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Ankle Fracure

Dr ibtissam akramDr ibtissam akram

Epidemiology: Of all the ankle injuries evaluated in the ED, only 15% are ankle fractures. The frequency of ankle fractures has been increasing for the past 20 years, and the rate is approximately 187 in 100,000 person-years. These fracture, if remain untreated are associated with high risk of infection both of bone and soft tissue. Fearsome infection is gas gangrene which can be life threatening. Vascular supplyto ankle and foot can be compromised by either direct injury to blood vessels or development of compartment syndrome (compression caused by increased interstitial pressure following injury). Diagnosis: History and physical examination is important for early diagnosis and avoiding unnecessary exposure of patient to radiation. Signs of fracture involve visible deformity, swelling, bony tenderness, bruising, and inability to bear weight. Differential Diagnoses: • Acute Compartment Syndrome. • Ankle Dislocation in Emergency Medicine. • Ankle Injury, Soft Tissue. • Deep Venous Thrombosis and Thrombophlebitis. • Foot Fracture. • Gout and Pseudogout. • Rheumatoid Arthritis. • Tibia and Fibula Fracture in the ED. No laboratory studies is required for an isolate dfracture caused by a plausible mechanism.. repated frature require complete worku of osteoporosis, charcot marie tooth disase arthritis connective tissue disease peripheral vascular disease. Indications for ankle radiographs in patients with acute ankle pain include pain in the ankle region plus one of the following 12 • 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) • Confounding variables to the Ottawa rules are (1) underlying neurologic deficit affecting lower limb(s), (2) altered mental status, and (3) multisystem trauma. CT and MRI imaging studies may be part of outpatient management where imaging features by the other modalities are equivocal. 17 Treatment: In emergency setup neurovascular status of the extrimities is assessed ankle fracture is identified if it is open fracture it should be ggaurded from further contamination by covering wound with wet sterile dressing secured by loosely wrapped dry sterile gauze . confirm the tetanus immunization status and use antibiotics for contaminated wounds Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone. You might need this procedure to treat your broken ankle. Open reduction means that the orthopedic surgeon reposition your bone pieces during surgery and bring them to their original position. Closed reduction means bringing bone in its original position without surgically exposing the bone. Internal fixation means reconnecting the bone with special screws, plates, rods, wires or nails in the correct place this prevent abnormal healing of the bone. Surgery is usually done under general anesthesia. The procedure is usually performed when: • The pieces of your leg are severely out of position • Your broken bones punctured your skin • Your bones broke into several pieces • Your ankle is unstable Discharge instructions should include elevation of the affected leg, application of ice, and non-weight bearing on the injured joint. Ice packs can be applied to areas of swelling for 10-15 minutes every 3-4 hours while awake for the first 24-48 hours. Ice works through splints. [21, 22] Advise patients to refrain from bearing weight on the ankle until seen by orthopedist. Provide crutches and instructions on their proper use. Ensure proper use of the crutches before discharge from the ED. All patients with ankle fractures should receive follow-up instructions for consultation with a specialist (eg orthopedist, podiatrist). Many fractures, with the exception of most unimalleolar fractures, will eventually require ORIF. Patients with gait disorders or other reasons that caused the ankle fracture must be assessed for a safe discharge to home. The ankle fracture might have a low morbidity, but concomitant inability to attend to activities of daily living due to conditions, such as ataxia or peripheral neuropathy, may warrant mobilization of additional support services or admission. Provide written and oral information on cast and/or splint care and ensure that the patient understands which symptoms warrant immediate physician notification and/or return to the ED. With increased immobilization, patients are at higher risk for deep vein thrombosis (DVT). Complications: • Nonunion of the fracture site requires orthopedic referral for operative repair. • Malunion occurs more frequently than non union leading to degenerative changes. Symptoms include pain, weakness and instability of the joint. • Traumatic arthritis complicates 20-40% of ankle fractures. Generally, the more severe the fracture, the greater the likelihood of posttraumatic arthriti. Older patients have an increased risk of arthritic complications. • Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle fractures. Clinical features include complex pain, muscle atrophy, cyanosis, and edema. The term Sudeck atrophy is reserved for RSD-like conditions accompanied by a characteristic radiographic appearance (ie, spotty rarefaction), as opposed to the ground-glass appearance seen with disuse atrophy of bone. • Osteochondral fractures of the talar surface can easily go unrecognized and if left untreated may result in chronic pain, locking, and swelling. If suspected, arrange appropriate orthopedic follow-up care. • In children, ankle fractures involving the growth plate may cause chronic deformity with disturbance of growth of the limb


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