Urgent Care Board Practice Questions

Based on the American Board of Family Medicine format.


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Sample Stem:

Two hours ago, a 26-year-old man slipped and fell while he was jumping off crates at work. He states that his right ankle twisted such that he felt a sharp pain. He was able to bear weight on that foot immediately after the injury. However, because this was causing some pain, he decided to use his brother’s old crutches.

On examination, there is significant soft tissue swelling over the lateral malleolus. There is no bony tenderness over the lateral and medial malleoli or proximally over the fibula or tibia. After some hesitancy, the patient is able to bear weight and slowly walks a few steps while avoiding flexion and extension of his right ankle.

Based on the Ottawa Ankle rules, the next best step is which of the following?


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Answer Options:

 Obtain radiography of his right ankle.
 Prescribe him nonsteroidal anti-inflammatory drugs.
 Prescribe him semi-rigid ankle support, crutches, and no weight bearing for 4 weeks.
 Obtain an orthopedic consultation before you discharge him.


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Correct Answer:

Prescribe him nonsteroidal anti-inflammatory drugs.

Educational Objective:

Describe treatment for isolated, minor blunt ankle trauma.

Key Point:

In most cases of isolated blunt ankle trauma evaluated within 48 hours of injury, the Ottawa Ankle rules should be used to determine whether radiography of the ankle is necessary. These rules state that ankle x-rays (there is a separate set of Ottawa rules for foot x-rays) are required if there is pain in the malleolar region with any of the following findings:

  • Bony tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus
  • Bony tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus
  • Inability to bear weight for ≥ 4 steps both immediately after the injury and at the time of evaluation

According to the Ottawa Ankle rules (not to be confused with the Ottawa Foot rules), which approach a nearly 100% sensitivity rate for detecting ankle fractures in adults, this patient would not benefit from radiography. Soft tissue magnetic resonance imaging or computed tomography would not be appropriate in this case either, because such a study would not change the management of an ankle sprain in which the patient can still ambulate.

Ligamentous ankle injuries are initially treated with rest, ice, compression, and elevation. In addition, studies show that analgesics such as nonsteroidal anti-inflammatory drugs, acetaminophen, topical diclofenac, or oral opioids are effective in severe cases. For grade 1/2 injuries, short-term protection with a tensor bandage, taping, a lace-up ankle brace, or a commercial walking boot, with the optional use of crutches for a few days, is appropriate.

For severe grade 2/3 injuries, splinting or casting for up to 3 weeks occasionally is necessary. Because there is no evidence for a more favorable outcome with immobilization than with functional treatment, use of a lace-up support or air cast that permits some ankle motion is generally preferable, even in patients with more severe sprains. Such patients also should use crutches for 2 to 3 weeks to avoid weight bearing until they can stand and walk several steps on the injured ankle without pain.

Urgent orthopedic consult before discharge is mostly a consideration in patients who might require emergent surgery. This is not the case in this patient.

By comparison, the Ottawa Foot rules state that foot radiographic series is required if there is pain in the midfoot region with any of the following findings:

  • Bone tenderness at the navicular bone
  • Bone tenderness at the base of the fifth metatarsal
  • Inability to bear weight for ≥ 4 steps both immediately after the injury and at the time of evaluation

Rose NG, Green TJ. Ankle and foot. In: Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:634-658.e3.

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