ORTHOPAEDIC CASE RECORD

I. ADMINISTRATIVE INFORMATION

II. CLINICAL CONTENT

1. Reason for Admission

2. History of Present Illness

3. Past Medical History

• Comorbidities: Gastroesophageal reflux disease (GERD / Benh trao nguoc da day - thuc quan, ICD K21) - previously known.
• Habits / risk factors: No documented tobacco, alcohol, or other substance use. No known drug allergies documented at admission.
• Residual musculoskeletal impairments: None documented prior to this admission.

4. Condition on Admission

• Level of consciousness: Alert and oriented, cooperative (Benh tinh, tiep xuc tot).
• Vital signs:
  • Heart rate: 78 bpm
  • Blood pressure: 120/70 mmHg
  • Respiratory rate: 20 breaths/min
  • SpO2: 98% (room air) at the left toe: 100%
  • Temperature: Afebrile (no fever documented)
  • Weight: 60 kg | Height: 165 cm | BMI: 22.04
• Key physical findings on admission:
  • Skin/mucosa: Pink, well-perfused
  • Left ankle: Significant deformity, open wound on medial aspect (~1 cm), minimal bleeding
  • Left foot pulses: Right dorsalis pedis - palpable; Left dorsalis pedis - NOT palpable
  • Left toe sensation and color: Normal (pink, SpO2 100%)
  • Left ankle and foot range of motion: Reduced
  • Cardiovascular: Regular rhythm, normal heart sounds
  • Lungs: Clear to auscultation bilaterally
  • Abdomen: Soft, non-tender, no localized tenderness

POSTOPERATIVE FORMAT

5. Clinical Diagnosis (Pre-operative)

• Primary diagnosis: Left ankle dislocation (open, post-traumatic) - Trat hop co chan trai da nan do tai nan lao dong
• Associated injuries:
  • Open wound of the left ankle (suspected intra-articular wound / vet thuong thau khop co chan trai)
  • Bong gan va cang co vung co the khong xac dinh (sprain and muscle strain at the ankle region, unspecified)
• Comorbidity: Gastroesophageal reflux disease (K21)

6. Investigations and Results

1. Chest X-ray (AP view, 08/07/2026):
   • No abnormal findings. Heart size normal. Lungs clear. No pleural effusion. No pneumothorax.
   • Conclusion: Normal chest X-ray.
2. Left ankle X-ray (AP + lateral views, 08/07/2026):
   • No bony fracture identified.
   • Widened talocrural (tibiotalar) joint space on the left - "Rong khe khop chay - sen trai" (widened tibiotalar / talar joint space on the left).
   • Soft tissue obscured by plaster cast artifact.
   • Conclusion: Widened left tibiotalar joint space, consistent with ankle dislocation. No fracture identified on available radiographs.
3. Left lower leg X-ray (AP + lateral views, 08/07/2026):
   • No bony injury detected.
   • Soft tissue: obscured by cast artifact.
   • Conclusion: No fracture of the left lower leg.

7. Definitive Diagnosis

1. Primary: Open left ankle (tibiotalar) dislocation - post-traumatic, occupational injury (ICD T14.3 / M24.37)
   • Associated with torn joint capsule and talar cartilage/osteochondral injury (found intraoperatively)
   • Associated with disruption of the calcaneofibular/deltoid ligament complex (Delta ligament - Day chang delta)
2. Complication: Open wound of the left ankle with suspected/confirmed intra-articular communication (penetrating joint wound - vet thuong thau khop co chan trai) (ICD S91)
3. Comorbidity: Gastroesophageal reflux disease (ICD K21)

8. Operative Report

• Phase 1 (Emergency, 16:10 on 08/07/2026): Closed reduction of left ankle dislocation + plaster cast immobilization (Nan, bo bot trat khop co chan [bot lien]) - performed under local intra-articular anesthesia (Lidocaine). Traction-reduction along the long axis of the left ankle was performed; the joint was confirmed reduced with return of the left dorsalis pedis pulse and SpO2 100% at the toes. An open/penetrating wound with yellowish fluid (suspected synovial fluid - intra-articular) was noted at the medial ankle.
• Phase 2 (Operative, 18:50 on 08/07/2026): Surgical exploration, debridement, capsular repair, and delta ligament repair of the left ankle (Phau thuat cat loc + khau bao khop + Day chang delta, co chan trai) under spinal anesthesia (gay te tuy song).
  • Patient positioned supine.
  • Left thigh tourniquet applied at 250 mmHg.
  • Wound was extended to allow full exposure.
  • Findings: Torn joint capsule, osteochondral/cartilage injury to the talus, lax/torn delta ligament.
  • Joint was thoroughly irrigated with large volumes of saline.
  • Capsule was repaired, delta ligament was repaired/reinforced, wound was closed in layers.
  • Posterior slab/splint applied in neutral position.

9. Postoperative / Post-Cast Course

• Postoperative day 1 (09/07/2026): Patient alert and cooperative. Stable vital signs. Wound dressed, minimal discharge. Both lower limbs move well. Bilateral dorsalis pedis pulses palpable. No numbness. Wound dressing and suture care performed.
• Postoperative day 2 (10/07/2026): Patient alert. Vital signs stable. Wound dressing shows minimal serous discharge. Both ankles move well. Bilateral dorsalis pedis pulses palpable. Wound dressing change performed.
• Postoperative days 3-5 (11-13/07/2026): Patient alert, cooperative. Vital signs consistently stable. Wound shows minimal serous discharge on dressing. Both lower limb movements maintained. Bilateral dorsalis pedis pulses intact. Wound dressing changes and suture care performed on each day. Mild wound pain noted on 13/07/2026.
• Current status (as of 14/07/2026, day 6 post-operation): Patient reports pain at the operative site. Wound shows minimal serous discharge. Motor function of both lower limbs maintained. Bilateral dorsalis pedis pulses present.

10. Clinical Examination (Current - Postoperative Day 6, 14/07/2026)

a. General Examination

• Conscious, alert, fully oriented, cooperative
• Vital signs: Stable (HR ~80 bpm, BP ~100/70 mmHg documented postoperatively; afebrile)
• Nutritional status: Normal (BMI 22.04)
• Skin/mucosa: Pink, warm, no jaundice or cyanosis
• Peripheral lymph nodes: Not enlarged

b. Systemic Examination

• Posterior plaster splint in situ, left ankle in neutral position
• Wound: Closed in layers, minimal serous discharge on dressing; wound is clean
• No signs of compartment syndrome (toes pink, warm, SpO2 100%, Homan's sign not documented as positive)
• Left dorsalis pedis pulse: Palpable (returned after reduction)
• Left toe sensation: Normal (pink, warm)
• Active toe flexion and extension: Preserved
• Ankle range of motion: Restricted by splint (appropriate at this stage)
• No local signs of infection (no erythema, no purulent discharge, no fever)

11. Case Summary

1. Confirmed left ankle dislocation (post-reduction / post-operative):
   • Mechanism: Crush/twist injury to left ankle at construction site
   • Pre-reduction: Deformity of left ankle-foot, absent left dorsalis pedis pulse, reduced ankle motion, open medial wound
   • Post-reduction confirmed by restoration of pulse and X-ray joint alignment
2. Open / penetrating ankle joint wound:
   • Medial ankle wound (~1 cm), with yellowish fluid (synovial fluid), confirmed intra-articular communication intraoperatively
   • Torn joint capsule and delta ligament found at surgery
3. Intra-articular (osteochondral) and ligamentous injury:
   • Torn joint capsule
   • Loose/torn delta (medial) ligament complex
   • Talar cartilage/osteochondral injury (found intraoperatively)
4. Postoperative stable course:
   • No compartment syndrome
   • No signs of surgical-site infection as of day 6
   • Bilateral lower limb perfusion intact
5. Comorbidity (GERD): Managed with esomeprazole throughout admission.

12. Conclusion

13. Further Treatment

a. Treatment Plan

1. Continue dual antibiotic therapy (oral phase) until wound is fully healed - to prevent/treat joint infection
2. Continue analgesia (paracetamol, celecoxib) for pain control
3. Continue proton pump inhibitor (esomeprazole) for GERD management
4. Continue wound dressing changes with suture care
5. Maintain posterior splint immobilization of the left ankle in neutral position
6. Plan for suture removal when wound healing is adequate (typically day 10-14 post-op)
7. Progressive protected weight-bearing and physiotherapy following confirmed wound healing and ligament healing
8. Follow-up X-ray of the left ankle at appropriate intervals

b. Specific Treatment Regimen

• Levofloxacin 500 mg/100 mL IV infusion, once daily (8:00 AM), drip rate XXX drops/min
• Amoxicillin-clavulanate (Curam) 1000 mg (875/125 mg), 1 tablet orally twice daily (morning and evening) - for step-down oral therapy

• Paracetamol (Hapacol Caplet 500) 500 mg orally, 3 times daily (morning, afternoon, evening)
• Celecoxib (Beroxib) 200 mg orally, once daily (morning) - as adjunct NSAID analgesic

• Esomeprazole 40 mg orally, once daily (morning)

• Wound dressing change with suture care (wound length <15 cm) once daily

• Continue posterior plaster splint, left ankle neutral position; transition to functional splint/cast when wound is healed

• Antibiotics: An open dislocation with confirmed joint penetration carries a high risk of septic arthritis and osteomyelitis. Dual antibiotic coverage (levofloxacin covering Gram-negative organisms and amoxicillin-clavulanate covering Gram-positive and anaerobic bacteria) is appropriate for a contaminated open joint wound in a construction worker. IV levofloxacin is continued for broad coverage while transitioning to oral amoxicillin-clavulanate for convenience and outpatient-readiness.
• Analgesia: Paracetamol is the first-line safe analgesic. Celecoxib (COX-2 selective NSAID) is added as a multimodal analgesic adjunct with a better gastric safety profile than non-selective NSAIDs, particularly appropriate given the patient's known GERD.
• Esomeprazole: Gastric protection is essential given the known GERD and concurrent NSAID use.
• Immobilization: Posterior splinting maintains reduction, protects the repaired capsule and ligament, and allows wound monitoring.

14. Prognosis

• Risk of surgical-site infection / septic arthritis: The open wound with intra-articular communication is the most significant short-term risk. Despite adequate debridement and antibiotic coverage, a contaminated joint remains at risk, particularly given the construction site environment.
• Risk of wound dehiscence: Tension on wound edges and movement could compromise healing; the splint mitigates this.
• Risk of re-dislocation or loss of reduction: The torn ligamentous complex may allow instability before adequate healing; the splint reduces this risk.
• Risk of deep vein thrombosis (DVT): Immobilization and lower limb injury increase DVT risk; no thromboprophylaxis was documented, which warrants monitoring.
• Expected hospital stay: Approximately 10-14 days from the date of surgery, pending wound healing and antibiotic completion.
• Ability to ambulate: Non-weight-bearing on the left lower limb during the acute phase; partial weight-bearing can be introduced at 4-6 weeks once ligament healing is underway.

• Ankle instability: Ligamentous injuries, even when repaired, may result in chronic lateral or medial ankle instability requiring further physiotherapy or bracing.
• Post-traumatic ankle osteoarthritis: Osteochondral injury to the talus found intraoperatively places the patient at risk for progressive ankle arthritis. Given that the patient is only 37 years old, this is a significant concern for long-term functional limitation.
• Stiffness: Prolonged immobilization and capsular injury can lead to ankle stiffness; aggressive rehabilitation is needed to restore range of motion.
• Occupational impact: The patient works in construction; return to full heavy occupational activity may be delayed for 3-6 months and may require modified duties depending on ankle function.
• Bone healing: No fracture was identified, so bony healing is not a primary concern; ligamentous and capsular healing typically takes 6-12 weeks.

15. Preventive Measures

1. Infection prevention:
   • Complete the full prescribed antibiotic course.
   • Strict aseptic technique during all wound dressing changes.
   • Monitor wound for early signs of infection (increasing pain, erythema, warmth, purulent discharge, fever) and escalate antibiotics if needed.
   • If signs of septic arthritis develop (fever, leukocytosis, joint swelling with purulent fluid), urgent joint washout/irrigation should be arranged.
2. DVT prevention:
   • Consider initiating pharmacological thromboprophylaxis (low-molecular-weight heparin) given immobility and soft-tissue trauma, particularly if mobilization is delayed.
   • Encourage active ankle pumping exercises with the unaffected limb.
3. Re-dislocation / wound dehiscence prevention:
   • Strict non-weight-bearing on the left lower limb until instructed by the surgeon.
   • Maintain splint integrity; avoid getting the cast wet.
   • Early outpatient follow-up for splint adjustment and wound review.
4. Joint stiffness and arthritis prevention:
   • Early supervised physiotherapy once wound healing is confirmed (typically 2-3 weeks post-op).
   • Progressive range-of-motion exercises and gradual weight-bearing as directed.
   • Long-term follow-up X-rays (at 3, 6, and 12 months) to monitor for post-traumatic arthritic changes.
5. GERD exacerbation prevention:
   • Continue esomeprazole throughout NSAID use.
   • Dietary advice (avoid triggers) and continue PPI for at least 4-6 weeks or for the duration of NSAID therapy.
6. Occupational safety:
   • After discharge and recovery, advise the patient regarding appropriate personal protective equipment and adherence to safety protocols at the construction site to prevent recurrence.

16. Comments

• Mechanism and injury pattern: The mechanism (crush/twist injury from being caught by scaffolding/formwork) is entirely consistent with a tibiotalar dislocation. High-energy direct trauma to the ankle can rupture the capsular-ligamentous complex and cause dislocation without necessarily fracturing the malleoli (a "pure" ligamentous dislocation), which matches the imaging findings (widened joint space, no fracture on X-ray).
• Open joint wound: The medial open wound with yellowish fluid (synovial fluid) strongly suggests intra-articular penetration. This was appropriately recognized early and upgraded from a simple closed reduction to operative exploration - which is the correct management per standard orthopaedic principles. Delayed or missed intra-articular contamination carries a very high risk of septic arthritis and should never be managed conservatively.
• Initial management - partially appropriate: The initial closed reduction under local anesthesia was appropriate and urgent given the absent dorsalis pedis pulse (vascular compromise mandates emergency reduction). However, field-level first aid (splinting at the scene) was not documented, which theoretically should have been performed to prevent further neurovascular damage during transport.
• Surgical decision - appropriate: The decision to proceed to operative debridement, capsular repair, and ligament repair after identification of the intra-articular wound was correct. For an isolated penetrating ankle joint wound without fracture, joint washout and capsular closure are the standard of care to prevent infection and maintain joint stability.
• Antibiotic selection - appropriate: Broad-spectrum dual coverage (levofloxacin + amoxicillin-clavulanate) is rational for a heavily contaminated open joint wound sustained in a construction/agricultural environment, where both Gram-positive, Gram-negative, and anaerobic organisms are potential pathogens.
• Osteochondral injury consideration: The finding of talar cartilage injury intraoperatively is consistent with the high-energy mechanism and the forceful joint dislocation. Long-term follow-up for post-traumatic ankle osteoarthritis is warranted and should be clearly communicated to the patient.
• GERD management: Continuation of esomeprazole with concurrent NSAID use is appropriate and consistent with standard gastric protection protocols.
• Thromboprophylaxis gap: The case record does not document any thromboprophylaxis, which is a potential gap. In a young patient (37 years) with lower limb immobilization following major soft tissue and joint surgery, DVT prophylaxis should be considered per institutional protocol.