51 AM
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bonez
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A little further info would be helpful. Where is the pain /where is the swelling. Were the only areas shot localized to the foot/ ankle? What happens on regional palpation? Is compression of the calf over the fibula sore? What is the status of distal pulses?
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RE: Case of the week Sept 4 - September 5, 2007 7:11:29 AM
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Sebastian Asselbergs
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How does she fall? With the foot stuck in stirrup? Or did she land on her foot?
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RE: Case of the week Sept 4 - September 5, 2007 7:18:49 AM
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SJBird55
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So... Wags, was she wearing a helmet? ;) Was the horse standing, walking, trotting, galluping? Was she using a saddle? What kind of saddle? What did the horse do when she was no longer on it's back? If she wasn't wearing a helmet, did you yap at her about how she's lucky she didn't damage her brain? Did the horse step on her? Sorry... I'm all into mechanism of injury. :) I won't be able to focus until I can "see" what happened. And.. hey... was she wearing riding boots? What kind?
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RE: Case of the week Sept 4 - September 5, 2007 10:30:45 AM
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Dr.Wagner
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Q:what about hip and back What about putting weight through the joint in non weight bearing, that is sending a longitudinal force through the foot while supine, what views were the X-rays? Did they rule outtalar dome fracture in the plantar flexed view?
A: Putting weight through the joint causes significant pain, which you were apprehensive to do anyway due to some significant swelling you are noting on exam. The xrays were standard views of the foot.
Q:The x-rays were negative for fractures? Besides the swelling, was there ecchimosis as well. How much weight could the female put on the affected foot?
A: At the Med Check facility (doc in a box)they were read as "negative". Yes, you begin to notice mild bruising. The patient cannot bear weight.
Q: How does she fall? With the foot stuck in stirrup? Or did she land on her foot?
A: The patient is unsure.
Q:Wags, was she wearing a helmet? ;) Was the horse standing, walking, trotting, galluping? Was she using a saddle? What kind of saddle? What did the horse do when she was no longer on it's back? If she wasn't wearing a helmet, did you yap at her about how she's lucky she didn't damage her brain? Did the horse step on her? Sorry... I'm all into mechanism of injury. :) I won't be able to focus until I can "see" what happened. And.. hey... was she wearing riding boots? What kind?
A: She was wearing a football helmet and carrying a trident. She had leather gucci boots from a sale at Saks and the saddle was made of fishhooks (which may have been why the horse disliked her so much). I discussed proper apparel with her, clearly the trident was too much.
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RE: Case of the week Sept 4 - September 5, 2007 10:54:36 AM
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SJBird55
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Now, some of my questions ARE serious questions... was she wearing riding boots? LOL Riding boots have a heel on them and depending on the boot go up at least mid-calf. They would provide support. Hmmm, quite the image... wearing a football helmet and carrying a trident. LOL Did she spear her foot? LOL
I'm not sure how you "fall off a horse" unless riding bareback.
Without observing or palpating, so just based on your description... she seems to fit the Ottawa ankle rules which is a 100% sensitive. I would believe she does have a fracture somewhere and that the "doc in the box" person must have missed it.
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RE: Case of the week Sept 4 - September 5, 2007 12:25:17 PM
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Sebastian Asselbergs
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You mention "significant swelling". Where exactly IS that swelling? Base of Vth MT, lateral or medial joint line, tarsus? Definitely sounds like #.
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RE: Case of the week Sept 4 - September 5, 2007 2:03:46 PM
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Dr.Wagner
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A: Don't focus on why she fell, in this case it isn't important. Lets say she fell off due to inexperience and bad luck.
A: Her swelling covers the dorsum of the foot.
The patient states "hey I brought my xrays, I like to carry them with me...would you care to see them?"
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Dr. Wagner DO
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RE: Case of the week Sept 4 - September 5, 2007 2:42:32 PM
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bonez
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Did she say that the horse stepped on her foot? Could we have diastasis of the mid foot that would swell but appear un fractured?
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RE: Case of the week Sept 4 - September 5, 2007 3:47:19 PM
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orthotherapist
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Lets do the obvious and take a look at the Xrays that she brought in for us
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RE: Case of the week Sept 4 - September 5, 2007 9:56:25 PM
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jma
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I agree. I would definitely like to look at what the x-rays look like.
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RE: Case of the week Sept 4 - September 6, 2007 12:33:26 AM
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Dr.Wagner
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1
 Attachment (1)
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Dr. Wagner DO
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RE: Case of the week Sept 4 - September 6, 2007 1:10:37 AM
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bonez
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Me thinks that diastasis of the mid foot might be seen on the ap view. The lateral shift of the mid foot starts at the lateral edge of the proximal first metatarsal and continues to shift the fore foot laterally so that the fifth metatarsal no longer articulates completely over the cuboid. A weightbearing ap view would confirm the spread nicely. The talus would also look better if it was truly under the tibia on the lateral view as well.
Interesting that an 18 year old already has calcification of the achilles insertion. I won't have expected this finding at that age. There is very little remnants of the secondary centers of osssification as well.
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RE: Case of the week Sept 4 - September 6, 2007 10:13:16 AM
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jma
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Ouch! It looks like the talus might either be fractured or no longer articulated with the calcaneous and far away from the navicular. At least by looking at the lateral view from the foot. Lot of swelling going on there too.
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RE: Case of the week Sept 4 - September 6, 2007 7:51:21 PM
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SJBird55
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Chuck Norris??? Chuck Norris??? Wags! Can't you do better than Chuck Norris??? I must be missing something. LOL You do realize that your physical features are more appealing than Chuck Norris!
I can't focus on the radiographs. Honestly, I can't see details when they are small. All I can see is that there is quite a bit of edema. I get a headache looking at them at that size and with those areas of brightness.
Could you please change your thingy... there has to be something more suitable for you. Really...
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