Leg pain (Full Version)

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Alex Brenner PT MPT OCS -> Leg pain (January 30, 2005 7:53:00 PM)

24 year old male was jumping down off his ladder. He felt a pop and pain in his lower leg. He was released from his ER and was told he had an ankle sprain. He comes to your clinic with leg and ankle pain. The ER only conducted one view of his leg, nothing of his ankle other than what was captured with this view.

What are the findings?

(all images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/leg1.jpg[/IMG]



pablo w -> Re: Leg pain (January 31, 2005 12:20:00 AM)

Fractured distal fibula, two fingers width from the tip of the lateral malleolus on my screen. the film looks normal otherwise, but with this one view it is hard to say what the ankle looks like. Pretty hard to miss. Did he only have this one film?



SJBird55 -> Re: Leg pain (January 31, 2005 1:18:00 AM)

I see the same thing that pablo does. I can't tell from one view how much it may or may not be displaced. Technically he needs more films. The mortise needs to be assessed too.



ehanso -> Re: Leg pain (January 31, 2005 2:49:00 AM)

I agree with pablo and SJ.



Dr.Wagner -> Re: Leg pain (January 31, 2005 4:59:00 AM)

One view? One view is no view...you can't even get reimbursed for reading a single ankle film...it is 3 or nothing. So in this case...it is a potential LAWSUIT. One, if it is true that only one view was taken then they did not meet the standard of care for radiographic diagnosis. Two, Missed fractures with inappropriate treatment is the NUMBER 1 most frequent reason for litigation in Emergency Medicine.


The patient needs 3 views of the ankle and better tib-fib views before an accurate diagnosis can be made...DON'T BE TEMPTED INTO MAKING A READING ON A SINGLE FILM!

Sorry, just thought I would add that bit of standard of care discussion.



Alex Brenner PT MPT OCS -> Re: Leg pain (January 31, 2005 5:19:00 AM)

Dr. Wagner, You are correct and I agree with you on all counts. To make the case a little more challenging I am only offering one view.



Jeep -> Re: Leg pain (January 31, 2005 6:32:00 AM)

Army-
you said:The ER only conducted one view of his leg, nothing of his ankle other than what was captured with this view.<<<

Now from your last post that is not the case?

I also had the same concerns of standard of care of this ER. If this was the only film taken, it is beyond substandard. I would classify it as negligent. This is BASIC stuff!!



Alex Brenner PT MPT OCS -> Re: Leg pain (January 31, 2005 9:08:00 AM)

Jeep,
If you read the objectives from the main page in the this forum you will notice that I put a disclaimer saying that the patient history's have been altered for patient privacy. This is word for word from my objectives "In some instances a certain view of the film or part of the patient history will be omitted to make the case more challenging."

I have tried to keep the fabricated history's very close to the actualy mechanism of injury. This patient was not seen in the ER and there were more than one view taken. If you all want the second view, I will post it even though it makes the fracture line blatently more obvious. The intent of this case was not to make fun of the incompetent ER although had this been the real history you all would be correct.



Jeep -> Re: Leg pain (January 31, 2005 9:55:00 AM)

Thanks for the clarification Army-
I feel better now!!

My findings on this film would be distal fibula frx



chiroortho -> Re: Leg pain (January 31, 2005 10:05:00 AM)

We're starting to get a little uptight here...we know it's a fx, so it's kind of fun waiting for the next film.

We know that Army wouldn't put up with one film, even if the ED only ordered one initially, and the chances of that happening have to be close to zero percent.



Synergy -> Re: Leg pain (January 31, 2005 3:15:00 PM)

Pablo, do you always have to post first and nail it every time? Just joking! :) I agree...distal fib fx. However, I need some more da*n views for crying out loud...oh wait...just read the disclaimer. :) Keep up the good work Army and realize that we all appreciate you posting films. I've found it very helpful!



FLAOrthoPT -> Re: Leg pain (January 31, 2005 3:48:00 PM)

yup

ben



pablo w -> Re: Leg pain (January 31, 2005 4:07:00 PM)

Sorry chris, it's the time difference Down Under I seem to check the board at the right times!



Synergy -> Re: Leg pain (January 31, 2005 5:39:00 PM)

I just wanted to have a good laugh Pablo! You're always right on target and I applaud you. :)



Alex Brenner PT MPT OCS -> Re: Leg pain (February 1, 2005 6:40:00 PM)

OK, I will take the hit on this one. Not a very exciting case.

Non displaced fracture of the distal fibula.

Good job Pablo, SJ, Falls, Jeep, Chris and Florida for correctly identifying the fracture. Good job Dr. Wagner and Jeep for busting the chops on my fabricated emergency room. Somebody needs to square them away! :)

[IMG]http://img.photobucket.com/albums/v85/brennerak/leg2.jpg[/IMG]



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