Teleconference Ext.พีรพัฒน์  17 พ.ค. 61

1. Peerapat Lertwiram
17/05/2018
Ramathibodi
Orthopedic
Teleconference

2. History
• Patient profile
– A 57-year-old Thai woman
• Chief complaint
– Right ankle pain for 1 hour PTA

3. History(Continue)
• Present illness
– One hour PTA , A patient
slipped on a dry banana
leaf and fell on her right
twisted ankle.
– After that she was not able
to stand or walk.
– Her right ankle was
bruised, swollen and hurt.

4. History(continue)
• Present illness(continue)
– Her head was not damaged and passed out.
– No further site was injured.
– She can still flex her right hip and extend her
right knee.

5. Physical examination
• General appearance
– A Thai woman, alert, well cooperative
• Vital signs
– BP 110/75 mmHg, HR 90/min, RR 16/min,
BT 37.2o
C
• HEENT
– No pale conjunctivae, anicteric sclerae, no
cervical lymphadenopathy

6. Physical examination
• Heart
– Normal S1,S2 , no murmur
• Lung
– Normal breath sound on both lungs, no
adventitious sound
• Abdomen
– Flat abdomen, normoactive bowel sound, no
tenderness, no rebound tenderness

7. Physical examination
• Extremities: Right ankle

11. Film X-ray
• Right ankle AP, Lateral and Mortise
AP Lat Mortise

13. Medial clear space
= 7.29 mm.

14. Talocrural angle = 83o

16. Tibiofibular clear
space = 4.34 mm.

17. Diagnosis
Right Bimalleolar fracture

18. Management
• At ER: Stabilization
– Posterior short leg slab
• Surgery
– ORIF with plate and screw

19. Knowledge
Review

20. Ottawa Ankle Rules
Sensitivity = 100%

21. Radiographs
1. AP view
• Tibiofibular clear space must < 5 mm.
• Talus must be concentric in the joint
1. Lateral view
• Dome of talus should be center under tibia
• Posterior tibial fracture can be identified
1. Mortise view
• Medial clear space < 4 mm.
• Talocrual angle = 83(+/- 4) degrees
• No talar shift

23. Conservative treatment
1. Stable fracture with an intact
syndesmosis
2. Displaced fracture which an
anatomical reduction is achieved

24. Conservative treatment
Short Leg Slab/Cast
6 weeks

25. Indication for surgery
1. Displaced bimalleolar or trimalleolar
fracture
2. Displaced distal fibular fracture with
deltoid insufficiency (Bimalleolar
equivalent)
3. Displace isolated medial malleolus
fracture

26. Indication for surgery
4. Fracture patterns with syndesmosis
disruption
5. Bosworth fracture dislocation
6. Open fracture

28. References