Case Discussion by Eric Malone, MD
Visual Stimulus Case:
A 26 year old male with a past medical history of schizophrenia presents after jumping out of a second story window in a possible suicide attempt. He was brought to the emergency department on petition and was originally taken to the crisis center, where, in addition to intramuscular haloperidol and lorazepam, he also received a foot X-ray, which is provided below.
He has no other injuries and complains only of right foot pain. Examination shows deformity of the dorsal aspect of the right foot with tenderness and soft tissue edema over the midfoot. Range of motion in the right ankle is intact, as are peripheral pulses and neurologic function.
- Based on the above X-ray, which of the following is the most appropriate course of management:
A. Order more haloperidol and lorazepam because the patient is clearly malingering and there is nothing wrong with his foot.
B. Posterior mold right leg splint (with stirrups), non-weight bearing on the right leg, crutches, adequate analgesia and rapid orthopedic outpatient follow up (following completion of psychiatric evaluation)
C. Pain control, preoperative laboratory studies, and emergency department orthopedic consultation
D. Post-op shoe, pain control, PRN orthopedic or podiatric follow up.
- In addition to the findings that you identified on the above x-ray, which of the following other injuries is also likely present:
A. Occult talar dome fracture
B. Disruption of the ligamentous structure of the midfoot at the tarsometatarsal joint
C. Disruption of the vascular supply of the fifth metatarsal head
D. Calcaneal tendon rupture
- Failure to diagnose and appropriately manage this injury pattern is most commonly associated with which of the following:
A. Midfoot instability and collapse, severe arthritis
B. Avascular necrosis of the fifth metatarsal head
C. Atrophic degeneration of musculature of the dorsal foot including extensor digitorum brevis
D. Fracture non-union
Filed under: Senior Report