Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

HPI: The patient is a 61-year-old female patient who presented to the local ED complaining of swelling and pain in her right ankle following a slip-and-fall injury she sustained in her kitchen approximately eight hours earlier. She relates that she has had some mild discomfort but decided that she should come to the ED when she noted the significant swelling and the position of her foot. She is a diabetic with a history of charcot neuroarthropathy and a rockerbottom foot on the contra-lateral extremity.

PMH: Diabetes Mellitus, HTN, Hyperlipidemia, Chronic Renal insufficiency, previous LLE ulcerations, Charcot neuroarthropathy, CVA, TIA

PSH: Left foot debridement, C-section, Flexor tenotomies of the 3 and 5th digits of the right foot

MEDs: ASA, Clonidine, Plavix, furosemide, glipizide, lantus, procardia-xL, Zantac, Crestor, Januvia

ALL: NKDA

PE: Vital signs: BP 180/74, pulse 78, respirations 22, saturation 99% on room air. The patient presents with significant non-pitting edema about the right lower extremity with an excessively externally rotated right foot and a dislocated ankle. During the initial exam and with gentle manipulation of the foot and ankle did spontaneously reduce, although that was not the goal that the time. Pedal pulses are weakly palpable due to swelling and capillary refill was less than 3 seconds, and the vascular status was maintained following ankle reduction. Protective sensation is absent about the bilateral lower extremities, as was proprioception and vibratory sensation. There was significant ecchymosis noted about the medial and laterally malleoli and crepitation noted with ankle range of motion. Muscle strength was not assessed.

Laboratory data: WBC 13.1, Hemoglobin 10.2, hematocrit 31.4, platelets 273.

Radiographs: Plain film radiographs were obtained which demonstrated a comminuted, unstable fracture of the distal fibula with a fracture of the medial malleolus and significant 8mm displacement and angulation of the medial malleolar fragment.

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