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Foot Case Study 2

Foot Case Study 2

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Published by superhoofy7186

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Published by: superhoofy7186 on Feb 03, 2009
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06/14/2009

 
Foot Case Study 2 : Lateral CollateralLigament Damage
Paul McMaster is a 30-year-old delivery van driver who overbalanced at work whilstloading parcels into his van. He sustained an inversion sprain of the left ankle 3 daysago and has a severe sprain to the lateral ligament complex of the ankle. At present itis difficult to diagnose precisely as the ankle is very swollen/bruised and painful oncertain movements and he requires crutches to walk. There is No Bony Injury to theankle, but he is keen to return to activities as soon as possible. He has a pronouncedlimp and in not weight bearing evenly through the ankle, showing obvious pain as aresult. He lives with his girlfriend in a 2
nd
storey flat.
Anatomy & Pathology
Lateral Collateral Ligaments:Anterior talofibular ligament – ATLCalcaneal fibular LigamentPosterior talon fibular ligamentSevere pain more common in repeating patients: commonly damage to interosseosligaments and associated deltoid pain.
Subjective Examination
Where\What:
left ankle – expect pain over injured ligaments – ask is there anymedial pain (around deltoid ligament) and had this happened before?
When
: 3 days ago
How
: overbalanced at work 
0-10 rating
: ask?
24-hour cycle
: ask?
Better for
: expect rest
Worse for
: weight bearing
Type of pain
: ask?
 
Past Medical History/ General History
: none
Red Flags and general concerns
: repeated sprain => chronic instability of ankle.Undiagnosed fracture.
SH
: lives with girlfriend in flat
DH
: ask?
Patient’s main outcome
: possibly return to work 
Objective Examination
Working Hypothesis
:Establish extent of injury – double check for fracture
Advice & Consent
: give and obtain
General Observations
: observe walking – does he protect ankle formlateral strain as he turns
Acute Observations
:Skin colour – bruisingSwelling – around lateral anklePosture – adapted to non-weight bearingMuscle bulk – unlikely to be affected

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