# Footnote



## mycrofft (Mar 24, 2014)

18 year old was showing off for the girls, playing beach volleyball and diamond softball at a picnic. At the end of the day, this athletic young man ℅ right ankle/distal leg pain, with tenderness; gait favoring the right with short stride and touchdown weight bearing only; and developing swelling near the lateral malleolus. Not able to clearly palpate due to swelling and tenderness. No neural deficits, can cautiously dorsiflex and plantar flex ("wave bye-bye") but no lateral flexion done or tolerated.

This really hurts, the swelling continues until the skin is fairly tense, but without ecchymosis.

So, what do you do? What do you think is happening? Does he need a ride home or just some blue ice and ACE wrap?

(PS: a nice web page I just stumbled onto looking this up more closely):

http://www.rheumatologynetwork.com/biomechanics-report/managing-foot-and-ankle-injuries-athletes


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## Akulahawk (Mar 24, 2014)

I have a good idea where I would start, but the swelling would not make it easy to do what I'd want to do.


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## mycrofft (Mar 24, 2014)

And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!


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## mycrofft (Mar 24, 2014)

Let's say I'm trying to elicit some treatment schemes based upon physical findings…and not from professional trainers!


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## mycrofft (Mar 24, 2014)

And I'm thinking about…fracture versus……


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## mycrofft (Mar 24, 2014)

…..one syllable, sounds like…….


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## mycrofft (Mar 24, 2014)

No, not "sedagive"...


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## Ewok Jerky (Mar 24, 2014)

DDx
*high ankle sprain 
*compartment syndrome
*fracture

splint and transport in position of comfort, consider pain control (I am liberal when it comes to pain control).  this gentleman needs an ortho workup.


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## mycrofft (Mar 24, 2014)

beano said:


> DDx
> *high ankle sprain
> *compartment syndrome
> *fracture
> ...



Ice is nice, too. No compression?

But, YES. Treatment even with a fine differential in the field is going to be the same. Spend half an hour doing drawer tests and otherwise imitating Kiefer Sutherland on "24" questioning a terrorist, but when it is time to finally take this pt in, he or she will be in a splint in position of comfort (often 90 degrees) and given pain meds. Or even just sandbagged on the litter.


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## Brandon O (Mar 24, 2014)

Ottawa ankle rules findings?


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## MrJones (Mar 24, 2014)

mycrofft said:


> And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!



What'd he tell you? I'm fixin' to cover my first Spartan Race next month.


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## Akulahawk (Mar 24, 2014)

MrJones said:


> What'd he tell you? I'm fixin' to cover my first Spartan Race next month.


Mostly he got that there's a lot to sports med... hence why it's a minimum 4 year degree.


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## Handsome Robb (Mar 24, 2014)

Beano took my DDx list.

From the sounds of it he sounds as though he's ambulatory on it. That's what I think when I hear "gait favoring the right".

That makes me think more soft tissue injury than orthopedic but he needs an x-ray. Now if his pain were so intense as to require narcotics and render him non-weight bearing if be thinking some sort of fracture. If it doesn't start resolving in a couple of weeks an MRI might be indicated. 

If he has a ride I see no problem with him going POV. 

RICE, and a ride to the ED or UC (he meets my ATA protocol so I could triage him to an urgent care, provided we don't give narcs. Once we give narcotic analgesia they have to go to the ED) by his choice of transportation.


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## mycrofft (Mar 24, 2014)

Brandon O said:


> Ottawa ankle rules findings?



Yeah! Right on. Now how to they dovetail with people's specific protocols, and versus distance, in individual cases,to the hospitals in urban and suburban settings?


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## Akulahawk (Mar 24, 2014)

mycrofft said:


> And that from the guy who got me tuned up on sports meds before covering a Spartan Race in 2012!


:glare:  


mycrofft said:


> Let's say I'm trying to elicit some treatment schemes based upon physical findings…and not from professional trainers!





beano said:


> DDx
> *high ankle sprain
> *compartment syndrome
> *fracture
> ...


High ankle sprain, distal fibular fx (or avulsion fx) are on my list as well. Compartment syndrome is a worry, but I would want to correlate that with physical findings... Minor, but very irritated anterior talofib ligament sprain is also possible. 

Tx would likely include ice, compression via horseshoe pad and ace wrap, and elevate for quite a while. Medication would be primarily for pain reduction vs anti-inflammatory actions. 


mycrofft said:


> Ice is nice, too. No compression?
> 
> But, YES. Treatment even with a fine differential in the field is going to be the same. Spend half an hour doing drawer tests and otherwise imitating Kiefer Sutherland on "24" questioning a terrorist, but when it is time to finally take this pt in, he or she will be in a splint in position of comfort (often 90 degrees) and given pain meds. Or even just sandbagged on the litter.


Me spend 1/2 hour doing ligament testing? Please... 3 minutes max.

Transport could very well be POV or ambulance, depending upon stability, need of en-route monitoring, or on-going pain control needs.


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## Brandon O (Mar 24, 2014)

mycrofft said:


> Yeah! Right on. Now how to they dovetail with people's specific protocols, and versus distance, in individual cases,to the hospitals in urban and suburban settings?



Let patient know it's probably not broken, see what they want to do.


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## mycrofft (Mar 24, 2014)

Brandon O said:


> Let patient know it's probably not broken, see what they want to do.



Is your boss listening to this?


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## mycrofft (Mar 24, 2014)

Akulahawk said:


> :glare:
> 
> 
> 
> ...



Naw.


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## Akulahawk (Mar 24, 2014)

mycrofft said:


> Naw.


Well, that would work... for Maryland... transport straight the RA Cowley STC.


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## Brandon O (Mar 24, 2014)

mycrofft said:


> Is your boss listening to this?



Can't fault you for the truth if you give an honest, full, and accurate description of the risks.

The caveat would be that the Ottawa rule was validated in the ED setting, and applying it on scene may or may not be as accurate. Two good reasons might be that you're not as smart as an ED doc, or that "ability to ambulate since the accident" is one of the rule-ins and you're assessing them much earlier, thus less opportunity to walk. Neither of those seem to apply, since you're very smart, and they ruled out anyway. Still, it hasn't technically been validated for EMS use, unless I missed that study.

A somewhat abbreviated description of all this would be a part of informed consent...


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## mycrofft (Mar 24, 2014)

I wonder what the synergistic effects of beer and girls has on perceived pain?


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## Akulahawk (Mar 24, 2014)

mycrofft said:


> I wonder what the synergistic effects of beer and girls has on perceived pain?


While I'm not entirely certain, I suspect that it is definitely related the amount of ice used and seriousness of facepalm applied later...


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## Medic Tim (Mar 24, 2014)

Brandon O said:


> Can't fault you for the truth if you give an honest, full, and accurate description of the risks.
> 
> 
> 
> ...




We use the Ottawa rules where I work. A mix of Ambulance and medical clinics. This is the cheat sheet we have posted in my clinic.


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## Brandon O (Mar 24, 2014)

Do you ask 'em to walk if they haven't tried yet?


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## Medic Tim (Mar 24, 2014)

Brandon O said:


> Do you ask 'em to walk if they haven't tried yet?




We ask them the "bear weight" or ambulate if they feel comfortable doing so.


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## mycrofft (Mar 24, 2014)

I used that exact chart to try to cram for my first (and second to the last) Spartan Race.

And trying to walk…talk about rapid results...


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## Rialaigh (Mar 26, 2014)

Brandon O said:


> Let patient know it's probably not broken, see what they want to do.



Hate to agree with the "non medical" answer but basically this. Regardless of whether it is broke or not based on the description and the complaint they don't need an ambulance. They don't need an ER visit. I can give them a phone number for the orthopedic in the area, they can schedule an appointment or head to an urgent care. Save them time, money, and headache...I guess I would even be super nice and do an ace bandage and some ice before they leave.


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## Medic Tim (Mar 26, 2014)

Rialaigh said:


> Hate to agree with the "non medical" answer but basically this. Regardless of whether it is broke or not based on the description and the complaint they don't need an ambulance. They don't need an ER visit. I can give them a phone number for the orthopedic in the area, they can schedule an appointment or head to an urgent care. Save them time, money, and headache...I guess I would even be super nice and do an ace bandage and some ice before they leave.




Pretty much what I do. I transport less than 5% of my pts( probably closer to 1%). Most all are treat and release or treat and refer. I get the odd AMA but they are rare.


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## Rialaigh (Mar 26, 2014)

Medic Tim said:


> Pretty much what I do. I transport less than 5% of my pts( probably closer to 1%). Most all are treat and release or treat and refer. I get the odd AMA but they are rare.



we are still a fairly behind the times US system. However we are really trying to implement some community programs so as to have referral lists on every ambulance for every conceivable complaint including free clinics, dental clinics, detox places that take Medicaid and Medicare. the whole works...really trying to reduce ER visits and get people to a primary care or specialist that can directly deal with the problem.


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## Melclin (Mar 27, 2014)

Brandon O said:


> Can't fault you for the truth if you give an honest, full, and accurate description of the risks.
> 
> The caveat would be that the Ottawa rule was validated in the ED setting, and applying it on scene may or may not be as accurate. Two good reasons might be that you're not as smart as an ED doc, or that "ability to ambulate since the accident" is one of the rule-ins and you're assessing them much earlier, thus less opportunity to walk. Neither of those seem to apply, since you're very smart, and they ruled out anyway. Still, it hasn't technically been validated for EMS use, unless I missed that study.
> 
> A somewhat abbreviated description of all this would be a part of informed consent...



Its worse when these rules use "brought in by ambulance" as a criteria. How do you take that in the prehospital environment?

I've used Ottawa ankle rule in the past. Got the cheat sheet in pocket along with the rest of things I can't be arsed remembering. Its usually a moot point though, on account of the need, or lack there of, for pain relief.


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