---

Clinical Assessment: Open Ankle Fracture - Right Medial Malleolus

Wound Analysis (Image)

• Size: Approximately 8-10 cm length x 3-4 cm width
• Depth: Through dermis, subcutaneous fat, and deep fascial/tendinous structures - dense white fibrous tissue (likely tendon) is visible in the wound bed
• Wound edges: Irregular, jagged, severely retracted - consistent with high-energy shear/avulsion mechanism
• Bleeding: Active bright red bleeding from inferior wound margin
• Contamination: Moderate; wound is being irrigated; no gross soil/debris but must be treated as contaminated
• No gross cortical bone exposure visible, though underlying calcaneus/malleolus may be accessible on probing

---

Gustilo-Anderson Classification

Gustilo-Anderson Type IIIA or IIIB

---

Emergency Department Management (Presurgical Phase)

1. Document and photograph the wound - limit repeated dressing removal
2. Neurovascular assessment - assess dorsalis pedis, posterior tibial pulses, capillary refill, sensation (deep peroneal, sural, saphenous territories). If vascular compromise: consider IIIC and call vascular surgery urgently
3. Gentle fracture reduction/realignment - do not force anatomical reduction in ED; aim to restore limb alignment and relieve soft tissue pressure
4. Splint the limb - well-padded posterior splint or bivalved cast in neutral position
5. Wound care - apply moist saline dressing; bedside saline irrigation to remove macroscopic contamination is acceptable; do NOT perform definitive debridement in ED
6. IV antibiotics within 1 hour of arrival (most important single intervention):
   • Type I/II: Cefazolin (Ancef) - 1-2g IV q8h x 48 hours from presentation
   • Type III (this case): Cefazolin + Tobramycin (aminoglycoside) x 48 hours from presentation
   • Penicillin allergy: substitute Clindamycin; high MRSA community rate: add Vancomycin
   • Soil/farm contamination: add Penicillin (single dose for anaerobes/Clostridia)
7. Tetanus prophylaxis - check immunization history; administer tetanus toxoid ± immunoglobulin (TIG) if unknown/unimmunized
8. Analgesia and IV access - adequate pain control, two large-bore IVs, type & crossmatch
9. Imaging: X-ray foot and ankle (AP, lateral, mortise views) - assess medial malleolus fracture pattern, comminution, talar shift, associated fibula/posterior malleolus involvement. Consider CT for surgical planning.
10. Inform senior orthopaedic surgeon immediately - this is an operative emergency

---

Surgical Phase

1. Thorough irrigation and debridement in OT under tourniquet - copious saline lavage (minimum 6L for Type III), excision of all devitalized tissue, loose/non-viable bone fragments
2. Fracture fixation - options:
   • Temporary external fixation as damage control (preferred first for Type IIIB with wound requiring staged closure)
   • ORIF medial malleolus with cannulated screws or tension band wiring once soft tissues allow (typically staged)
   • Assess for bimalleolar/trimalleolar pattern on imaging - may require syndesmosis assessment
3. Soft tissue coverage - wound should NOT be primarily closed in high-energy open fractures; options:
   • Negative pressure wound therapy (VAC dressing) as bridge
   • Delayed primary closure at 48-72 hours if clean
   • Split-thickness skin graft (STSG) or local/free flap if wound cannot be closed (Type IIIB) - plastic surgery involvement within 7 days
4. Antibiotics: Continue per protocol, reassess at each return to OR

---

Special Considerations - Electrical Injury

• Electrical burns can cause injury far beyond visible surface wounds - muscle necrosis, nerve damage, and vascular injury may appear over days (watch for compartment syndrome, myonecrosis)
• Monitor: Urinalysis/urine myoglobin (rhabdomyolysis risk), CK levels, ECG (cardiac arrhythmia risk with high-voltage exposure), renal function
• Surgical debridement may need to be more aggressive than apparent wound suggests - necrosis progresses

---

Summary of Priorities

• Bailey and Love's Short Practice of Surgery, 28th Ed, p.465
• Sabiston Textbook of Surgery, 11th Ed, Table 40.5
• Rockwood and Green's Fractures in Adults, 10th Ed, p. classification chapter

---

Diagnostic Workup - Open Right Ankle Fracture (Medial Malleolus) + Electrical Mechanism

---

A. IMAGING

1. Plain Radiographs (First Line - Do Immediately)

• Medial clear space >4 mm = deltoid ligament disruption / unstable fracture
• Tibiofibular clear space >6 mm = syndesmotic injury
• Talocrural angle asymmetry suggests fibular shortening

• AP, lateral, oblique - rule out associated midfoot, talar, calcaneal injuries from fall impact
• Miller's Review of Orthopaedics, 9th Ed; Rockwood and Green's Fractures in Adults, 10th Ed

---

2. CT Ankle (Urgent - pre-op planning)

• Comminuted medial malleolus fractures
• Suspected posterior malleolus fragment (trimalleolar pattern)
• Intra-articular extension assessment
• Pilon/plafond involvement (from axial load component of fall)
• Syndesmotic injury evaluation
• 3D reconstruction for surgical planning

---

3. Doppler Ultrasound / Ankle-Brachial Index (ABI)

• Mandatory given electrical injury + high-energy mechanism
• Assess posterior tibial and dorsalis pedis flow
• ABI <0.9 = significant vascular compromise → urgent vascular surgery review
• If pulse absent or ABI equivocal → CT Angiography of the limb

---

4. MRI

• Not indicated acutely in this setting
• Reserve for post-acute assessment of ligamentous injury, osteochondral damage, or tendon integrity if clinically relevant

---

B. LABORATORY INVESTIGATIONS

Trauma / Pre-operative Panel (Routine)

---

Electrical Injury-Specific Investigations (Critical in this Case)

---

Infection/Tetanus Baseline

---

C. COMPARTMENT PRESSURE MONITORING

• Clinical signs: 5 Ps - Pain (out of proportion, especially on passive stretch), Pressure (tense compartment), Paralysis, Paraesthesia, Pallor
• Measure compartment pressures if clinical signs equivocal (Stryker or arterial line transducer)
• Threshold for fasciotomy: delta pressure (diastolic BP - compartment pressure) <30 mmHg

---

D. SUMMARY TABLE

---

---

TXA (Tranexamic Acid / Trapic) in This Case

Short Answer

---

1. Systemic IV TXA - GIVE IT (Strong Evidence)

• 1g IV over 10 minutes (loading dose) - give NOW in ED
• Then 1g IV over 8 hours (maintenance infusion)

---

2. Local Wound Soakage (Topical TXA) - Reasonable but Limited Evidence

• 500mg TXA in 10-15 mL normal saline, soak gauze, apply with gentle pressure

• Well-established in elective orthopaedic surgery (arthroplasty, spine) - reduces local blood loss with minimal systemic absorption
• Evidence in open traumatic wounds is limited - most studies are in surgical settings
• Some emergency medicine units use TXA-soaked gauze for traumatic lacerations as local haemostatic adjunct
• No randomised trial specifically in open ankle fractures with active traumatic bleeding

• Direct pressure dressing
• Wound tamponade
• While preparing for definitive haemostasis in OT

---

3. What NOT to Do

• Do NOT delay systemic TXA while preparing local soakage
• Do NOT give if >3 hours from injury (risk of thromboembolic complications)
• Do NOT give if patient has known thromboembolic disease, DIC, or haematuria (renal pelvic clot risk)
• Caution in electrical injury patients - some may have underlying coagulopathy; check coags first if time allows, but do not delay TXA significantly for this

---

Practical Order of Actions

1. IV TXA 1g over 10 min - start immediately if <3h from injury
2. Apply TXA-soaked gauze + pressure dressing to wound as local adjunct
3. Moist saline dressing after haemostasis achieved
4. Splint and arrange urgent theatre