Author: Rachel Holeman, DO
Co Author #1: Ashley Yelinek, DO
Co Author #2: Suzanne Whitney Courtney, DO

Patient Presentation:
A 15 year old male soccer player and swimmer presented with right ankle pain for 2 days after being kicked in the shin with a soccer ball causing immediate pain. He developed bruising and mild swelling with intermittent sharp pain, worse with direct pressure and weight bearing. He presented to the ED and was placed in a splint and given crutches.

History:
Patient has a history of multiple fractures including a left tibial spine fracture 2 years ago and a left tibial spine fracture requiring open reduction internal fixation 8 months ago. Of note, he was diagnosed with Crohn's disease just over 2 years ago by pediatric gastroenterology and was initially treated with prednisone to control his symptoms, then with Mecaptopurine and is currently being treated solely with Remicade injections every 2 months along with vitamin D, which is controlling his symptoms. He reports eating several meals and snacks per day and normal bowel movements daily.

Physical Exam:
Vitals: BP 100/68, Height 5' 3" (7th %), Weight 100 lbs (5th %), BMI 17.7 (14th %)
General: normal appearance, no distress, alert and oriented
HEENT: NCAT, no scleral icterus
CV: no LE edema
Pulm: Breathing non-labored, normal respiratory pattern
Abdomen: soft, non-obese
Neuro: no focal neuro deficits, normal coordination, normal muscle tone
Skin: Warm and dry, no ecchymosis, erythema, warmth, or induration, no rashes
Psych: normal mood and affect
MSK Exam:
Stance: antalgic gait on crutches, unable to do single leg heel raise
Inspection: mild swelling, no effusion, no obvious deformity
Palpation: tender over soft tissue & anterior distal tibia, non-tender over medial and lateral malleoli, tarsal bones, base of the 5th metatarsal, navicular, and Achilles tendon
ROM: near full dorsiflexion, plantar flexion, inversion, eversion but with mild pain
Strength: intact but initiates pain
Normal pulses at posterior tibialis and dorsalis pedis
Special tests: Negative anterior drawer, talar tilt, squeeze test, and Thompson test

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