Case Study:
A 14-year-old male is out in triage with an ankle injury. The nurse calls back to see if you want to send him di¬rectly to radiology. You decide to examine the patient first. On the way out to triage, you ask yourself some ques¬tions about ankle injuries in the pediatric patient. Do the Ottawa ankle rules apply? Are adolescents more likely to get a sprain or a fracture? Are there any differences in the fracture patterns seen in younger children, adolescents, and adults?
When you arrive in triage, you see a football player still in pads, with his ankle elevated. The patient tells you he was just standing when someone playfully pushed him down from the side. He reports no previous ankle injuries and has been unable to bear weight since the accident. You notice he has a large amount of swelling about the ankle, but his pulses and sensation are intact. His pain is diffuse around the ankle, but it appears most intense over the distal anterior tibia. You decide to provide him with some narcotic analgesia and send him to radiology.
Case Study Conclusion:
Your 14-year-old football player has made it back from radiology and is awaiting your interpretation of his films. He has an SH IV triplane fracture of the distal tibia with minimal displacement. You recall that this is one of the few instances where more advanced radiology is helpful in ankle injuries, so you send him back to radiology for a CT of the distal tibia and ankle. Fortunately, CT does not reveal any displacement or fragmentation, as can occur with these fractures. After orthopedic consultation, the patient is admitted to the hospital with a bulky posterior splint and no weight-bearing until definitive surgical repair can take place in the morning. You wish the family luck since the triplane fracture carries quite a bit of risk for growth dysfunction no matter what is done due to significant damage to the growth plate.
Risk Management Pitfall:
“My patient has anterior ankle pain but I don’t see any evidence of a fracture on her x-rays.” Always look closely at the mortise views to best see the distal tibia, and pay close attention to make sure spacing around the mortise is equal.
Ottawa Ankle Rules:
The Ottowa Ankle Rules state radiographs are only required when there is an ankle/midfoot injury with:
• Bony tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
• Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
• Bone tenderness at the base of the fifth metatarsal (for foot injuries)
• Bone tenderness at the navicular bone (for foot injuries)
• An inability to bear weight both immediately and in the emergency department for 4 steps
Posted by empracticenews 