Musculoskeletal Medicine/Office Orthopedics
Performance-Based Learning in Family Medicine
X-RAY INTERPRETATION and CASE MANAGEMENT
MODULE IV ANSWERS
Ankle and Foot
Original July 1992, #8 1/27/99
Wm. MacMillan Rodney, M.D., FAAFP, FACEP
Family and Emergency Medicine
Reviewed by Phil Cheatham, M.D.
Radiology, 1993, 1994
Reviewed by John R. Janovich, M.D.
Orthopedics, 1993, 1994
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CASE 41
BACKGROUND
A 40-year old junior faculty had decided to organize an intramural basketball team. On the first night of
practice, he went up for a rebound and landed on his left ankle. He perceived a pop at that time.
His past medical history is unremarkable and the skin is not broken. Examination reveals a tender left
lateral malleus with swelling. No ecchymosis is present. The neurovascular examination is intact. The
range of motion is limited by pain.
Teaching Point. What is the radiographic diagnosis and which management would you suggest?
1.
In terms of describing this, the best terms would be:
A.
Normal ankle, probably a sprain.
B.
Non-displaced fracture of the tibia.
C.
Non-displaced fracture of fibula.
D.
Widing of talus.
E.
None of the above.
2.
The physician fails the “four-step test.” Regarding best management choice for this case, select
one of the following:
A.
Immediate referral to orthopedist in a larger town 40 miles away.
B.
Ice elevation, splinting, crutches.
C.
Immediate cast and/or referral.
D.
Hiking boot.
E.
None of the above.
CASE 42
BACKGROUND
Thirty-nine year old Black female presents today after hitting the lateral aspect of her ankle on the
wooden corner of a sofa two days ago. Patient states that the ankle is swollen and painful.
Exam reveals left ankle which is swollen with significantly decreased range of motion, especially upon
flexion and extension. Tenderness is noted in response to palpation over the ankle and on the lateral
aspect of the distal leg. The skin is not broken. The neurovascular exam is intact.
Teaching Points
3.
What is your diagnosis and suggested management?
Non-Operative Orthopedics for the Family Physician, Module IV
Sequence of Views:
AP/oblique
Lateral
AP Oblique
Lateral
Day 1
Day 1
Day 3
Day 3
AP/oblique
AP/oblique
AP/oblique
3
Day 37
Day 53
Day 77
Case 43
BACKGROUND
A 57-year old male hit foot on pipe while at work 2-3 hours ago. Has been able to walk, but it has been
so painful that his gait is impaired. His foreman has requested evaluation.
On physical examination, there is minimal swelling, but obvious pain over the 5th metatarsal.
4.
In regards to this fracture, the best description would be which of the following.
A.
Simple.
B.
Transverse
C.
Spiral
D.
Oblique
E.
Comminuted
Case 44
BACKGROUND
A 53-year-old white female who tripped, twisting her ankle yesterday. Did not hear a pop or snap. Did
not perceive a cracking. Was able to continue walking with some pain. The patient’s past medical history
is noncontributory.
On physical exam, mild swelling is noted. The patient treated the painful injury with ice last night. Still
painful this morning. There is a diffuse ecchymosis on the left lateral dorsal portion of the foot. There is
distinct pain to palpation over the fourth and fifth metatarsals.
5.
Most likely, management of this fracture would be:
A.
Surgical.
B.
Casting for at least 8 weeks.
C.
Splint with partial weight baring as allowed by pain.
D.
Short-leg cast for 4 weeks and then partial weight baring as allowed by pain.
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Case 45
BACKGROUND
A 43-year-old white female who experienced an inversion injury to the left ankle two hours ago. She
denies hearing a snap or pop. She did not perceive anything cracking in her ankle. She has no history of
a previous injury, and her past medical history is noncontributory.
On examination her vital signs are stable and there is tenderness over the left anterior paleofibular area.
She has difficulty in walking, but is able to walk six steps without stopping.
6.
In viewing these images, the physician concludes:
A.
There is an unusual separation between the talus and the fibula.
B.
There is an unusual separation between the talus and the tibula.
C.
There is a non-displaced fracture of the lateral fibula.
D.
No fracture can be seen.
E.
None of the above.
Case 46
Foot/Great Toe Injury
BACKGROUND
A 53-year-old white male makes a New Year’s resolution to exercise regularly. On the 3rd of January, he
purchases a health club membership. During his first session, he drops a 45 lb. Weight on his left foot.
Because of the pain, he stops his workout and visits his family physician seeking an evaluation. The
patient was able to walk with a limp. His past medical history is unremarkable.
The physical examination reveals a white male who appears to be his stated age. He walks with a mild
limp, but he is in no obvious pain. Examination of the foot reveals normal neurovascular findings. The
great toe is red and swollen. It is extremely painful to light touch. Range of motion is limited by pain.
There is obvious asymmetry when one toe is compared to the other toe.
7.
At this point, the physician is considering the utility of additional information from the physical
examination. Management would be assisted by which of the following maneuvers?
A.
Measuring range of motion with a gonimeter for degrees of flexion and extension.
B.
Capillary refill time on the nail beds of both feet.
C.
Testing for vibration sense on both feet.
D.
Test for ability to detect pin prick on both feet.
E.
None of the above.
8.
Regardless of x-ray findings, the management of this case is clear.
True
False
Non-Operative Orthopedics for the Family Physician, Module IV
9.
5
The patient states that he is about to lose a sizable amount of sick leave that he has accumulated
over the last nine years. The finding of a fracture is usually grounds for up to six weeks of sick
leave unless desk duties can be found. The patient is concerned regarding a potential fracture, and
the physician agrees. In ordering the images most likely to meet the minimum standard of care for
diagnosis of a fracture of this type, the physician would request:
A.
B.
C.
D.
E.
AP and lateral of the forefoot and great toe.
PA and lateral of the forefoot and great toe.
AP, lateral, and oblique of the forefoot and great toe.
PA, lateral, and oblique of the forefoot and great toe.
AP view alone would be sufficient.
10.
Regardless of the above order, the physician receives the following two images (Image A1 and
Image A2). They are presented for your review. On these views, a fracture is visible.
True
False
11.
The one correct best management approach for this injury would include:
A.
Nonweight-bearing with crutches.
B.
Weight-bearing as allowed by pain tolerance.
C.
Ice bag for 20 minutes every hour for the first two days.
D.
Ice and elevation as needed for patient’s comfort. Patient permitted to return to work.
Physical rehabilitation program three times weekly for four weeks.
E.
All of the above.
12.
The patient decides that he will self-manage this injury. He does not apply ice, he does not elevate
the injury, he takes no medication, and he resumes his usual routine at work. A report has
returned from the previous films stating that “no fracture was visible.”
Two weeks later, the patient reports that his wife would like him to enroll in a ballroom dancing
course. He reports that he continues to experience pain. Furthermore, he remains convinced that
the toe was fractured.
On physical examination, the toe remains swollen and the range of motion is decreased when
compared to the other foot. Otherwise the neurovascular exam is within normal limits. There is
some decrease in sensation to light touch over the swollen toe. The physician requests a second
set of x-rays which are presented for your review (Image A3 and Image A4). Please describe your
findings.
A.
A nondisplaced, nonangulated fracture line is visible.
B.
Callous formation is visible.
C.
No fracture is visible.
D.
The views are inadequate to make a diagnosis.
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13.
How are these views different from the first views?
A.
An oblique view has been obtained.
B.
An appropriate maneuver isolating the great toe has been requested.
C.
There is someone’s hand on one of the views.
D.
I’m not sure.
E.
None of the above.
Four weeks later the patient reports that over his futile objections, he and his wife have attended
three sessions of ballroom dancing. The next session is tonight and the patient has requested an
urgent visit. An additional two views of the foot/toe are obtained (Image A5 and Image A6).
14.
On physical examination the toe remains swollen and the range of motion is decreased when
compared to the other foot. Otherwise the neurovascular exam is within normal limits. There is
some decrease in sensation to light touch over the swollen toe. The physician requests a second
set of x-rays which are presented for your review. Please describe your findings.
A.
A nondisplaced, non-angulated fracture line is visible.
B.
Callous formation is visible.
C.
No fracture is visible.
D.
The views are inadequate to make a diagnosis.
15.
How are these views different from the first views?
A.
An oblique view has been obtained.
B.
An appropriate maneuver isolating the great toe has been requested.
C.
There is someone’s hand on one of the views.
D.
I’m not sure.
E.
None of the above.
Case 47
BACKGROUND
A 54-year-old male physician is observing a high school football game when he is called down to the
field to evaluate a potential dislocated shoulder on one of the players. In his enthusiasm, he vaults a
three-foot fence onto the field. He fails to notice that the stadium floor is an additional six feet below. He
lands on both feet. Upon impact, he experiences a sharp pain in his right heel. With great pain and a
limp, he walks across the field, evaluates the player, and returns to his seat.
The next morning he is in great pain, has difficulty putting his shoe on, and comes to the office for an xray. Prior to the x-ray, his past medical history is reviewed and found to be unremarkable. Upon
examination, there is point tenderness on the lateral posterior edge of the foot. Swelling is difficult to
assess, but the foot appears normal. There is a subcutaneous bruise along the lateral posterior edge of the
foot. He was walking with an obvious limp.
An x-ray is taken. This image is available for review. (Image B-1)
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Based on the history, the physical findings, and the imaging information available, the following
management issues should be discussed and a plan should be created.
16.
True False
17.
At this point, you would advise the patient that:
A.
Non-weight bearing with crutches is advisable.
B.
Weight bearing as tolerated is allowed.
C.
Splinting would be helpful.
D.
A cast is indicated.
E.
None of the above.
18.
The patient is well-known to you in the community. He played linebacker on your high school
and community college football teams. He has a high threshold for pain. Regarding pain
management, you suggest the following (more than one choice may be correct):
A.
B.
C.
D.
E.
The radiographic image reveals a fracture.
Patient may purchase over-the-counter analgesics prn.
Tylenol #3, 1po q 4h pm.
Percodan tablets.
Demerol 100mg IM now, and/or any of the above.
None of the above.
Non-Operative Orthopedics for the Family Physician, Module IV
Image 41-B1
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Non-Operative Orthopedics for the Family Physician, Module IV
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19.
The patient returns two weeks later for a follow-up visit. He has not taken any time off from
work. He continues to have substantial, but not disabling pain in the heel. He walks with an
obvious limp and there is tenderness to palpation on the lateral posterior heel. A second
radiographic image is obtained. (Image B2) At this point, you conclude:
A.
The patient probably has a non-displaced fracture or a stress fracture of the calcaneus even
though you can’t see it.
B.
The patient has a visible fracture of the calcaneus.
C.
CT or MRI would be helpful.
D.
Bone scan to evaluate a stress fracture is indicated.
E.
None of the above.
20.
The patient asks how long he can expect to have the pain. Although he can work, he would like to
ake his son hunting which requires considerable ambulation over rough terrain. You advise him:
A.
The pain, for all practical purposes, will be gone in an additional 1-2 weeks.
B.
The pain, for all practical purposes, will be gone in an additional 4-6 weeks.
C.
He should be ready to go (fit for hiking) in 3-5 days.
D.
None of the above.
21.
Three weeks later, the patient returns with a continuing limp and palpable heel pain. An image of
the foot is obtained. (Image B3)
A.
The patient probably has a non-displaced fracture or a stress fracture of the calcaneus even
though you can’t see it.
B.
The patient has a visible fracture of the calcaneus.
C.
CT or MRI would be helpful.
D.
Bone scan to evaluate a stress fracture is indicated.
E.
None of the above.
22.
Management advice should include:
A.
Non-weight bearing with crutches for two weeks.
B.
Weight-bearing as personal tolerance allows.
C.
Restricted activity with partial weight-bearing, but mainly desk duty at work. No walking.
D.
Continued weight-bearing may lead to disability.
E.
None of the above.
Non-Operative Orthopedics for the Family Physician, Module IV
Image 41-B2
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Non-Operative Orthopedics for the Family Physician, Module IV
Image 41-B3
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