BRIEF HISTORY: The patient is a 77-year-old retired gentleman
who complains of right ankle pain that started on January 4, 2009
when he slipped on some black ice and twisted his ankle. He was
seen by Dr. Eakin and was found to have a distal fibula fracture
and a widened mortise. He was placed into an above-the-knee
condylar cast for 2 weeks, and then subsequently into a Cam
walker boot. He has remained nonweightbearing for the last 3
weeks. He has noticed continued pain. Overall, he thinks things
are staying the same. His pain is better with rest and worse
with motion. He has no radiation of his symptoms. No numbness.
He is currently taking occasional Vicodin for his pain. He does
have a history of diabetes but denies any history of retinopathy,
nephropathy, neuropathy, or coronary artery disease. On a scale
of 1 to 10, he rates his pain as 7 out of 10.
He typically is not participating in any regular exercise
program. He typically wears tennis shoes, and prior to his
injury his walking tolerance was unlimited.
PHYSICAL EXAMINATION:
GENERAL: The patient is generally well appearing, in no acute
distress. Stated height and weight is 5 foot 6 inches, 160
pounds.
HEENT: Normocephalic, atraumatic. Oropharynx is clear
HEART: Regular rate and rhythm.
LUNGS: Unlabored respirations.
ABDOMEN: Nontender, nondistended.
RIGHT LOWER EXTREMITY: He has a neutral lower extremity
alignment. He has an antalgic right gait. He has tenderness to
palpation particularly along the distal fibula and ATFL. He has
less tenderness medially, though he is somewhat tender along his
medial gutter. He has mild diffuse swelling of his ankle. His
skin is intact. His sensation is intact to monofilament testing.
His ankle motion and stability are guarded.
IMAGING: X-rays reveal a distal fibular fracture with medial
mortise widening.
ASSESSMENT AND PLAN: Right ankle distal fibula fracture with
widened mortise. Discussed the nature of this problem with the
patient and discussed both conservative and surgical treatment
options. We have discussed with him that if treated
conservatively he has a higher risk going on to develop ankle
arthritis down the road. We would recommend at this point a
surgical fixation, though this does carry some risk of wound
healing problems related to his diabetes, and infection. At this
point, we feel that the risk is lower than not operating. We
discussed with him further the risks, benefits, and alternatives
which include but are not limited to damaging nerve, tendons, or
blood vessels, bleeding, wound healing problems, infection,
stiffness, need for further physical therapy, continued pain, or
down the road even the chance of developing arthritis. He
understands these risks and wishes to proceed.
arrange this for him.
We will help to
Dr. Haskell was present for the history and physical examination
of this patient.