Rearfoot / Ankle · Trauma · Infection & Wound · Advanced
Retaining Wall
Podiatric surgery residency interview case. Work through it the way you would at an interview: take the history, ask for the exam and imaging, then commit to a diagnosis and plan.
Chief complaint
"I fell off a wall and my ankle is broken. The bone is sticking out."
45-year-old male laborer brought to the ED by EMS about 6 hours after a fall from a height of roughly 15 feet. Open fracture; neurovascular status intact on arrival.
History of present illness
Fell about 15 feet from a retaining wall at work and landed feet-first onto concrete, about 6 hours before arrival. Immediate severe left ankle pain, deformity and bleeding with a wound on the medial ankle. Unable to bear weight. Splinted and given IV analgesia by EMS; no antibiotics or tetanus given yet.
- Mechanism: axial load (fall from height)
- No loss of consciousness, no head, neck or back pain, no chest or abdominal pain
- Wound contaminated with soil and gravel at the scene
- Foot stays warm with intact sensation per EMS
- Last oral intake about 8 hours ago (NPO status favorable)
- Tetanus status: last booster > 10 years ago
Questions a strong candidate asks at this step
- Mechanism: height, landing surface, axial load vs. twist, was it a high-energy injury
- Time since injury (6 hours = past the ideal 'golden period' for debridement and antibiotics)
- Wound contamination at the scene (soil, water, farm/livestock)
- Tetanus immunization status
- NPO status and time of last meal (urgent OR)
- The 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (compartment syndrome / vascular injury)
Present the rest of the case
Past history, exam, imaging, assessment, plan and discussion questions, with model answers, are in the interactive trainer. The diagnosis is kept there on purpose so you can practice committing to one.