Fracture/Sprain Management Note (Foot/Ankle)

Date/Time: [Encounter date and time]
Site of Care: [ED / Urgent Care / Orthopedics / Sports Medicine / Primary Care]
Laterality: [L / R]
Anatomic Region: [ankle / midfoot / forefoot / toes]
Work-related / Workers' Compensation: [yes / no / N/A] (If yes, include employer and claim details if available.)

Chief Complaint

[Reason for visit] (Include brief patient quote when mechanism or symptom description is clinically meaningful, e.g., "felt a pop," "foot went numb.")

History of Present Illness

[Narrative describing mechanism, time course, and clinical presentation] (Open with mechanism and timing. Include: time of injury and time to presentation; mechanism [inversion / eversion / axial load / fall / crush / direct blow / twist]; immediate ability to bear weight after injury and at presentation; pain location and severity; swelling, bruising, visible deformity; neurologic symptoms; skin integrity; prior injuries or surgeries to same limb and baseline function; self-treatment before arrival. Include high-risk modifiers when present: anticoagulant/antiplatelet use, diabetes/peripheral neuropathy, immunosuppression, osteoporosis, smoking. Note pregnancy status if imaging may be obtained. Document bony tenderness locations assessed [posterior malleoli, navicular, base of 5th metatarsal] and whether patient could bear weight for 4 steps. If critical information is unknown, explicitly state "unknown/not obtained" and why. Do not infer absent symptoms or weight-bearing ability.)

Relevant History

• Medical history: [Pertinent conditions] (e.g., coagulopathy, diabetes/neuropathy, vascular disease, prior VTE, osteoporosis)
• Medications: [Current medications] (Emphasize anticoagulants, antiplatelets, steroids, diabetes medications)
• Allergies: [Allergies] (Highlight analgesic and antibiotic allergies if open wound present)
• Tetanus status: [Status] (Include only if wound or skin break present)
• Functional context: [Occupation, athletics, baseline mobility, ability to use crutches, home barriers]

Physical Examination

Vitals: [Vital signs including pain score if used clinically]

General: [Appearance, distress level, cooperation with exam]

• Inspection: [Swelling location, ecchymosis, deformity, skin breaks, fracture blisters]
• Palpation: [Mapped tenderness locations] (Include posterior edges/tips of malleoli, navicular, base of 5th metatarsal, midfoot joints, Achilles tendon, proximal fibula if mechanism suggests higher injury.)
• Range of Motion: [Findings as tolerated]
• Strength: [Dorsiflexion, plantarflexion, inversion, eversion, toe movement as relevant]
• Stability/Special Tests: [Findings if performed] (e.g., anterior drawer, talar tilt, squeeze test, Thompson test. Document "deferred due to pain/swelling" if not performed.)
• Gait/Weight-bearing: [Attempted 4 steps: yes/no; limp; assistive device needed]
• Neurovascular (mandatory): [Pulses: DP and PT; perfusion: capillary refill, temperature, color; sensation: distal foot distributions; motor: toe and ankle movement] (If compartment syndrome concern, document pain out of proportion, pain with passive stretch, increasing tightness.)
• Exam limitations: [Components limited and why; mitigation if attempted] (Omit if exam was complete.)

Imaging

Decision: [Imaging obtained / deferred / not obtained] (Provide explicit clinical rationale. If deferred or declined, document safety-net plan.)

• Modality/Region: [Ankle series / Foot series / Tib-fib / CT / MRI] (Note if weight-bearing views attempted for suspected midfoot injury.)
• Results: [Fracture present/absent; location; displacement/angulation; intra-articular extension; mortise alignment; syndesmosis widening] (If negative but suspicion persists, note "occult fracture cannot be excluded.")
• Read status: [Preliminary / Final] (If preliminary, document how final read discrepancies will be communicated.)

Procedure

(Include this section only if splinting, casting, boot fitting, closed reduction, or crutch training is performed.)

• Procedure performed: [Posterior short leg splint / Stirrup splint / Short leg cast / Walking boot / Closed reduction / Crutch training]
• Materials/Positioning: [Materials used and limb position]
• Pre-procedure neurovascular status: [Exam immediately before procedure]
• Post-procedure neurovascular status: [Reassessment after procedure] (Do not copy pre-procedure findings; document actual reassessment.)
• Tolerance/Complications: [Tolerated well / issues encountered / adjustments made]

Assessment

• [Problem with laterality]: [Working diagnosis with key supporting findings] (Note differential considerations when significant: syndesmotic injury, Lisfranc, tendon rupture, occult fracture, compartment syndrome. Include severity/risk flags. If stability uncertain, state "treating as potentially unstable.")
• [Additional problem with laterality if applicable]: [Diagnosis or clinical impression]

Plan

• Immobilization: [Device type and position; expected duration; elevation and ice guidance] (For fractures, document stable/nondisplaced vs. requiring urgent orthopedic evaluation.)
• Weight-bearing status: [NWB / TTWB / PWB / WBAT / FWB]; mobility aids: [crutches / walker / knee scooter / none] (Note if patient demonstrated safe use.)
• Pain management: [Non-pharmacologic measures; pharmacologic plan with precautions; medications administered and response if applicable]
• VTE risk and counseling: [Risk factors reviewed; prophylaxis recommended/deferred with rationale; DVT/PE warning symptoms reviewed] (Include when lower-limb immobilization or NWB prescribed. Omit if not applicable.)
• Follow-up: [Timeframe and destination: Orthopedics / Podiatry / Sports Medicine / PCP] (Note indications for expedited referral or advanced imaging if needed.)
• Activity restrictions: [Driving, work/school, sports restrictions] (Note if written documentation provided.)
• Patient education: [Discharge instructions reviewed; splint/cast/boot care; skin monitoring; elevation/ice; medication instructions; communication plan for pending results]

Return Precautions

• Worsening pain not controlled by recommended medications or pain out of proportion
• Increasing tightness or pressure under immobilization device
• New or worsening numbness, tingling, weakness, or inability to move toes
• Foot becoming cold, pale, blue, or with delayed capillary refill
• Drainage, odor, fever, or spreading redness
• Calf pain or swelling, chest pain, or shortness of breath (Include if VTE counseling provided.)

Disposition

Disposition: [Discharged / Admitted / Transferred] · Condition: [Stable / Improved / Unchanged] · Ambulation: [Device in place and ambulation status] · Follow-up: [Arranged / Advised with timeframe]