This case involves a 35-year-old Thai male who experienced a motorcycle accident 11 hours prior to arriving at the hospital. He sustained an open fracture of the right distal fibula and a closed fracture of the right medial malleolus. In the emergency room, his wounds were irrigated and dressed, and antibiotics and splinting were provided. In the operating room, he underwent debridement, irrigation, fracture stabilization, and wound closure. As this was a Gustilo Type IIIA open fracture, antibiotic treatment included clindamycin and an aminoglycoside for several days. Operative management with open reduction internal fixation was indicated given the displaced fractures and open nature of the injury.

1. Interesting Case
Conference

2. ชายไทยอายุ 35 ปี
ประสบอุบัติเหตุรถจักรยานยนต์ล้ม 11 ชั่วโมง ก่อนมา
โรงพยาบาล

3. Primary survey
Airway and C-spine
able to talk, no tracheal shift, no c-spine tender
Breathing
Equal breath sound both sound both lungs,
clear, no rib stepping
Circulation
BP 134/85mmHg, PR 97 bpm
Disability and neurologic status
E4V5M6 pupil 2mm RTLBE
Exposure/Environment control
Laceration wound 5cmx6cm at Right dorsal
ankle, able move toes, not able to move ankle

5. Adjunct to Primary survey
Chest X-ray

6. Adjunct to Primary survey
Chest X-ray
No Hemothorax, No Pneumothorax

7. Secondary survey
Allergy : Penicillin Allergy (Rash)
Medication : No current medication
Past history : No underlying disease
Last meal : 11Hr PTA(12:00)

8. Secondary survey
Event :11 Hr PTA ขับรถจักรยานยนต์แล้วจักรยานยนต์ล้มเอง
จักรยานยนต์ไม่ได้ทับขาขวาของตนหลังจากล้ม
ไม่หมดสติตอนที่จักรยานยนต์ล้ม ไม่มีศีรษะกระแทก
สามารถขยับ นิ้วเท้าได้ แต่ขยับข้อเท้าขวาไม่ได้
มีแผลเปิดที่ข้อเท้าขวา
มีผู้เห็นเหตุการณ์นาส่งโรงพยาบาลเอกชน
ที่โรงพยาบาลเอกชนได้ irrigate, Dressing, Short leg slab
แล้ว Refer มาโรงพยาบาลมหาราชนครราชสีมา

9. Secondary survey
GA: Thai male, good consciousness, well co-operative
V/S: T 37.2C,BP 134/85mmHg, PR97bpm, RR20
HEENT: Not pale conjunctivae, no icteric sclerae
Heart: full regular pulse, normal S1S2, no murmur
Lungs: clear and equal breath sound both lungs
Abdomen: normoactive bowel sound, soft, not tender
Extremities: 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 feet
Skin: no rash, no petechiae

12. Adjunct to Secondary survey
1.Film Right ankle AP
Lateral
Mortise
2.Film Right Foot AP
Oblique
3.Film Right leg AP
Lateral

13. AP Lateral Mortise

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

15. Lateral
- comminuted oblique Fx of distal fibula

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

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

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

21. Problem list
1. Open fracture of right distal fibula
2. Close fracture of right medial malleolus

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

27. Diagnosis
1.Open fracture (Gustilo IIIA)
2.Ankle fracture (SA II)

28. Open fracture management
1.Management in the Emergency Room
2.Management in the Operating Room
3.Antibiotics treatment

29. 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

30. Management in the Emergency Room
In this case
1.Initial trauma survey and resuscitation
2.Antibiotics
Gentamycin 240g iv od x3 days
Clindamycin 600mg iv q8hr
3.Control bleeding
-Venous suture มาจากที่โรงพยาบาลเอกชน
4.Assessment
-soft-tissue damage :deep to subcutaneous
-neurovascular exam :intact
5.Dressing
-remove gross debris from wound : ส่งไปทาใน OR ทันที
-place sterile saline-soaked dressing on the wound
6.Stabilize
-on short leg slab มาจากโรงพยาบาลเอกชน

31. Management in the operating room
1.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 removed
2.Fracture stabilization
- can be with internal or external fixation, as indicated
3.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

32. Management in the operating room
In this case
1.Debridement and Irrigation with Normal Saline
2.Repair extensor digitorum longus muscle
3.Place Drainage
4.Suture wound with Nylon 3-0
5.On short leg slab

33. Management in the operating room
In this case

34. Management in the operating room
In this case

35. Antibiotics treatment
Gustilo 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

36. Antibiotics treatment
In this case
Gustilo Type IIIA
-1st generation cephalosporin and aminoglycoside
So
-Gentamycin 240mg iv od x 3days
-Clindamycin 600mg iv q8hr

37. 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

38. 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

39. Ankle fracture management
Nonoperative
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

40. Ankle fracture management
Nonoperative
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

41. Ankle fracture management
Operative
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

42. Ankle fracture management
Operative
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