Interesting: especially 2, 3 and 4. A study-mate of mine had the "point 2"
situation once with a person who had a elbow fracture. He had to mobilize
the person's elbow and he/she was in very much pain. When they found out the
elbow was indeed broken, this person was very angry at my friend. He/she
should have been angry with the docter who ordered the mobilisation.
Difficult situation for student who do not have build up any
reference-knowledge.

What I can remember of tibialis posterior damage from my paper that I had to
do in the final year of my education, I can say that it is relativally rare.


When to do MRI?
I don't know exactly but I DO know that there is a diagnose testing
procedure that is called "the Ottawa Ankle rules". It was designed to reduce
the frequence with which x ray are done with suspected ankle fractures after
inversion trauma. It consists of series of pressure points over the whole
foot. When the person experiences pain, the test is positive.

Isaac

-----Opprinnelig melding-----
Fra: Chris Murphy [mailto:[log in to unmask]]
Sendt: 11. april 2002 16:29
Til: [log in to unmask]
Emne: Degree to which patients perceptions influence their
rehabilitation.


This question was prompted by a patient seen yesterday (15 years old) who
was referred with a 3 week old sprained ankle. At the time of the initial
injury the patient was seen at a local hospital, X rayed and told he had a
fractured lateral malleolus. He then returned home, he was then reviewed a
week later by a local orthopaedic surgeon and told he did not have a
fracture. He was put in an Aircast boot told to mobilise with that for a few
days and then 'get going' on it. I saw him yesterday, he was non weight
bearing on crutches wearing the Aircat boot.. He had moderate movement in
the foot with pain limiting all movements, tender over the lateral
ligaments, no obvious instability on testing and painless resisted tests.
During our discussion the questions of whether he may have a fracture was
raised by himself and his mother repeatedly. I wrote a letter to the
consultant who he was seeing today regarding the possibility of a check X
ray to clear the uncertainty up once and then we could rehab him
effectively. The patients mother rang up today to inform me that he had
refused to send him for a repeat X ray as it was not broken but has referred
him for an MRI scan instead.

My conversation with the consultant was short, he hung up on me. However he
did mange to justify the MRI scan on the basis it would show up if there was
a fracture and also the patient was tender over the tibialis posterior
tendon.

I realise that virtually all of my patients with inversion sprains have
tenderness over the tibialis posterior post sprain and especially if they
have kept it still for three weeks let alone the influence of central
mechanisms.

My questions therefore are these:

1. Is there any published literature on the amount a patients perception of
their physical wellbeing influences their compliance and ultimately their
functional outcomes post injury.
(e.g. if their was a chance of a fracture how likely is he to comply,
despite my explanations and reassurance)

2. If there was a fracture and I begin to mobilise him on the word of the
orthopaedic surgeon, who is liable for this.

3. What is the incidence of tibialis posterior damage with inversion sprains
of the ankle and what are the likely outcomes.

4. What do people feel are the criteria for an MRI scan (within the UK) in
this sort of case.





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