Conference Extern คณิตพัชร์ 8 มิ.ย. 61

1. Noon Conference

2. Case 1
• ผู้หญิงไทยอายุ 35 ปี มาด้วยเท้าขวากระแทกคันเร่งขณะโดนชน 6 ชม.ก่อนมาโรงพยาบาล
• 6 ชม.ก่อนมาโรงพยาบาลขณะขับรถอยู่ได้เกิดอุบัติเหตุรถยนต์ เท้าขวากระแทกคันเร่งรถ หลังจากนั้นมี
อาการปวดบวม ขยับข้อเท้าไม่ได้ จึงมารพ.

3. History
• No U/D
• No drug/food allergy
• No current medication

4. Primary Survey
• A : Can speak, no c-spine tenderness , can flex neck > 45 degree
• B : Normal breathsound equal both lung, trachea in midline, SpO2 99%
CCT => negative
• C : BP 117/80 mmHg, PR 86 bpm, no active bleeding, PCT => negative
• D : E4V5M6, pupil 2 mm RTLBE, orientate to time, place, person
• E : Tender at medial and lateral malleolus with swelling and hematoma

5. Physical examination
• V/S : BP 117/80 mmHg, PR 80, RR 20/min
• GA : A thai woman, alert, well cooperative
• Heart : normal S1S2, no murmur
• Lungs : normal breathsound equal both lung
• Abdomen : Soft, not tender, no guarding
• Extremities : Swelling and tenderness lateral malleolus with
hematoma, limit ROM due to pain, intact sensation, DPA 2+

7. DDx
• Ankle fracture
• Calcaneous fracture
• Talar fracture/Talar neck fracture
• Ankle Sprain

8. Investigation
• Film : Rt ankle AP,Lat
• Film : calcaneus (axial-view)

11. Diagnosis
• cFx Rt calcaneous

12. Calcaneus fracture
• Mechanism traumatic axial loading is the primary mechanism of injury
• fall from height
• motor-vehicle accidents
• Associated injuries
• extension into the calcaneocuboid joint
• vertebral injuries
• contralateral calcaneus

13. Investigation
• Film : AP, lateral, and oblique foot
• Film : Harris view (axial view)

14. Measurement
• Bohler angle (20-40), Gissane angle

15. Classification
• Intra-articular (75%)
-Essex-Lopresti classification
-Sanders classification
• Extra-articular (25%)

16. Extra-articular
• Avulsion injury
=> anterior process by bifurcate ligament
=> calcaneal tuberosity (Achilles tendon avulsion)

17. Bifurcate ligament

18. Calcaneal tuberosity

19. Intra-articular

20. Sanders classification
• based on the number of articular fragments seen on the coronal CT
image at the widest point of the posterior facet

21. Treatment
• Nonoperation
Cast immobilization with nonweightbearing
calcaneal stress fracture [6wk]
small extra-articular fracture (<1cm) [10 – 12 wk]
anterior process fracture involving <25% of calcaneocuboid joint
comorbidities
• Operation
Close reduction with percutaneous pinning
ORIF
Primary subtalar arthrodesis

22. Thank you