Interesting Case Conference

ชายไทยอายุ 35 ปี

ประสบอุบติัเหตรุถจกัรยานยนต์ล้ม 11 ชัว่โมงก่อนมาโรงพยาบาล

Primary surveyAirway and C-spine

able to talk, no tracheal shift, no c-spine tenderBreathing

Equal breath sound both sound both lungs, clear, no rib steppingCirculation

BP 134/85mmHg, PR 97 bpm Disability and neurologic status

E4V5M6 pupil 2mm RTLBEExposure/Environment control

Laceration wound 5cmx6cm at Right dorsal ankle, able move toes, not able to move ankle

Adjunct to Primary surveyChest X-ray

Adjunct to Primary surveyChest X-ray

No Hemothorax, No Pneumothorax

Secondary surveyAllergy : Penicillin Allergy (Rash)Medication : No current medicationPast history : No underlying diseaseLast meal : 11Hr PTA(12:00)

Secondary surveyEvent :11 Hr PTA ขบัรถจกัรยานยนต์แล้วจกัรยานยนต์

ล้มเองจกัรยานยนต์ไมไ่ด้ทับขาขวาของตนหลังจากล้ม

ไมห่มดสติตอนท่ีจกัรยานยนต์ล้ม ไมม่ศีีรษะกระแทก สามารถขยบั นิ้วเท้าได้ แต่ขยบัขอ้เท้าขวาไมไ่ด้

มแีผลเปิดท่ีขอ้เท้าขวา

มผีู้เห็นเหตกุารณ์นำาสง่โรงพยาบาลเอกชน ท่ีโรงพยาบาลเอกชนได้ irrigate, Dressing, Short leg slab

แล้ว Refer มาโรงพยาบาลมหาราชนครราชสมีา

Secondary surveyGA: Thai male, good consciousness, well co-operativeV/S: T 37.2C,BP 134/85mmHg, PR97bpm, RR20HEENT: Not pale conjunctivae, no icteric scleraeHeart: full regular pulse, normal S1S2, no murmurLungs: clear and equal breath sound both lungsAbdomen: normoactive bowel sound, soft, not tenderExtremities: laceration wound at right dorsal ankle, size 5x6cm, deep to subcutaneous tissue, no ankle deformities, Posterior tibialis pulse 2+ both feet,Dorsalis pedis pulse 2+ both feetSkin: no rash, no petechiae

Adjunct to Secondary survey1.Film Right ankle AP

LateralMortise

2.Film Right Foot APOblique

3.Film Right leg APLateral

AP Lateral Mortise

AP -Fx distal fibula-widening(>5mm) syndesmosis space-Vertical Fx medial malleolus

Lateral - comminuted oblique Fx of distal fibula

Mortise - equal clear space (tibiotalar,talofibula) - accept angle (<20 degree)(no talar tilt)

Mortise- equal clear space (tibiotalar,talo

- Medial malleolus fracture- No fracture of tarsal, metatarsal, phalanx

-no knee dislocation-no fracture of tibial shaft-no fracture of proximal fibula

Problem list1. Open fracture of right distal fibula2. Close fracture of right medial malleolus

Open fracture definition a fracture with direct communication to the external environment

Diagnosis1.Open fracture (Gustilo IIIA)2.Ankle fracture (SA II)

Open fracture management1.Management in the Emergency Room2.Management in the Operating Room 3.Antibiotics treatment

Management in the Emergency Room 1.Initial trauma survey and resuscitation 2.Antibiotics initiate early IV antibiotics and update tetanus prophylaxis as indicated 3.Control bleeding

-direct pressure will control active bleeding-do not blindly clamp or place tourniquets on damaged extremities

4.Assessment -soft-tissue damage-neurovascular exam

5.Dressing -remove gross debris from wound -place sterile saline-soaked dressing on the wound

6.Stabilize splint fracture for temporary stabilization

decreases pain, further injury from bone ends, and disruption of clots

Management in the Emergency RoomIn this case

1.Initial trauma survey and resuscitation 2.Antibiotics

Gentamycin 240g iv od x3 daysClindamycin 600mg iv q8hr

3.Control bleeding -Venous suture มาจากท่ีโรงพยาบาลเอกชน

4.Assessment -soft-tissue damage :deep to subcutaneous-neurovascular exam :intact

5.Dressing -remove gross debris from wound : ส่งไปทำาใน OR ทันที-place sterile saline-soaked dressing on the wound

6.Stabilize -on short leg slab มาจากโรงพยาบาลเอกชน

Management in the operating room1.Aggressive debridement and irrigation - thorough debridement is critical to prevention of deep infection - low and high pressure lavage are equally effective in reducing bacterial counts - saline shown to be most effective irrigating agent - bony fragments without soft tissue attachment can be removed2.Fracture stabilization - can be with internal or external fixation, as indicated3.Early soft tissue coverage or wound closure is ideal - timing of flap coverage for open tibial fractures remains controversial - increased risk of infection beyond 7 days 4.Can place antibiotic bead-pouch in open dirty wounds - beads made by mixing methylmethacrylate with heat-stable antibiotic powder

Management in the operating roomIn this case

1.Debridement and Irrigation with Normal Saline2.Repair extensor digitorum longus muscle3.Place Drainage4.Suture wound with Nylon 3-05.On short leg slab

Management in the operating roomIn this case

Management in the operating roomIn this case

Antibiotics treatmentGustilo Type I and II

-1st generation cephalosporin -clindamycin or vancomycin can also be used if allergies exist

Gustilo Type III -1st generation cephalosporin and aminoglycoside

Farm injuries or possible bowel contamination -add penicillin for anaerobic coverage (clostridium)

Duration -initiate as soon as possible

studies show increased infection rate when antibiotics are delayed for more than 3 hours from time of injury

-continue for 24 hours after initial injury if wound is able to be closed primarily-continue until 24 hours after final closure if wound is not – closed during initial surgical debridement

Antibiotics treatmentIn this case

Gustilo Type IIIA -1st generation cephalosporin and aminoglycoside

So -Gentamycin 240mg iv od x 3days -Clindamycin 600mg iv q8hr

Ankle fracture Pattern-isolated medial malleolus fracture-isolated lateral malleolus fracture-bimalleolar and bimalleolar-equivalent fractures-posterior malleolus fractures-open ankle fractures-associated syndesmotic injuries

isolated syndesmosis injury

Ankle fracture Pattern-isolated medial malleolus fracture-isolated lateral malleolus fracture-bimalleolar and bimalleolar-equivalent fractures-posterior malleolus fractures-open ankle fractures-associated syndesmotic injuries

isolated syndesmosis injury

Ankle fracture managementNonoperative

short-leg walking cast/boot indications

-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

Ankle fracture managementNonoperative

short-leg walking cast/boot indications

-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

Ankle fracture managementOperative

open reduction internal fixation indications

-any talar displacement -displaced isolated medial malleolar fracture-displaced isolated lateral malleolar fracture

-bimalleolar fracture and bimalleolar-equivalent fracture-posterior malleolar fracture with > 25% joint involvement-open fractures

Ankle fracture managementOperative

open reduction internal fixation indications

-any talar displacement -displaced isolated medial malleolar fracture-displaced isolated lateral malleolar fracture

-bimalleolar fracture and bimalleolar-equivalent fracture-posterior malleolar fracture with > 25% joint involvement-open fractures