Extern conference at MNRH

1. Extern Conference
Chatnupon Prasit
Faculty of medicine, Ramathibodi hospital
Mahidol university

2. A Thai young
man comes with
the Rt ankle pain
2 days ago

3. Present Illness
- 2 days ago he fell in the hold at the street when
he came back to his home after finished the school
- 1 days ago the pain was progressed and not
relieved by the pain killer balm, so he comes to see
the doctor today
- No U/D and history of surgery
- No drug and food allergy
- No smoking, sometimes drink alcohol

4. Primary survey
A : can answer the question, no neck pain
B : normal breathing, good air entry,equal both lungs
C : no sign of shock, no active bleeding
D : E4V5M6, pupil 3 mm RTLBE
E : no external wound

5. Secondary survey
A : no drug and food allergy
M : no current medication
P : none
L : 3 hrs
E : as in the present illness

6. Physical Examination
- V/S : T 36.2 , BP 113/78 , P 80 , RR 18 Sat 100%
- GA : A Thai young man, look pain, good consciousness,
well co-operative
- HEENT : not pale conjunctival, anicteric sclera
- Neck : Impalpable LN
- Heart : normal S1,S2 ,No murmur
- Lung : Normal breath sound, clear both lungs
- Abdomen : soft, not tender , no palpable mass

7. Extremities
Pain, swelling, erythema ,
stepping, no deformity

11. What is your diagnosis ?
Fracture or not ?
If yes, Where ?
What is your management ?

12.  Rt distal fibular fracture
 Increase Medial clear
spaceDeltoid ligament injury

13. Treatment
- ORIF

17. Ankle Fractures

19. Biomechanics
- deltoid ligament (deep portion)
primary restraint to anterolateral talar
displacement
- fibula
acts as buttress to prevent lateral
displacement of talus

20. Mechanism
1.Rotational force
: low energy injury
2.Axial compression
: high energy injury

21. Investigation
1. Plain X ray : AP, Lat , Mortise views to evaluate the
stability and congruity of ankle
1.1 Medial clear space(Mortise view) : ≤ 4 mm and
equal to superior clear space
1.2 tibiofibular clear space : ≤ 6 mm in AP and Mortise
1.3 talocrural : 8-15 degree or ± 2-3 degree from
normal side

24. Classification
1. Lauge-Hansen
1.1 Supination - Adduction (SA)
1.2 Supination - External Rotation (SER)
1.3 Pronation - Abduction (PA)
1.4 Pronation - External Rotation (PER)
2. Danis- Weber
2.1 Infrasyndesmotic(A)
2.2 Transsyndesmotic(B)
2.3 Suprasyndesmotic(C)

25. Lauge-Hansen(SER)

26. Lauge-Hansen(SA)

27. Lauge-Hansen(PER)

28. Lauge-Hansen(PA)

29. Danis - Weber
Infrasyndesmotic
Suprasyndesmotic
Transsyndesmotic
PER
SER
SA

30. Treatment
1. Isolated fracture of medial malleolus
2. Isolated fracture of lateral malleolus(Danis-Weber)
3. Bimalleolar fracture
4. Trimalleolar fracture
5. Pilon fracture

31. 1. Isolated fracture of medial malleolus
- Non-displaced, minimally displaced  Short leg cast
- Displaced > 2 mm  ORIF

32. 2. Isolated fracture of lateral malleolus(Danis-Weber)
- Non-displaced, minimally displaced  Short leg cast
- Displaced(Danis-Weber)
- A  ORIF(if failed Close reduction)
- B  ORIF if displacement > 2 mm or deltoid
ligament, syndesmosis injury
- C  ORIF(for Fibular Fracture) with syndesmosis
screw fixation

33. 3. Bimalleolar fracture
- ORIF(medial and lateral malleolus) with syndesmotic
screw fixation(if injury)
- Not recommend to close reduction and casting
because malunion and nonunion

34. 4. Trimalleolar fracture
- ORIF for medial and lateral malleolus
- Posterior malleolar fragment fixation if
- Fragment > 25% of articular surface
- Gap > 2 mm

35. 5. Pilon fracture
- Non-displaced  closed reduction and casting
- Displaced 
- ORIF
- EF if severe soft tissue injury

36. “감 사”