Extern conference ปิ่นธิศา 9 ก.ค. 61

1. EXTERN
NOON
CONFERENCE
Ext.Pinthisa Nisagornsen
Faculty of Medicine Ramathibhodi Hospital

2. Case
• ชายไทย 39 ปี มาด้วยกระโดดจากกาแพง เอาเท้าซ้ายลง ข้อเท้า
บวม เจ็บ
• 7 hr PTA ขณะกาลังตัดกิ่งไม้กระโดดลงจากกาแพงสูง 1 เมตร
เอาเท้าซ้ายลง ไม่เสียหลักล้ม หลังจากนั้นเท้าและข้อเท้าซ้ายบวม
ปวดมาก เดินลงน้าหนักไม่ได้ขยับข้อเท้าไม่ได้จึงมา
โรงพยาบาล

3. Past history
 No underlying disease
 No drug or food allergy
 No current medication

4. Primar
y
Survey
 A: Can speak, No c-spine tenderness,
full active ROM of neck
 B: Normal BS, equal both lungs.
 C: BP 144/93, PCT negative
 D: E4V5M6
 E: Marked swelling with echymosis,
marked tender at lateral maleolus

5. Secondar
y
Survey
 A: No food and drug allergy
 M: No Current medication
 P: No underlying disease
 L: 17.00 1/7/61 (3 hr PTA)
 E: ขณะกาลังตัดกิ่งไม้กระโดดจากกาแพงสู ง 1 เมตร เอา
เท้าซ้ายลง ไม่มีบริเวณอื่นกระแทกพื้น

6. Physical Examination
 V/S : BP 144/93, PR 84, RR 20
 GA : Thai man, Alert, Well cooperate
 Heart & Lungs : Normal
 Abd : Soft not tender
 Back : No midline tenderness
 Extremities : Swelling and tenderness at Lt. lateral
malleolus with echymosis, Limit ROM due to pain,
intact sensation, DPA 2+, Cappillary refill<2 sec

8. Differential Diagnosis
 Ankle fracture [lateral malleolus]
 Calcaneous fracture
 Ankle sprain
 Talus fracture

9. Investigation
 Film Left ankle AP, Lat , Mortise
 Film Left foot AP, Oblique

10. Ankle AP, Lat

11. Ankle Mortise

13. Calcaneus axial view

14. Foot AP, Oblique

15. Diagnosis
 Close fracture left calcaneous
 Close fracture left lateral malleolus

16. Management at ER
 On posterior short leg slap
 Admit
 Pre-op lab : CBC, Elyte, BUN, Cr
 CXR, EKG
 Pain control : Tramol

17. At ward
 Imaging : CT left calcaneous sagittal+
coronal oblique

18. CT scan

20. Management
 Set OR for ORIF with screw

22. Calcaneous Fracture

23. Epidemiology
 Most frequently fractured tarsal
bone
 60-70% is displaced intraarticular
fracture
 10% of calcaneus fracture are open
injuries

24. Anatomy

25. Anatomy

26. Anatomy

27. Mechanism of injury
Traumatic axial loading is the primary of
injury
 Fall from height [most common]
 Motor-vehicle accidents
Twisting forces may be associated with
extra-articular calcaneus fracture

28. Clinical presentation and
evaluation
 Moderate to severe heel pain, associated
with tenderness, swelling, heel widening,
shortening and varus deformitiy
 Echymosis around heel extending to the
arch.
 Blistering from massive swelling
 Open fracture

29. Clinical presentation and
evaluation
 soft tissue and neurovascular status is
essential, Compartment syndrome of
the foot must be ruled out!!!

31. Associated injuries
 Extension to calcaneocuboid joint
[65%]
 Other fracture of lower extrimities
[25%]
 Lumbar spine fractures[10%]
 Bilateral calcaneus fracture [10%]

32. Radiograph evaluation
 AP, lateral and oblique foot
 Harris axial view
 Ankle series

33. Measurement
 Bohler angle [normally between 20-40 degrees]

34. Meaturement
 Gissane angle [105-135 degrees]

35. Radiographic evaluation
 CT scan : obtained in the axial, 30 degree
semicoronal, and saggital plain

36. Classification
 Extraarticulat fracture: avulsion of
• Anterior process by bifurcate ligament

37. Classification
• Sustentaculum tali
• Calcaneal tuberosity [Archillis tendon
avulsion]

38. Classification
 Intraarticular fracture : 2
classification
1. Essex-Lopresti Classification
• Tongue type
• Joint depression type
• Comminuted type

39. Classification
1. Sanders classification
: base on the number
of articular fragments
seen on coronal CT
image at the widest
point of posterior
facet

40. Treatment
 Non-operative

41. Treatment
 Initial treatment is
placement of a
bulky Jones
dressing

42. Treatment
 Non-operative : cast immobilization with
nonweightbearing
• 6 weeks if Calcaneal stress fracture
• 10-12 weeks if
• Small extraarticular fracture [<1cm] with
intact archilis tendon and <2 mm
displacement
• Anterior process fracture involing < 25% of
calcaneocuboid joint

43. Treatment
 Operative
 Indication :
 Displaced intra-articular fractures involving the posterior
facet
 Anterior process of calcaneus fractures with> 25%
involvement of the calcaneal-cuboid articulation
 Displaced fracture of calcaneal tuberosity
 Fracture dislocation of calcaneus
 Open fractures

44. Treatment
 Operation
 Close reduction with percutaneous pinning
 ORIF
 Primaty subtalar arthrodesis

45. THAN
K
YOU
16x9
4x3