Ankle Trauma
Age: years old
Gender:
HISTORY:
Presents with a ankle pain following an injury ago
Mecanism of injury:
Location is
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: ,
EXAM:
Ankle:
Inspection:
Palpation: on
Range of motion:
- Dorsiflexion:
- Plantarflexion:
- Inversion:
- Eversion:
Strength: , except on
Neurovascular: pulses , cap refill sec, sensation
Special tests:
- Anterior drawer test:
- Compression test:
Gait: ,
Ottawa rule:
ASSESSMENT:
DDx: ankle sprain, ankle fracture, ankle contusion, Achilles tendon rupture, high ankle sprain, talar dome lesion, peroneal tendon subluxation, posterior tibial tendon dysfunction, medial malleolus fracture, lateral malleolus fracture, fifth metatarsal fracture, Lisfranc injury, bimalleolar fracture, trimalleolar fracture, syndesmotic injury, osteochondral injury of the talus, gout, septic arthritis, osteochondritis dissecans
PLAN:
Investigations:
- Ankle X-ray
- CT scan of the ankle
- MRI of the ankle
Treatments:
- Rest, ice, compression, elevation (RICE)
- Ankle
- ]
-
-
- Physical therapy
- Orthotics
- for
Further care:
- Referral to orthopedic surgeon
- Referral to podiatrist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as redness, swelling, or inability to bear weight
HISTORY: Associated symptoms: EXAM: Ankle: ASSESSMENT: PLAN: