Case Study 7.1: Acute Ankle Fracture
Karen M. Myrick
SETTING: URGENT CARE
Definition and Incidence
Ankle fractures are common, and occur at an annual incidence of one in every 800 people (Mehta, Rees, Cutler, & Mangwani, 2014). Ankle fractures occur across the life span and with a variety of mechanisms of injury.
Patient presents with the chief complaint of right ankle pain. She describes a history of walking her dog when she stepped into a hole that she was not aware of. She twisted her ankle, and felt pain immediately. She was not able to ambulate home, and used her cell phone to call her husband who came to pick her up. She has not been able to bear weight on the ankle since the injury, and has pain that is a 7 out of 10. She notices swelling and bruising over the lateral ankle. There is no associated numbness or tingling, and pain is less with ice that she placed on her ankle on her way to the clinic.
This 37-year-old female is a stay-at-home mother who has a small business in consulting for fitness. She has three children: twin girls aged 4, and a 5-year-old son who is in kindergarten this year.
The patient is a 37-year-old female who is in no acute distress, but demonstrates hesitancy and some discomfort throughout the physical examination. She is 5′4″ and weighs 132 lb. She is unable to weight bear in the clinic, and hops onto the examining table for assessment. On inspection, there is a moderate amount of swelling over the lateral ankle, and ecchymosis in a somewhat dependent pattern as well. The skin is intact without tenting or open cuts or abrasions. With palpation, she has bony tenderness that begins 6 cm above the malleolus, and is tender to the lateral malleolus with palpation. She has no tenderness with medial palpation, including over the deltoid ligament. Dorsalis pedis and posterior tibialis pulses were strong and intact. She is hesitant to perform range of motion (ROM) in the ankle, but is able to move all of her toes, and to demonstrate approximately 10 degrees of ankle dorsiflexion and plantar flexion. There are no focal neurological deficits in the left lower extremity, and good color throughout.
The presence of any medial injury determines the stability of fractures of the medial malleolus (Goost et al., 2014).
Radiographs were obtained, including an anterioposterior, lateral, and mortise view. The x-ray demonstrated a fracture of the distal fibula of the right ankle (see Figure 7.1). The ankle mortise is intact and anatomically aligned, as is seen on the mortise view, Figure 7.2.
Fractured fibula, right ankle.
The patient was placed into a posterior and U-splint and given crutches. She was instructed to be nonweight bearing until her follow-up visit, and a follow-up visit was made for 8 days later. She was instructed to move her toes frequently, ice 20 minutes several times a day, and elevate above the level of the heart.
Teach the patient that a large majority of pain from the injury will be due to inflammation. It is important to practice modalities that will decrease and keep inflammation at bay to help with the healing process and to keep the discomfort under control.
This patient followed up in 8 days and was placed into a walking boot. She was instructed to return in 2 weeks for x-ray evaluation. She returned at the 2-week time point, and the radiographic evaluation demonstrated early callus formation and stability to the fracture. She was allowed to weight bear for the next 2 weeks, and returned for x-rays that demonstrated healing of the fracture. She was placed into a stirrup splint and told to begin physical therapy and return at the 6-week mark. At the 6-week mark, she was ambulatory without pain, had occasional swelling at the end of the day, and was ready to return to full activities.
Goost, H., Wimmer, M. D., Barg, A., Kabir, K., Valderrabano, V., & Burger, C. (2014). Fractures of the ankle joint. Deutsches Aerzteblatt International, 111(21), 377–388. doi:10.3238/arztebl.2014.0377
Mehta, S., Rees, K., Cutler, L., & Mangwani, J. (2014). Understanding risks and complications in the management of ankle fractures. Indian Journal of Orthopaedics [serial online], 48(5), 445–452.
Case Study 7.2: Acute Achilles Tendon Rupture
Phoebe M. Heffron
SETTING: ORTHOPEDIC URGENT CARE
Definition and Incidence
The Achilles tendon is a long fibrous tissue in the posterior lower leg that attaches distally to the calcaneus and proximally to the gastrocnemius and soleus muscles. Achilles tendon ruptures have increased more than tenfold over the past several decades from 2.1 in 100,000 to 21.5 in 100,000 (Lantto, Heikkinen, Flinkkilä, Ohtonen, & Leppilahti, 2015).
Patient presents to orthopedic urgent care, complaining of pain in the back of his left lower leg. He states, “I was playing basketball two nights ago in my men’s recreation league game. I drove down the lane to shoot a layup and heard a pop; it felt like someone hit me in the back of the leg with a baseball bat. I immediately crumpled to the floor in pain.” The patient states that his teammates helped him up and assisted him to the sidelines—he was able to bear some weight but it was very painful. Once he got to the sidelines, he applied ice immediately. Over the course of the past 36 hours, he has noticed some bruising and swelling. He has continued to ice intermittently. He has taken ibuprofen 600 mg twice a day and says, “It’s still sore but not quite as painful.” He has an old elastic bandage at home that he has been wearing. He has continued to go to work, play with his children, and help cook and clean but feels like his gait is off. He has not attempted to go back to the gym since the injury.
This 42-year-old man is a father of two young boys. He was away on business for the past 2 weeks and was excited to get back home to his weekly basketball game. He has had ankle problems before and is worried this is more serious than his previous sprained ankles. He is frustrated by the possibility of a lengthy recovery and is worried about how he will manage shoveling and snow-blowing duties this winter.
Achilles tendon injuries are most often seen in men in their 40s and 50s (Pedowitz & Kirwan, 2013).
The patient is a 42-year-old male who stands 5′11″ tall and weighs 170 lb. He sits on the exam table in no acute distress. He walks on his tiptoes in obvious discomfort. His lower calf has moderate swelling and bruising. The left foot is of normal temperature and color, has a capillary refill of less than 3 seconds, and demonstrates a 2+ posterior tibial pulse. When lying prone with feet hanging off the table, the left foot lies in decreased plantar flexion compared with the right side. Palpation shows notable step off in the Achilles tendon about 5 cm superior to the calcaneus. The Thompson test is positive.
An MRI may be obtained in cases of diagnostic uncertainty; often, however, the diagnosis is clear and additional imaging can delay treatment. An x-ray is unlikely to aid in the diagnosis.
Achilles tendon rupture.
The nurse practitioner provides the patient with a set of crutches, a posterior splint, and advice to be nonweight bearing. The splint has a slight equinus position (plantar flexion) to keep the tendon lengthened and as approximated as possible. He is scheduled to see an orthopedic surgeon today to discuss the possibility of surgical intervention.
As a nurse practitioner, you must be able to educate the patient on treatment options including surgical versus nonsurgical treatment, the recovery time, and benefits and adverse outcomes associated with the different treatment modalities.
As it is possible that this patient will have a surgical intervention, the nurse practitioner may not have the opportunity to follow up directly unless working in a setting where nurses collaborate with the orthopedic surgeon. In such a case, the nurse practitioner may write a prescription for pain medication and physical therapy and may see the patient postoperatively. It is even possible that the nurse practitioner will assist the orthopedist during surgery. If the patient opts for nonsurgical rehabilitation, the nurse practitioner working in orthopedics may also have the opportunity to prescribe a course of physical therapy. For a nurse practitioner in a primary care setting, he or she may not see this patient again for this particular injury but will likely encounter other patients with Achilles tendon injuries during the time in practice. It is imperative that the nurse practitioner understands that prompt treatment is essential for optimal patient outcomes, particularly if the patient elects to have surgery. The nurse practitioner in primary care may also help this patient with paperwork needed to apply for short-term disability through his employer.
Lantto, I., Heikkinen, J., Flinkkilä, T., Ohtonen, P., & Leppilahti, J. (2015) Epidemiology of Achilless tendon ruptures: Increasing incidence over a 33-year period. Scandinavian Journal of Medicine & Science in Sports, 25, e133–e138. doi:10.1111/sms.12253
Pedowitz, D., & Kirwan, G. (2013). Achilles tendon ruptures. Current Reviews in Musculoskeletal Medicine, 6(4), 285–293. doi:10.1007/s12178-013-9185-8
Case Study 7.3: Acute Peroneal Tendon Dislocation
Karen M. Myrick
SETTING: ACUTE CARE
Definition and Incidence
Peroneal tendon subluxations or dislocations are often mistaken as simple ankle sprains, and may go undiagnosed (Espinosa & Maurer, 2015). The peroneal tendons are held in the fibular groove by the superior peroneal retinaculum, which can be torn with forceful ankle dorsiflexion and eversion injuries (Espinosa & Maurer, 2015).
A 17-year-old patient presents to the urgent care with the chief complaint of ankle pain. Just 2 hours prior to presentation, she reports running on the soccer field when she unexpectedly stepped into a hole in the turf. She reports that she felt a pop in the ankle, and fell to the ground. She was unable to weight bear initially, and was helped to the sidelines by a teammate and her coach. She placed ice on the ankle immediately, and elevated it as well. After the game, she was able to minimally weight bear with an antalgic gait to the car with her parents and came right to the urgent care clinic for evaluation. Pain is worse when the limb is kept dependent; it is better with elevation. She describes the pain as 6 out of 10 without pressure; when bearing weight, the pain is 8 out of 10. She denies any numbness or tingling of the lower leg.
This 17-year-old female is a high school junior, and plays with a travel soccer team, as well as with her high school team.