Note
Doctor Notes - Ortho follow up.
Heather L. Grothe, MD at 9/8/2020 9:40 AM
PHYSICAL EXAM:
BMI Readings from Last 1 Encounters:
No data found for BMI
Well-appearing, no acute distress, pupils equal, respirations are nonlabored. Psych is appropriate, pleasant. Left ankle and foot are mildly swollen. Skin is closed and intact without erythema. He is tender to palpation over the site of the fracture at the fibula. Nontender along the proximal fibula. Pain-free range of motion of the knee. Does have some pain along the syndesmosis approximately. Tender over the posterior lateral malleolus. Mild discomfort over the anterior process of the calcaneus. Nontender with calcaneal squeeze. Nontender over the midfoot or forefoot or metatarsals. Sensation intact distally light touch. Skin is with good tone and turgor.
IMAGING: Radiographs performed today and personally reviewed of the left foot and ankle demonstrate a oblique mildly displaced fibular fracture along the syndesmosis. There is a visible posterior malleolus nondisplaced tibial fracture.
CT scan personally reviewed demonstrates mildly displaced fracture of the distal fibular shaft. There is concern for anterior tibiofibular syndesmosis disruption given the cortical fragments seen. Fracture of the posterior malleolus without articular step-off. Chronic appearing irregularity at the medial malleolus. Also navicular with appearance of pseudoarthrosis.
IMPRESSION/ RECOMMENDATIONS: Scott A Erlandson is a 52 year old male with l an acute left ankle fibular fracture along the anterior tibiofibular syndesmosis, with a nondisplaced posterior mall intra-articular fracture. We reviewed the images and discussed based on these findings I would recommend a CT scan. This was performed the same day and he did return later in the afternoon for review. I did have a very long discussion with the patient and his significant other regarding these findings. The patient performs and competes at a high level and states that he would like to ensure an optimal outcome. He would like to return to activity as soon as possible and has been recommended by outside colleagues to consider fixation for this. I did run this by Peggy Stevens, Nurse ractitioner trauma who feels at this time this would be best managed with a nonsurgical condition. The patient would like to set up a consultation with her orthopedic surgeon here. He is out of town and lives in St. Louis Missouri and would like this taken care of here as he is already 5 days out. I will set him up with a surgical consult with 1 of my colleagues, trauma surgeons of foot and ankle specialist, Dr. Jefferson Davis. He is interested in the discussion, risks and benefits of surgical versus nonsurgical option. He would like to proceed with the planned that we will allow the optimal and quickest return to activity and minimize any long-term effects. He was placed in an posterior, sugar tong splint. Patient and significant other happy with this plan. All questions answered.
Thank you for involving me in the care of your patient. Please be in touch with any questions.
Heather Grothe, MD
Orthopedics/Sports Medicine/ Musculoskeletal Ultrasound
Essentia Health-Duluth Clinic 3rd Street Building
400 East 3rd Street, Duluth, MN 55805-1951
218-786-3520
CC: Martinelli, Jennifer L, MD
My opinion and recommendations will be communicated with the consulting physician or provider via US mail or shared electronic medical record.