Telecon ext.นวพรรษ 28ธค.60

2. ผู้ป่วยชายไทยโสด อายุ 38 ปี อาชีพรับจ้าง ภูมิลาเนาจังหวัดนครราชสีมา
ขับมอเตอร์ไซค์ล้มเอง 1 ชั่วโมง ก่อนมาโรงพยาบาล

4. A : can talk clearly, no stridor ,no posterior neck tenderness

5. ❄B : no trachea shift , no subcutaneous emphysematous
, normal breath sound , equal both lung , CCT : negative

6. C : Vital sign stable ( BP 120/76 mmHg, pulse rate 68 bpm ),
abdomen soft,not tender,no guarding , PCT : negative

7. D : E4V5M6 pupil 3 mm RTLBE

8. E : swelling at right foot with limit ROM due to pain

11. A
M
P
L
E

12. No food and drug allergy

13. No current medication

14. No underlying disease

15. Last meal 19.00
(4 hr ก่อนมา รพ)

16. ดื่มสุรา แล้วขับ MC ล้มเอง ไม่สลบ ไม่มีศีรษะ
กระแทก จาเหตุการณ์ได้หลังล้มปวดเท้าขวามาก

17. ❄HEENT : no pale conjunctivae, anicteric sclerae
❄CVS : full and regular pulse, normal s1 s2 ,no murmur
❄LUNG : equal breath sound ,clear both lungs
❄ABDOMEN : soft ,not tender ,no guarding
❄NEURO : good consciousness,motor power grade V all except right foot ,
sensory intact
❄EXTREMITIES : Rt foot swelling ,limit ROM due to pain
, no pain on passive stretching , no paresthesia
, capillary refill <2 sec
Marked tender

21. ❄ Lisfranc injury Rt foot
❄ Closed fracture base of 5th MTB Rt foot

22. ❄At ER : on posterior short leg slab
❄Set OR for ORIF with Screw with K-wire

24. Intraoperative finding :
• Lisfranc joint injury Rt foot
( Myerson BII )
• Closed fracture Rt 5th MTB
• Tarsometatarsal joint injury
3rd,4th and 5th Rt foot
ORIF with Screw with K-wire

25. Lisfranc
Injury

26. • Diagnosis is missed in about 20% - 30%
• If Lisfranc injury is not diagnosed and
treated properly, it can lead to an altered
gait, midfoot arthritis, and long term
disability ( foot deformity, chronic pain
and dysfunction)
• Associated with compartment syndrome

28.  Large oblique ligament extend from
the plantar aspect of the medial
cuneiform to the base of 2nd
metatarsal bone
 Stabilize the 2nd metatarsal and
maintains the midfoot arch

29.  Medial : 1st tarsometatarsal joints
-> 6 mobility
 Middle : 2nd , 3rd tarsometatarsal joint
-> Rigid
 Lateral : 4th , 5th tarsometatarsal joint
-> Mobile

30. The dorsalis pedis artery and the deep
peroneal nerve both run between the
1st and 2nd metatarsal bases

32. ❄Severe pain at the midfoot and unable to bear weight
❄Swelling in the midfoot dorsally
❄Tenderness over the tarsometatarsal joint
❄Plantar bruising may be present, especially medially

33. • Medial border of the second metatarsal
should line up with the medial border
of the middle cuneiform on both the
AP and Oblique view
• Check for fractures, especially at the
base of the 2nd metatarsal, navicular
and cuboid

34. • Check for widening between
the first and second ray
(more than 2 mm is an
indication for surgery)

36. • In the lateral view, check the dorsal displacement or subluxation of a metatarsal

38. • Check for the FLECK sign
(bony fragment)
• Avulsion fragment of the lisfranc
ligament form the base of the 2nd
metatarsal

39. • The medial side of the fourth
metatarsal should line up with the
medial side of the cuboid

41. Non-operative : Cast immobilization for 6-8 weeks
indications
• no displacement on weight-bearing and stress
radiographs and no evidence of bony injury on
CT ( usually dorsal sprains )
• certain nonoperative candidates

42. Operative : open reduction and rigid internal fixation
indications
• any evidence of instability (> 2mm shift)
• favored in bony fracture dislocations as opposed to
purely ligamentous injuries

43. Skin incision at medial + lateral + dorsal of Rt.foot and release hematome