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Fractured lateral malleolus?

by Jen
(Fostoria, MI)

Hi,


I rolled my ankle in a "pot hole" running through a barn chasing pigs on July 20th. I felt it pop quite a few times, but didn't feel pain immediately. My body reacted in a way that surprised me, by nearly passing out. The swelling happened immediately, before my boot was off my left ankle was twice it's normal size.
Being a Sunday, and due to high deductible high copay insurance I opted for urgent care rather than the hospital. The urgent care performed x-rays and stated they were negative but their machine was not the best quality and the provider diagnosed me with a lateral malleolus fracture based on the location of the pain upon palpating and location of the swelling. He ordered crutches and a high tide boot and told me to bear weight as I could tolerate and follow up with my PCP in a week.
I used the crutches for about 24 hours before attempting weight bearing, and have been on the boot since. It isn't extremely painful unless I try to turn or roll my foot, or even stretch my leg. Also, when I take the boot off and walk at home I feel electric shock type feelings in the bridge of my foot intermittently. It is still swollen, no longer bruised. I have not followed up with my PCP because I felt that it was a waste of another copay at that point, I'm not sure that she could tell me anymore than the urgent care provider did. My question now is will this ever heal, should I seek a second opinion, when can I get rid of the dang boot. :)
Thank you,
Jen


RESPONSE

Hi Jen,

In spite of a poor quality x-ray, the doctor you saw made a diagnosis of a fracture. The question then becomes, how bad a fracture? Is there just a "crack" in the bone or is the break bigger than that. Is part of the bone broken away from the remaining bone? What I am getting at here is that not all fractures are the same and for that reason they are all treated differently, particularly ankle fractures.

I cannot speak on behalf of the doctor that treated you, but I would hope if the fracture was severe enough, the doctor would have suggested you see a foot specialist as your problem might require surgery. (A simple crack in the bone would not require surgery, but a more severe fracture, particularly if a piece of bone is displaced might very well require surgery)

I bother to make this distinction because if your fracture is just a simple non-displaced fracture then the instructions you were given were fine up to a point. My thought would be that if there is any consideration of a simple fracture then I would want you off the foot in the boot and on crutches for a minimum of 3-4 weeks with re-evaluation at that point, requiring another x-ray to track the progress of your healing. I do not know your age or any thing about your medical history so I am erring on the side of caution.

Now there is also the issue that perhaps you do not have a fracture at all as the only way to make a diagnosis of fracture is with an x-ray or some other imaging modality. Since you did hear/feel a popping in your ankle, there is a very good chance that to partially tore ligaments or did damage to the tendon that passes below the lateral malleolus. So, to be on the safe side, again, by staying off the foot for a few weeks should allow whatever damage you sustained to heal itself. The problem with this advice is that if you just did mild damage to your lateral ankle ligaments or did some other soft tissue damage, then you may end up wasting too much time being off your foot for a problem that does not require this much immobilization.

I think the "bottom line" is that you need an accurate diagnosis in order to know how long you will be incapacitated with this issue. Obviously, I cannot tell you without seeing an x-ray and having the luxury of examining you.

In this day and age, I get the whole concept of co-pays and high deductibles and the reluctance to go to the doctor every time you have an issue.

So, If you are looking for a strategy that you might want to consider, try this. Stay non-weightbearing on the foot for two weeks. That is a relatively short period of time and if you do not have a fracture, of any kind, then you should be able to start bearing weight after that. When you do start bearing weight, if you find that the ankle begins to hurt again, you would want to rule out more severe damage and that point you will have to bite the bullet and see a local doctor who can give you more accurate advice then I possibly can from the other side of the internet.

Additionally, do not bother going to your general doctor because if you are still having pain the general doctor will not be able to treat it adequately and will probably send you to a specialist and you will end up paying two co-pays.

Marc Mitnick DPM
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