Two fractures of the lower extremity not to miss in the emergency department.

Case 1 description Buddy is an active 33-year-old man who presents to the emergency department (ED) complaining of pain in his left ankle and foot after falling while back-country skiing 3 days ago. The fall involved a moderatespeed slide down a steep chute and rotational release of the left leg from the ski binding. Buddy experienced immediate pain to the lateral malleolar region. Immediately after the injury, he painfully skied the return trip to the cabin. He has been bearing weight since the injury and complains of persistent pain to the lateral malleolar area. Physical examination reveals tenderness over the anterior talofibular ligament and the distal aspect of lateral malleolus. The medial malleolus, fifth metatarsal, and proximal fibula are nontender. An anterior draw test reveals negative results. There is marked swelling and effusion of the ankle joint. There is no bruising. The knee and hip are normal. Conventional radiography of the ankle reveals normal results (Figure 1). The diagnosis of an anterior talofibular ligament sprain is made, and the patient is given ankle-support products and physiotherapy instructions. Buddy returns to the ED 2 months later complaining of persistent pain, ongoing swelling, and the new sensation that his foot is “flatter and less stable.” A physical examination reveals an obvious ankle joint effusion, tenderness over the area below the lateral malleolus, and a hindfoot that is splayed laterally. The distal lateral malleolus is nontender. During the 2 months between the ED visits, Buddy has been running and cross-country skiing regularly despite experiencing persistent pain with these activities. An x-ray scan shows a large ankle joint effusion, and a computed tomography (CT) scan of the ankle (Figure 2) shows an intra-articular displaced fracture through the lateral process of the talus (LPT). How do you treat Buddy now? What are the complications of missing this injury? How could it have been picked up during Buddy’s first ED presentation?