A 34-year-old man presents to the urgent care with severe pain and inability to bear weight on his right ankle following a fall while playing recreational league basketball in the past hour. The patient reported landing awkwardly after a jump, hearing a “pop” sound, and feeling immediate pain. He reports no significant past medical history or prior ankle injuries. He indicates that he has type 2 diabetes that is well managed with metformin; however, he has occasional numbness in his feet due to diabetic peripheral neuropathy.
There is a visible deformity of the right ankle with significant swelling and bruising on physical examination. Tenderness is present over the lateral malleolus and the posterior tibial region. Sensation over the dorsum of his foot is diminished, which is consistent with diabetic neuropathy, and distal pulses are present but weak. X-rays reveal a displaced bimalleolar fracture with talar shift. Which of the following is the most appropriate next step in managing this patient?
- Immobilize the ankle with a splint and refer for outpatient orthopedic follow-up in 1 week.
- Provide pain medication, apply a posterior splint, ensure neurovascular integrity, monitor for signs of infection, and arrange immediate orthopedic consultation.
- Attempt a closed reduction and discharge with crutches.
- Prescribe pain medication and recommend rest, ice, compression, and elevation (RICE) therapy.
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Answer: b. For this patient, immediate referral to an orthopedic surgeon was warranted due to his increased risk of complications such as poor wound healing, infection, or Charcot arthropathy in the context of diabetes. You prescribed adequate pain medication because of the time of day (evening) and instructed him to not eat anything after midnight as surgery is likely imminent. A displaced bimalleolar fracture requires surgical intervention and there is a high risk of long-term disability without appropriate and timely management, especially given the added risks associated with diabetes. Before he was discharged, you checked the splint to make sure it was not too tight and ensured that he planned to follow up with the orthopedic surgeon the next day.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
