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It is early evening and the predictable “surge” of patients has arrived.  The daytime doctor is wrapping up a few cases and getting ready to leave. As you enter one patient’s orders, nurse Helpful taps you on the shoulder. She places two more patients in the empty trauma bay, both with sprained ankles.  The X-rays were ordered from triage earlier, and the patients have been waiting for an empty room. “I know you are busy, but these two have been waiting since last shift to see the doctor.”  The X-rays were done hours ago.”  You softly curse the prior shift -- two more patient satisfaction scores that will be in the toilet.  You close your eyes.  Big deep cleansing breath, happy attitude, OK you are ready to see them.

The nurse has placed them side-by-side in the trauma bay, in wheelchairs.  They look like book-ends -- one left ankle injury, and one right ankle injury, side by side.  What is this, Noah’s Ark day or something?  At least the stories are different.  Ankle number one stepped in a hole earlier today.  Hurts to walk.  Number two was thrown off a horse.  No other injuries, but can’t walk at all.  Both have swelling around the lateral ankle and mid-foot, and no other problems.  You order pain meds and stirrup splints all around.  You pull up both sets of X-rays (see below), and pause.  Ankle number one’s X-rays look fine.  Number two’s are very odd-looking.  Something is wrong but you can’t put your finger on it.  By the way, it is now after 8pm and the radiologists have gone home.  Over-read in the morning.
 
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What is wrong with Ankle number two’s X-ray?  What should happen next? For the rest of the case, see the next page.
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Diagnosis: Talus Fracture 
 
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In this case, co-incidence provided the needed element to make the diagnosis.  Ankle case number one is a sprain, with a normal x-ray (shown on the left, prior page).  Ankle x-ray number two, however is different.  Often, the hard to read fracture in the foot is the calcaneus.  Boehler’s angle (shown on ankle number one’s film) is normal in both of these X-rays, and would be flatter with a calcaneus fracture.
 
This situation is different, however.  Both calcanei are normal.  The abnormal bone is the above-lying talus.  An infrequently fractured bone, it is subject to avascular necrosis in a manner similar to the scaphoid and lunate in the hand.  This talus is crushed, basically hacked in half.  The normal juxtaposed ankle x-ray from the first case shows a normal-appearing talus quite nicely.  Also, all other things being equal, ankle number two has a much more significant mechanism of injury, i.e. thrown off a horse.  This is not a trivial fall.  Many of these equestrian mis-adventures end up with broken bones in the operating room.

After a phone call to orthopedics, you order a CT scan and update both patients.  You, number one, home with stirrup and crutches, don’t do it again.  You, number two, more serious problem.  Off to CT scan (shown), and maybe surgery, discuss with ortho tomorrow in the office.  Looking at the CT scan, you can see the much disrupted talus, fractured in several places.  Even with surgery, this injury is associated with high morbidity.
 
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Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course.  www.emprepcourse.com
 
 

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