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Curb drop off
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Curb drop off - April 4, 2005 9:16:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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25 year old male was walking with a friend and did not see the traffic curb drop (about 8 inch drop). Without knowing he stepped forward and stumbled. He is unsure how he landed but he felt a pop in his right ankle and had a large swelling within 15 minutes. He was unable to put full weight on the right foot but with assistance he was able to place partial weight on the ankle and made it to the hospital.
What are the findings?
(all images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle4.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle5.jpg[/IMG]
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Alex Brenner, PT, MPT, OCS
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Re: Curb drop off - April 5, 2005 5:46:00 AM
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ehanso
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I'm not quite sure but I am a bit suspicious of a Lateral malleolar fracture. In the first film there appears to be a small fragment medially.
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Re: Curb drop off - April 5, 2005 6:41:00 AM
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jma
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I agree as well. Small medially displaced fracture of the distal fibula with swelling noted on the first view
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Re: Curb drop off - April 5, 2005 6:58:00 AM
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Jon Newman
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I'm looking at these pictures on a lap top computer today and the images look poor. I'm not sure if they are of the usual good quality and this screen isn't doing justice or if these pics are bit hard to see. I can't see any fractures.
The fact that they can bear at least some weight is somewhat positive. Is there bone tenderness upon palpation?
jon
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Re: Curb drop off - April 5, 2005 5:46:00 PM
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Synergy
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I see a small (hairline?), non-displaced fx of the distal lateral tibia.
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Chris Adams, PT, MPT
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Re: Curb drop off - April 6, 2005 3:50:00 AM
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JLS_PT_OCS
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Jon-
I think they already met Ottawa criteria, hence the pictures.
I'm not sure what to make of the lateral malleolus, I see what people mean re: fracture, but that density looks rounded to me, and therefore not likely a fracture.
The medial clear space looks widened, and though this isn't a stress film, I wonder about a syndesmosis injury. That would certainly explain the pop and the edema.
Don't know exactly what to make of the lateral malleolus there, but certainly doesn't look like the textbook Weber As I remember.
But maybe I should open up my book again... :)
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Curb drop off - April 10, 2005 4:48:00 PM
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jma
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Okay, what is the clincal and radiologic diagnosis?
JMA
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Re: Curb drop off - April 10, 2005 8:03:00 PM
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Alex Brenner PT MPT OCS
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The patient clinically appeared to have a grade III lateral ankle sprain. Since he was unable to place full weight on the ankle and due to the point tenderness over the lateral malleolus he was sent for x-rays (Ottawa Ankle Rules). The radilogy report could not rule out a large avulsion fracture versus an accessory ossicle. To me it appeared to be an accessory ossicle, however, due to the point tenderness over this area and the apparent size of the ossicle he was sent to orthopaedics. Ortho decided to leave it alone. The patient was sent back to physical therapy where we treated it as a normal lateral ankle sprain. The patient recovered about 2 months later and resumed normal activity.
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle7.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle6.jpg[/IMG]
Can anyone describe the Ottawa Ankle rules and list them without looking it up?
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Alex Brenner, PT, MPT, OCS
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Re: Curb drop off - April 11, 2005 3:57:00 AM
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Jon Newman
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Hi Alex,
I think there are 3 criteria. I seem to remember 2 of them being
1. Inability to bear weight on the LE immediately and at the ER or where ever they are receiving a possible x-ray.
2. Bony tenderness to the distal 1/3 of the fibula or along the lateral aspect of the foot distal to the body of the talus.
I don't remember the 3rd. There was no specification of the tenderness in your opening and the patient was able to bear some weight (with assistance) at the ER. But then again maybe I've got my rules screwed up.
jon
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Re: Curb drop off - April 11, 2005 9:50:00 AM
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JLS_PT_OCS
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Ottawa Ankle Rules:
Ankle Films IF:
Bone tenderness in the malleolar area AND:
1. Tenderness at lateral malleolus OR
2. Tenderness at medial malleolus
3. Inability to bear weight both immediately after and in the treatment area
Foot Films IF:
Pain near midfoot AND
1. TTP Navicular OR
2. TTP 5th metatarsal
3. Inability to bear weight.
You only need 2/3 to meet the criteria. So if this guy was tender at the lateral malleolus and couldn't bear weight, he met the criteria.
I remember it this way, ankle or foot:
1. Inability to bear weight (both)
2. For ankle - medial or lateral malleolar TTP
3. For foot - navicular or 5th Met TTP
It's important to remember you don't have to be tender both places to meet the criteria.
I forget things all the time (ask my wife), but this is the way I have to organize it in my walnut-sized brain to keep it there.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Curb drop off - April 11, 2005 8:48:00 PM
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Alex Brenner PT MPT OCS
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Very nice.
I have the Ottawa rules taped on my wall next to my computer monitor because I have a tough time remembering things too. :)
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Alex Brenner, PT, MPT, OCS
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Re: Curb drop off - April 20, 2005 12:01:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Ottowa Ankle Rules:
Malleolar Zone:
-Bone tenderness at posterior edge of distal 6cm or tip of medial or lateral melloelus and/or
-Unable both to weight bear on involved side immediatly after injury AND unable to walk 4 steps at time of visit.
Midfoot Zone:
-Bone tenderness at base of 5th metatarsal
-Bone tenderness at navicular and/or
-Unable both to weight bear on involved side immediatly after injury AND unable to walk 4 steps at time of visit.
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Alex Brenner, PT, MPT, OCS
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Re: Curb drop off - April 20, 2005 12:29:00 PM
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steve
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Alex,
not having looked this up, isnt there an age criteria of 18 to 50 or 55?
Steve
BTW - good topic, there are some great rules around to help guide assessment, including the Canadian C-spine rules, Ottawa knee rules, CPR for assessment... Anyone know of others that would be beneficial from an orthopaedic perspective?
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Re: Curb drop off - April 20, 2005 10:27:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Steve,
I will have to pull the article. I am not sure about the age criteria off the top of my head; I will try to get back to you.
Have you read the latest CPR study for carpal tunnel syndrome?
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Alex Brenner, PT, MPT, OCS
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Re: Curb drop off - April 21, 2005 9:46:00 AM
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steve
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From: Canada
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Alex,
I downloaded the article from the evidenceinmotion listserv but havent had a chance to read it yet - part of the big stack beside my desk. Looks interesting though.
Steve
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Re: Curb drop off - April 23, 2005 11:02:00 AM
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tim
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From: Portland, OR
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Anyone over 55..... according to the Ottawa rules and lots of other sources...
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