Sarawut Watt.

Extern Conference

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CC : ปวดขอเทาขวา 6 ชวโมงกอนมาโรงพยาบาลPI : 6 ชวโมงกอนมาโรงพยาบาล ขบมอเตอรไซคหลบ

สนข เกดลม ขาขวากระแทกพน มอาการปวดเทาขวา ขนมาทนท ขอเทาขวาบวม ขยบไมไดเพราะเจบ ไมม

ชา จงมาโรงพยาบาล

Case Scenerio

A Thai man, Good consciousnessVital Signs stable, AfebrileHEENT : not pale, no jaundiceHeart : normal S1, S2, no murmurLungs : Clear and equal BS both lungs Abdomen : soft, not tender

Physical Examination

Ext : Affected Part Rt. Foot : - abrasion wound 1*3 cm. at medial side of foot, - tender at lateral Malleolus and below medial malleolus, - Limit ROM due to pain , - normal pinprick sensation, - Dorsalis pedis & post. Tibial artery can palpable 2+

Film Right Ankle AP , Lateral View

Film Right Ankle mortise view

Closed fracture of right distal fibular (closed fracture right lateral malleolus)

Diagnosis at ER

- On Right Posterior Short leg slab- Follow up 2 weeks + film Right ankle AP, lateral, Mortise view- Advice : Non weight bearing with crutches

Home Medication- Paracetamol(500) 1tab po prn q 6hr- Tramol(50) 1*3 po pc

Management at ER

Right Bimalleolar Fracture

Definite Diagnosis

Ankle Fracture

Three bones make up the ankle joint Tibia - shinbone Fibula - smaller bone of the lower leg Talus - a small bone that sits between the heel

bone (calcaneus) and the tibia and fibula

Anatomy

Anatomy

Twisting or rotating your ankleRolling your ankleTripping or fallingImpact during a car accident

Causes

Immediate and severe painSwellingBruisingTender to touchCannot put any weight on the injured footDeformity ("out of place")

Symptoms

The Ottawa ankle rules the need for plain films in patients with ankle injury.

Patients should have a plain film, if there is malleolar tenderness and at least one of the following

tenderness along the posterior surface of the distal fibula tenderness along the posterior surface of the distal tibia inability to weightbear after the trauma and when being

assessed

Diagnosis

Ottawa Ankle rules

- AP view- Lateral view- Mortise view (Internal rotation 10 degree)

Plain film of Ankle

AP View TibioFibular Overlap <10mm implies Syndesmosis injury TibioFibular Clear space >5mm implies Syndesmosis injury Talar Tilt >2mm is considered abnormal

Radiographic Measurement

Lateral View Posterior malleolus fracture Subluxation of the talus Angulation of distal fibula Talus fracture Calcaneus fracture

Mortise ViewAbnormal findings• TibioFibular overlap < 1mm• Medial Joint space widening

Classification of distal fibula fractures split fractures into groups by severity

Weber classificationWeber A: below the syndesmosis (stable)Weber B: at the syndesmosis (may be unstable)Weber C: above the syndesmosis (unstable)

Classification

Weber Classification

Nonoperativeshort-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

Operativeopen reduction internal fixationindications any talar displacement displaced isolated medial or Lateral malleolar fracture bimalleolar fracture and bimalleolar-equivalent fracture posterior malleolar fracture with > 25% or > 2mm step-off open fractures

Wound problems Deep infections Post-traumatic arthritis

Complications