Right Lower Limb Injury - Football

Abstract

HISTORY: 18 y/o college linebacker with prior history of bilateral shoulder dislocations sustained a right lower limb injury while defending a pass. After successfully deflecting a pass he landed on his plantar flexed/inverted right foot. His medial foot was then struck by a teammate’s helmet at high velocity, forcing it into eversion. He went down immediately in obvious distress. PHYSICAL EXAMINATION: Obvious closed deformity of the distal fibula, prominence of the anterior tibial plafond/medial malleolus, excessive external rotation of the foot. Dorsalis pedis was not palpable. Light touch sensation to the dorsal/pedal foot remained intact. Edema was expanding acutely at/distal to the ankle. 5/5 dig 1-5 flexion/extension was noted. DIFFERENTIAL DIAGNOSIS: 1. Bi/Tri Malleolar Fracture/Syndesmosis Tear/Ankle Dislocation 2. Fibula Fracture/Syndesmosis Tear/Subtalar Dislocation 3. Fibula Fracture/Syndesmosis Tear/Deltoid Ligament Tear TEST AND RESULTS: XR TIBIA/FIBULA: 10/20/14, 10:27pm Fracture distal fibula with angulation laterally, fracture posterior malleolus displaced posteriorly, lateral dislocation talus. XR TIBIA/FIBULA: 10/21/14, 12:23am Successful reduction of the fracture/dislocation at the tibiotalar joint. Markedly improved alignment of fibular fracture. Asymmetric widening of the medial mortise. Posterior malleolar fracture displaced posteriorly 6 mm. PRE-OPERATIVE FLOROSCOPIC EXAM: 10/24/14, 12:16pm Displaced/shortened fracture distal fibula with lateral angulation and comminuted distal aspect. Passive dorsiflexion induced widening of the medial mortise from approximately 6 mm (at neutral) to approximately 10mm. FINAL/WORKING DIAGNOSIS: Right tri-malleolar ankle fracture/dislocation with distal tibiofibular dysfunction. TREATMENT AND OUTCOME: 1. Ankle reduced on the field, dorsalis pedis palpable immediately thereafter. 2. EMS contacted immediately, vacume air splint placed on the field, patient transferred to local ED emergently. 3. Pulses remained palpable, yet due to unstable mortis ankle required re-reduction and solid splinting in the ED. 4. 4 days later ORIF of distal fibula & tibiofibular joint performed. 5. The patient was placed in a knee high boot and will continue as NWB with crutches x 6 weeks. ROM therapies initiated immediately.