Step in hole (Full Version)

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Alex Brenner PT MPT OCS -> Step in hole (May 5, 2005 5:08:00 AM)

27 year old male was walking across an open field when he stepped into a hole and fell forward. When he fell foward his foot would not release from the hole and he forcefully inverted his foot and ankle. He had immediate pain and swelling over the global ankle and dorsum of foot. He met the Ottowa ankle rules and radiographs of the foot and ankle were obtained. What are the findings?

(All images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle003.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle004.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/foot001.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/foot002.jpg[/IMG]



Shill -> Re: Step in hole (May 5, 2005 5:51:00 AM)

Avulsion fx of base of 5th metatarsal. Ive done this twice. Same foot. In my understanding, this is NOT a "Jones" fx, as it does not extend into the 4th MT. Those are much worse, in terms of ability to heal.



jbeneciuk -> Re: Step in hole (May 6, 2005 6:42:00 PM)

Avulsion fx of lateral malleolus ??



jbeneciuk -> Re: Step in hole (May 6, 2005 6:46:00 PM)

Avulsion fx of lateral malleolus ??



jma -> Re: Step in hole (May 7, 2005 5:23:00 AM)

There seems to be a nondisplaced avulsion fx at the lateral base of the 5th metatarsal.Swelling noted on dorsum of foot.



chiroortho -> Re: Step in hole (May 7, 2005 8:15:00 AM)

Only thing I see is the 5th MT nondisplaced avulsion. Lat malleolus looks completely normal to me.

Another great thread Alex.



SJBird55 -> Re: Step in hole (May 7, 2005 4:17:00 PM)

How deep was the hole? I'm caught up on the image in my head dealing with the mechanism of injury.... if I can understand that a little better, I might be able to focus my attention on the radiographs.



Alex Brenner PT MPT OCS -> Re: Step in hole (May 7, 2005 9:38:00 PM)

SJ. I am not too sure but it was deep enough that his entire foot and ankle went into the hole.



jma -> Re: Step in hole (May 8, 2005 5:13:00 AM)

Did we miss anything else? Hard to see the dorum of the foot clearly with the swelling



SJBird55 -> Re: Step in hole (May 8, 2005 7:10:00 AM)

Hmmm, more stupid questions... but could you clarify the images for me? What position is the person in for the first image and which foot?
Then, the 4th image... what position and is it the left foot? And if the last image is for comparison... which of the images would be used for comparison?



jma -> Re: Step in hole (May 8, 2005 1:09:00 PM)

I think the first view is an oblique or mortice-view (internally rotated view)



connie.pt -> Re: Step in hole (May 8, 2005 1:42:00 PM)

I agree with the avulsion fx of the 5th met, and add that there is most likely a complete tear of the anterior talo-fibular ligaments as the position of the ankle would indicate.

Connie A.



Alex Brenner PT MPT OCS -> Re: Step in hole (May 9, 2005 4:35:00 AM)

SJ,
The radiographs are both of the right foot and ankle although I know that the ankle series was labeled left. The ankle series is your standard AP, lateral, and an oblique view. The foot radiographs are AP of the foot and an oblique (foot in eversion).



SJBird55 -> Re: Step in hole (May 9, 2005 6:47:00 AM)

How about if I have my hand held and I get walked through this...

So, radiograph #1 = right ankle oblique view? (I couldn't for the life of me figure out how it could be the left and how it got positioned.)

Radiograph #2 = left ankle AP view?

Radiograph #3 = left ankle lateral view?

Radiograph #4 = right foot oblique view?

Radiograph #5 = right foot AP view?

So, were the radiographs labeled correctly? I mean the second one does look like a left to me. I would have no idea on the third. I'm having mental difficulties because if the left is the involved body part, then well, how come the right is mixed in? Are you being tricky, or am I just stupid? LOL



JLS_PT_OCS -> Re: Step in hole (May 9, 2005 7:51:00 AM)

#1 The Oblique view, suboptimal, as you cannot get a good view of the talus/mortise
#2 The AP view, is suboptimal for the same reason.
#3 The lateral view
#4 Oblique foot
#5 Foot

I'm not sure I'm sold on the avulsion of the 5th met.
I would call these "poor radiographs" and if there was trauma, ask for additional films and bring it to the attention of the quality control people in Radiology. Especially since it seems to be sided incorrectly.
If we can't see the mortise, we can't make a good call.
So after that cop-out :) I will call this a within normal study.

But I have to say that my clinical experience leads me to believe that the "stepping in a hole" etiology is a bad actor, and is frequently the cause of some nasty injuries.
J



SJBird55 -> Re: Step in hole (May 9, 2005 11:15:00 AM)

LOL Jason.

If the left was the injured extremity and all the views aren't of the left extremity, well, I'm not sure how a decision is made. OR... did someone in radiology screw up and mix up different patient radiographs? Or did someone in radiology get left and right confused? (I do that quite frequently.)



jma -> Re: Step in hole (May 9, 2005 2:44:00 PM)

Hmmn, he has a point. Explanation for this?



FLAOrthoPT -> Re: Step in hole (May 9, 2005 3:55:00 PM)

I have a thing about treating people with 2nd toes larger than first, so I would not see this person, and refer them next door



FLAOrthoPT -> Re: Step in hole (May 9, 2005 3:55:00 PM)

not really but it would sure be a funny scenario



JLS_PT_OCS -> Re: Step in hole (May 11, 2005 3:55:00 AM)

That's what I'm getting at, SJ.
Either the wrong side marker was placed on the films, or this is the wrong side or wrong patient.

I think Alex has assured us above this is the correct side and patient.
But this kind of mistake is why radiology has quality control people in the first place.

I still see what seems to be a within normal suboptimal study.
J



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