a tonne of bricks…

… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.

Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).

These are two of his original xrays.

Can you see a fracture ???

I thought this case gave me the perfect excuse to share one of my favourite orthopaedic papers that I discovered earlier in the year.

by Yu JS, Cody ME in Emerg Radiol. 2009 Jul;16(4):309-18.
They present a helpful template for evaluating the plain ankle x-ray, involving a systematic review of 11 important target sites including; the medial & lateral malleoli, anterior tibial tubercle & posterior tibial malleolus, talar dome, lateral talar process, tubercles of the posterior talus process, dorsal to the talonavicular joint, anterior calcaneus process, calcaneal insertion of EDB and base of 5th metatarsal.
The following image (taken from their paper) demonstrates these….
Did this approach help my patient… I’d like to think so !
On reviewing his films…
As above, there is an abnormality at the lateral talar process as well as a bony injury involving the neck of the talus.
He was admitted under Orthopaedics for a CT the following morning….
The surgeons where happy to treat this conservatively and our patient went home….
Hope you find this helpful,

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