• Patient: Nguyen Duc Long, male, 37 years old (DOB 16/09/1989)
• Admitted: 08/07/2026, 15:49, from Nghe An province
• Mechanism: Workplace accident - pulled into a rotating machine drum
• Injury: Left ankle dislocation with penetrating joint wound (thau khop), lateral ligament tear (day chang delta rupture), articular cartilage injury
• Comorbidity: Gastroesophageal reflux disease (GERD)
• Initial management: Closed reduction + cast (anterior slab)
• Surgery (18:50, 08/07/2026): Wound exploration + debridement + deltoid ligament repair + joint capsule repair
• Post-op course: Stable, daily wound care, good distal pulses
• Currently (examination day 14/07/2026 = POD 6): Stable, wound with minimal serous drainage, bilateral lower limb movement intact, bilateral pedal pulses palpable
• Labs: WBC 10.43 (elevated), neutrophil 57%, Hb 12.9 g/dL, platelets 258, PT 106%, INR 0.96, APTT 27.2s, Na 143.8, K 3.97, Cl 108, Cr 97, glucose 4.76, GFR 80.73, ALT 37, AST 27 - all largely normal
• X-rays: No bony injury; widened tibiotalar joint space (left); no lung pathology on CXR
• Medications post-op: Ceftazidime IV + Levofloxacin IV (switched to Amoxicillin-clavulanate oral on day 5), Paracetamol IV/oral, Celecoxib oral, Esomeprazole oral
• Classification: Open ankle dislocation (Gustilo-type open wound with joint penetration) - Shelbourne classification or standard open dislocation

ORTHOPAEDIC CASE RECORD

I. ADMINISTRATIVE INFORMATION

II. CLINICAL CONTENT

5. Clinical Diagnosis

6. Investigations and Results

• Chest X-ray (AP, 1 film): No abnormal findings. Heart not enlarged. Lungs clear. No pleural effusion or pneumothorax.
• Left ankle X-ray - AP and lateral views (2 films):
  • Bone structures: No fracture identified.
  • Joint space: Widened tibiotalar (mortise) joint space on the left - indicating disruption of supporting ligamentous structures.
  • Soft tissues: Difficult to assess due to overlying cast artifact.
  • Conclusion: Widened left ankle (tibiotalar-fibular) joint space - consistent with ankle ligament disruption and dislocation.
• Left leg X-ray - AP and lateral (2 films):
  • No bony injury identified.
  • Conclusion: Soft-tissue blurring artifact over left ankle region; no osseous injury on left leg.

7. Definitive Diagnosis

• Left open ankle dislocation with penetrating ankle joint wound (open dislocation, Gustilo-Anderson Type I - wound <1 cm, clean, without extensive soft-tissue damage)
• Deltoid ligament (medial collateral ligament) rupture, left ankle
• Articular cartilage injury of the left ankle (talus/distal tibia surface)

• Open ankle dislocation: Gustilo-Anderson Type I (wound ~1 cm, minimal contamination)
• ICD-10: T14.3 (Dislocation, sprain, and avulsion of unspecified body region) / M24.37 (Pathological dislocation, ankle and foot) / S93.0 (Dislocation of ankle joint)

• Superficial wound of the left ankle (penetrating joint wound)
• Pre-existing gastroesophageal reflux disease (GERD) - K21 (not related to injury)

8. Operative Report

1. Patient positioned supine. Left lower limb prepped and draped in sterile fashion.
2. Tourniquet inflated to 250 mmHg.
3. The existing medial ankle wound was extended and explored: a tear of the joint capsule was identified; the medial articular surface (talus/tibia) showed cartilage damage; the deep venous structures were intact.
4. The deltoid (medial collateral) ligament was found to be completely ruptured.
5. The joint was thoroughly irrigated with copious normal saline; necrotic/contaminated tissue was debrided.
6. The deltoid ligament was repaired with interrupted absorbable sutures. The joint capsule was repaired in layers.
7. Skin closed in layers; wound dressed; a below-knee posterior slab cast was applied with the left ankle in neutral position.

9. Postoperative / Post-Cast Course

10. Clinical Examination (POD 6 - 14 July 2026)

• Level of consciousness: Alert, oriented to person, place, and time; Glasgow Coma Scale 15/15
• General appearance: Well-nourished male, appears comfortable at rest, in mild to moderate distress on movement of the left lower limb
• Vital signs:
  • Blood pressure: 100/70 mmHg (within normal limits)
  • Heart rate: 80 beats/min, regular
  • Respiratory rate: 18 breaths/min
  • SpO2: 98% on room air
  • Temperature: Afebrile (no fever documented)
  • Body weight: 60 kg; height: 165 cm; BMI: 22.0 kg/m²

• Inspection: Left ankle and distal leg in a below-knee posterior slab plaster cast in neutral position. The medial aspect of the left ankle is visible at the wound site: wound approximately 1 cm in length (medial ankle), edges approximated with sutures, wound covered by dressing; minimal serous discharge noted on dressing change. Surrounding skin is mildly oedematous. No erythema spreading beyond wound margins. No skin necrosis.
• Palpation: Tenderness at the medial ankle wound. Left foot warm. Left dorsalis pedis pulse palpable (was absent on admission, now restored post-reduction). Capillary refill <2 seconds, left toes pink and warm.
• Movement: Left toe flexion and extension present and equal bilaterally. Left ankle range of motion not assessed (cast in situ). Right ankle and foot: full, pain-free range of motion.
• Neurovascular status: SpO2 100% on left toe pulse oximetry. No signs of compartment syndrome (no tense calf, pain with passive toe extension, or paraesthesia).

• Joint space: Reduction maintained; tibiotalar alignment restored.
• Bone: No fracture. No hardware (no metallic implant - soft-tissue repair only).
• Soft tissue: Cast in situ.
• Conclusion: Satisfactory anatomical reduction of left ankle dislocation maintained.

11. Case Summary

• History: Left ankle deformity, reduced range of motion, and medial ankle wound immediately after workplace injury
• Pre-reduction X-ray: Widened tibiotalar joint space (left)
• Intraoperative: Confirmed torn joint capsule and deltoid ligament; loose ankle joint

• Wound at medial ankle approximately 1 cm, with intraoperative communication with the joint space confirmed
• Serous/synovial-like discharge noted intraoperatively and on dressing changes
• Elevated WBC on admission (10.43 x10⁹/L) consistent with acute traumatic/inflammatory response

• On admission: left dorsalis pedis pulse absent
• Post-reduction and post-operative: left dorsalis pedis pulse palpable; SpO2 100% left toe; foot warm and well-perfused

• All X-rays: no cortical break, no periosteal reaction; purely ligamentous/soft-tissue injury

• Toes warm, pink, SpO2 100%, pain not disproportionate, passive stretch did not elicit severe pain, no tense calf compartment

• Active toe movement present bilaterally; no footdrop; sensation intact

12. Conclusion

13. Further Treatment

1. Continue analgesics (stepwise: IV Paracetamol transitioning to oral; add Celecoxib for anti-inflammatory effect)
2. Continue antibiotic course (oral Amoxicillin-clavulanate to complete a 7-10 day total antibiotic course from the time of surgery)
3. Continue proton pump inhibitor (Esomeprazole) for GERD and gastric protection during NSAID use
4. Daily wound dressing and suture care; plan for suture removal at approximately POD 10-14 if wound healed
5. Continue posterior slab cast immobilisation for 4-6 weeks total
6. Physiotherapy and rehabilitation after cast removal
7. Follow-up outpatient review at 4-6 weeks (with repeat X-ray), 3 months, and 6 months

• Paracetamol (Hapacol Caplet 500 mg) - 500 mg orally, 1 tablet three times daily (morning, afternoon, evening; every 8 hours); maximum 4 doses/day
• Celecoxib (Beroxib) 200 mg - 1 capsule orally once daily in the morning with food; continue for 5-7 days post-discharge

• Amoxicillin/Clavulanate (Curam 1000 mg: Amoxicillin 875 mg + Clavulanate 125 mg) - 1 tablet orally twice daily (morning and evening) for a total antibiotic duration of 10 days from the day of surgery (08/07/2026); course ends approximately 18/07/2026

• Esomeprazole (Esomeprazol 40 mg) - 1 tablet orally once daily in the morning (30 minutes before breakfast); continue throughout antibiotic and NSAID course and ongoing for GERD management

• Daily wound dressing change by nursing staff; inspect for signs of infection (erythema, purulent discharge, wound dehiscence)
• Suture removal: POD 12-14 (approximately 20-22 July 2026) if wound is fully healed

• Maintain posterior slab below-knee cast in neutral ankle position
• Non-weight-bearing on left lower limb with crutch support
• Transition to a removable cast brace at 4-6 weeks, then protected weight-bearing with physiotherapy

• Oral Amoxicillin-clavulanate is chosen for step-down therapy from IV antibiotics; its broad spectrum covers skin flora and anaerobes appropriate for a contaminated open joint wound in a construction worker. The deltoid ligament and capsule repair was chosen over conservative management because: (1) the joint was found to be loose and unstable intraoperatively, (2) the open wound allowed direct access for repair, and (3) primary repair of the deltoid ligament in acute open ankle dislocations has better outcomes than delayed reconstruction. Cast immobilisation maintains alignment during ligament healing.

14. Prognosis

• Risk of surgical site infection: moderate - given the open (contaminated) nature of the original wound in a construction worker; mitigated by adequate debridement, copious irrigation, and antibiotic therapy. Requires vigilant wound monitoring.
• Risk of wound dehiscence: present given the anatomical location (the ankle is subjected to skin tension); managed by keeping the limb elevated and immobilised.
• Risk of deep vein thrombosis (DVT): present due to immobility and lower limb injury; patient should be encouraged to perform active toe and knee exercises while in bed; consider low-molecular-weight heparin prophylaxis if prolonged immobility.
• Vascular status: currently restored; close monitoring of distal pulses required to detect any delayed vascular compromise.
• The patient had no pre-operative cardiovascular, renal, or hepatic impairment, and no diabetes, which reduces risks of delayed wound healing and systemic complications.

• Ankle joint instability: if ligament repair heals adequately, recurrent instability is unlikely; however, incomplete healing of the deltoid ligament may result in chronic medial ankle instability requiring bracing or delayed reconstruction.
• Post-traumatic ankle osteoarthritis: cartilage damage noted intraoperatively makes early osteoarthritis a realistic long-term complication, particularly if anatomical reduction was not perfectly maintained or if weight-bearing is resumed prematurely.
• Functional recovery: expected gradual return to full ambulation over 3-6 months with dedicated physiotherapy; return to construction work possible but may require modified duties for 6-12 months.
• Stiffness: ankle stiffness is common after prolonged cast immobilisation; aggressive physiotherapy post-cast-removal is essential to restore full range of motion.

15. Preventive Measures

1. Infection prevention:
   • Complete the full antibiotic course (do not stop early even if wound appears healed).
   • Strict wound care technique with daily sterile dressing changes.
   • Educate the patient to watch for warning signs of infection: fever, increasing redness, purulent discharge, or wound breakdown, and to return to hospital immediately if these occur.
2. DVT/PE prevention:
   • Active ankle pumping exercises and quadriceps sets while immobilised in bed.
   • Early ambulation with crutches (non-weight-bearing on left) once safe.
   • Consider pharmacological DVT prophylaxis (enoxaparin 40 mg SC once daily) if the patient remains bed-bound for more than 48 hours post-operatively.
3. Ankle instability and osteoarthritis prevention:
   • Strict compliance with cast immobilisation for the prescribed 4-6 weeks to allow adequate ligament healing.
   • After cast removal: structured physiotherapy including proprioception training, peroneal and tibialis strengthening, and progressive range-of-motion exercises.
   • Avoid early return to high-impact or uneven-surface activities.
   • Long-term follow-up with repeat X-ray at 6 months and annually to detect early osteoarthritic changes.
4. GERD management:
   • Continue Esomeprazole throughout the course of NSAID (Celecoxib) use to prevent peptic ulceration.
   • After stopping NSAIDs, reassess the need for continued PPI therapy.
5. Workplace safety:
   • On return to work, advise the patient and employer on workplace modifications to prevent recurrent machinery-related injuries (mandatory machine guards, personal protective equipment for lower limbs).

16. Comments

• At the scene: the record does not specify field immobilisation; ideally, the injured limb should have been splinted in the position found and the wound covered with a clean dressing before transport to hospital. Improper movement at the scene risked worsening vascular compromise and contaminating the wound further.
• In the Emergency Department: the initial closed reduction with a plaster slab was appropriate first-line management to restore alignment and vascular flow (left dorsalis pedis pulse returned post-reduction). Urgent surgical exploration was then correctly indicated given the penetrating joint wound.

• Operative management with wound exploration, debridement, deltoid ligament repair, and joint capsule repair was appropriate for this open ankle dislocation. For a Gustilo Type I open ankle dislocation, surgical debridement and primary repair within 6 hours of injury is the standard of care. The surgery was performed approximately 3 hours after admission, which is within the optimal window.
• The choice of soft-tissue repair alone (no metallic implant) is consistent with the absence of a concomitant fracture; internal fixation would only be indicated if bony instability were present.
• The antibiotic choice (Ceftazidime + Levofloxacin IV, stepped down to Amoxicillin-clavulanate oral) is appropriate for a contaminated open joint wound in a construction worker, covering gram-positive, gram-negative, and anaerobic organisms.

• Mild leukocytosis (10.43 x10⁹/L) is expected in acute trauma with open wound and is not necessarily indicative of established infection.
• Normal coagulation profile and renal function support safe surgical intervention and antibiotic use.
• X-ray showing widened tibiotalar joint space without fracture is consistent with a purely ligamentous dislocation pattern.
• The absence of bony injury on X-ray is consistent with the mechanism (rotational dislocation rather than axial fracture mechanism).

• An MRI of the left ankle (once acute phase resolved) would better characterise the extent of cartilage and ligament damage and guide rehabilitation.
• Formal ankle scoring (e.g., AOFAS Ankle-Hindfoot Scale) should be recorded at baseline and follow-up visits to objectively quantify functional recovery.
• DVT prophylaxis documentation was not explicitly noted in the record and should be addressed.