EXTERNCONFERENCE

4/11/2559Ext. Praetip Praikaew

Case scenario

ผปวยหญงไทยโสดอาย 16 ป นกเรยนชน มธยมศกษาปท 5

ขอเทาขวาพลกมา 1 ชม.

Primary survey◦ A Patent airway, no C-spine injury ◦ B Normal chest wall movement, normal breath sound

equal both lung, CCT- negative◦ C BP 124/71 mmHg, Capillary refill < 2 sec◦D E4V5M6, pupil 3 mm RTLBE ◦ E No external wound, tender at Rt. ankle

Secondary survey ◦ A no drug allergy ◦M no current medication ◦ P no underlying disease◦ L last meal 4.00 pm ◦ E ขอเทาขวาพลกมา 1 ชม

1 ชม.กอนมารพ. ขณะลงบนไดสะพานลอยหนาโรงเรยน พลดลนตกจากบนได 4 ขน เทาทงสองขางกระแทกพน รสกปวดขอเทาขวาทนทจนตองนงลง ผปวยพยายามลกขนเดนแตเดนไมไหว เพราะปวดขอเทามาก ไมมศรษะกระแทกพน ไมหมดสต

Secondary surveyHead to Toe examination Vital sign BP 124/71 mmHg, P 84 bpm, RR 20 /min, T 36.2 ºC

SpO2 99 %HEENT not pale conjunctivae, anicteric scleraHeart normal s1s2, no murmur Lung normal breath sound equal both lung, no

adventitious sound Abdomen soft, not tender

Secondary survey Extremities Affected part (Rt. foot) :

abrasion wound 1x3 cm above Rt. ankle marked swelling and tender at medial and lateral

malleolus limit ROM of Rt.ankle due to pain intact PPS DPA and PTA – 2+ capillary refill < 2 sec

Secondary survey

Adjunctive to secondary survey

Film Rt.ankle AP, Lateral, Mortise

AP view

Lateralview

Mortise view

Diagnosis?Closed Bimalleolar Fracture of Rt. ankle

Management at ER◦Pain control◦ Immobilize : Posterior short leg slab◦Pre-op

NPO 5%D/N/2 1000 ml IV rate 80 ml/hr CBC, Anti HIV CXR Cefazolin 1 g to OR

AP view

Lateralview

Mortise view

Post-operative film

ANKLE FRACTURE

AnatomyThree bonesTibia FibulaTalus

Anatomy

Anatomy

Anatomy : Vascular

Cause Twisting or rotating the ankle Rotating the ankle Tripping or falling Impact during a car accident

*Common associated fracture : - 5th Metatarsal base fracture- Calcaneal fracture

Clinical manifestation Immediate and severe pain Swelling Bruise/ecchymosis Tender on palpation Inability to bear weight on the injured foot Deformity

Physical examination Inspection Palpation Neurovascular function

Special testRelated to sysdesmotic injuryAnterior drawer test Talar tilt Squeeze test External rotation stress test

Do not test if suspeted fracture!

Special test Anterior drawer test Talar tilt Squeeze test External rotation stress test

Special test Anterior drawer test Talar tilt Squeeze test External rotation stress test

Special test Anterior drawer test Talar tilt Squeeze test External rotation stress test

Special test Anterior drawer test Talar tilt Squeeze test External rotation stress test

Mechanism◦Lauge-Hansen

◦ based on foot position and force of applied stress/force◦ has been shown to predict the observed (via MRI)

ligamentous injury in less than 50% of operatively treated fractures

Lauge-Hansen Class Sequence

Supination - Adduction (SA) 1.Talofibular sprain or distal fibular avulsion2.Vertical medial malleolus and impaction of anteromedial distal tibia

Supination - External Rotation (SER) 1.Anterior tibiofibular ligament sprain2.Lateral short oblique fibula fracture (anteroinferior to posterosuperior)3.Posterior tibiofibular ligament rupture or avulsion of posterior malleolus4.Medial malleolus transverse fracture or disruption of deltoid ligament 

Pronation - Abduction (PA) 1.Medial malleolus transverse fracture or disruption of deltoid ligament 2.Anterior tibiofibular ligament sprain3.Transverse comminuted fracture of the fibula above the level of the syndesmosis

Pronation - External Rotation (PER)    

1.Medial malleolus transverse fracture or disruption of deltoid ligament 2.Anterior tibiofibular ligament disruption3.Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint4.Posterior tibiofibular ligament rupture or avulsion of posterior malleolus 

Ottawa ankle rulePatient should have plain films if there is malleolar tenderness and at least one of following

Tenderness along the posterior surface of the distal fibula or tibia

Inability to walk with weight-baring after trauma

PEARLS/PITFALLS◦ The Ottawa ankle rule were derived to aid in the efficient use

of radiography in acute ankle and midfoot injuries.◦ Rules have been prospectively validated on multiple

occasions in different populations and in both children and adults.

◦ Sensitivities for the Ottawa ankle rule range from the high 90%-100% range for “clinically significant” ankle and midfoot fractures. This is defined as a fracture or an avulsion greater than 3 mm.

◦ Specificities for the Ottawa ankle rule are approximately 41% for the ankle and 79% for the foot, though the rule is not designed/intended for specific diagnosis.

◦ The Ottawa ankle rule are useful in ruling out fracture (high sensitivity), but poor for ruling in fractures (many false positives).

Investigation◦ Plain films AP view Lateral view Mortise view

Radiographic measurement◦ AP view Tibiofibular overlapIf < 10 mm Syndesmotic injury Tibiofibular clear spaceIf > 5 mm Syndesmotic injury Talar tiltIf > 2 mm Abnormal

Radiographic measurement◦ AP view Talocrural angleIf > 75-87 ° or difference from opposite site > 3 ° Shortening

Radiographic measurement◦ Lateral view Posterior malleolus fracture Subluxation of the talus Angulation of distal fibula Talus fracture Associated injury - Calcaneous fracture- 5th metatarsal fracture

Radiographic measurement◦Mortise viewAbnormal finding Tibiofibular overlap < 1 mm Medial clear space widening > 4mm Lateral shift of talar

Classifications◦ Classification of distal fibular fracture level related to

syndesmosis ◦Weber classification

Mortise view

Treatment non-operative : short-leg walking cast/bootIndications◦ Isolated nondisplaced medial malleolus fracture or tip

avulsions◦ Isolated lateral malleolus fracture with < 3mm displacement

and no talar shift◦ Posterior malleolar fracture with < 25% joint involvement or

< 2mm step-off

Treatment Operative : ORIFindications •Any talar displacement  •Displaced isolated medial malleolar fracture •Displaced isolated lateral malleolar fracture•Bimalleolar fracture and bimalleolar-equivalent fracture •Posterior malleolar fracture with >25 % or > 2 mm step- off                   •Open fractures

Complication

◦ Wound problems (4-5%)◦ Deep infections (1-2%) up to 20% in diabetic

patients◦ Post-traumatic arthritis

Thank you