Extern ConferenceBY CHAWANIN LERSPONGPAIBOOL RAMATHIBODI 5402029

ผปวยหญงไทยค 32 ป ภมลำ�เน� จ.นครร�ชสม� อ.ปกธงชย สทธประกนสขภ�พถวนหน� Chief Complaint : ลมขอเท�ขว�พลก 4 ชม.

PTA

Primary Survey

A : can speak, no cervical tenderness, full ROM of neck

B : clear breath sound both C : BP 133/76 mmHg, full regular pulse 91 bpm,

capillary refill < 2 sec D : E4V5M6 pupil 3 mm RTLBE E : no external wound

Secondary survey A : no drug allergy M : no current medication P : no underlying disease L : last meal 5 hr PTA E : 4 ชม. PTA ผปวยเดนอยบรเวณบ�น เท�ขว�สะดด

กบรองปน ขอเท�บดออกด�นนอก เสยหลกลมลง หลง จ�กนนมอ�ก�รปวดบรเวณขอเท�ขว� ขยบขอเท�ไดเลก

นอย มอ�ก�รปวดม�กขนเมอขยบ ขยบนวเท�ไดปกต เดน ลงนำ�หนกไมได รสกเจบหน�แขงเลกนอย ไมมอ�ก�รช�ท

บรเวณเท� ขยบนวเท�ไดปกต ไมมอ�ก�รเจบบรเวณอน

Physical Examination: Vital signs: BP 133/76 mmHg, PR 91 bpm, T 36.8 C, RR 20 General Appearance: A Thai female, good consciousness, well

co-operative HEENT: not pale, no jaundice Lung: clear, equal breath sound both CVS: normal s1, s2, no murmur Abdomen : soft, tender

Extremities: Right leg

Ottawa ankle rule Bony tenderness at

the distal 6 cm of the posterior edge of the medial malleolus

Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus

Inability to bear weight both immediately and in the ED (defined as 4 steps)

(1) underlying neurologic deficit affecting lower limb(s), (2) altered mental status, and (3) multisystem trauma. (4) age < 18 years

Investigation Film right ankle AP, Lateral, Mortise Film right leg AP, lateral

11.69 mm

5.72 mm

Diagnosis Right proximal fibular fracture with right medial malleolus

with distal tibiofibular syndesmosis injury

Maisonneuve injury

Maisonneuve injury Spiral fracture of the upper third

of the fibula with disruption of the distal tibiofibular syndesmosis and associated injuries

eg. fracture of the medial malleolus, fracture of the posterior malleolus, and rupture of the deltoid ligament

Key point! Ankle joint sprain or ankle fracture alone – proximal

fibular is missed.

Proximal fibular fracture alone – ankle injury is missed.

Long leg film that includes the ankle is necessary in case

Patient with proximal fibular fracture to exclude the presence of ankle injury

Unexplained increase in the medial clear space of the ankle joint to diagnose that presence of a high fibular fracture

Syndesmosis rupture Decreased tibiofibular overlap - normal >6 mm on AP view - normal >1 mm on mortise view Increased medial clear space - normal less than or equal to 4 mm Increased tibiofibular clear space - normal <6 mm on both AP and mortise views

Initial Management Check neurovascular (Beware of compartment

syndrome) Immobilize with Posterior long leg slab Leg Elevation Control pain Admit for observation of compartment syndrome Refer for surgery

Definite Treatment

Open reduction with fixation

Syndesmotic fixation Immobilization with

posterior long leg cast for 8-12 wk

References Bharati S. Kalyani, MD; Craig S. Roberts, MD; Peter V.

Giannoudis, MD, FRCS; The Maisonneuve Injury: A Comprehensive Review, Orthopedics March 2010 - Volume 33 · Issue 3

www.orthobullets.com ; Ankle fractures by Ben Taylor www.radiologyassistant.nl www.youtube.com ; Dr. Nabil A. Ebraheim