MDM - Ankle Sprain

[##]-year-old [male/female] with history and exam consistent with ankle sprain.

Initial consideration in this patient included ankle fracture or sprain, and foot or leg fracture or sprain among others.

Patient noted to [not] meet all of the Ottawa ankle rules upon presentation to the ED, [so plain films of the ankle/foot were obtained/imaging was not obtained due to low risk for significant injury/but plain films of the ankle/foot were obtained in triage].  Patient noted to have [minimal/no evidence of significant] laxity of the ankle on exam.  [Plain films of the ankle/ankle and foot showed no evidence of fracture or dislocation.]  Ankle [placed in splint/wrapped] in the ED, and patient provided with crutches and training prior to discharge.

We discussed RICE measures (rest, ice, compression, and elevation) and use of crutches with early weight bearing as tolerated with the patient.  We discussed return precautions, symptomatic treatment, and follow up with primary care doctor within 1 week as needed for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://orthoinfo.aaos.org/globalassets/pdfs/2017-rehab_foot-and-ankle.pdf
https://orthoinfo.aaos.org/en/diseases--conditions/sprained-ankle/