ORTHOPAEDIC CASE RECORD

I. ADMINISTRATIVE INFORMATION

II. CLINICAL CONTENT

5. CLINICAL DIAGNOSIS (POSTOPERATIVE)

6. INVESTIGATIONS AND RESULTS

1. Chest X-ray (AP, 1 film): No bony abnormality. Lung parenchyma clear. Cardiac silhouette not enlarged. No pleural effusion. No mediastinal widening. Conclusion: No radiographic abnormality.
2. Left leg/lower-leg X-ray (AP + lateral, 2 films): Bony structures not clearly assessed due to plaster cast artifact. Soft tissue obscured. Conclusion: Plaster cast obscuring left lower leg - no fracture definitively identified on available views.
3. Left ankle X-ray (AP + lateral or oblique, 2 films): No bony injury identified. Joint space: Widening of the talo-fibular (chay-sen) joint space on the left side, indicating ligamentous disruption. Soft tissues difficult to assess. Plaster cast artifact present. Conclusion: Widening of the left talo-fibular joint space (chay-sen khe khop) - consistent with left ankle dislocation/ligamentous disruption.

7. DEFINITIVE DIAGNOSIS

• Left ankle penetrating wound with suspected joint communication (open joint injury)
• Left ankle ligamentous disruption (widening of talo-fibular joint space on X-ray)
• Absent left dorsalis pedis pulse at initial presentation (vascular compromise, resolved after reduction)

8. OPERATIVE REPORT

1. Patient positioned supine under spinal anaesthesia. Sterile draping of left lower limb.
2. Left thigh tourniquet inflated to 250 mmHg.
3. The existing wound was extended (wound debridement and exploration).
4. Intraoperative findings: Joint capsule laceration confirmed; articular cartilage injury of the talus observed; delta ligament avulsion/tear identified; ankle joint found to be unstable.
5. Thorough irrigation of the joint cavity with copious normal saline.
6. Repair of the delta ligament, joint capsule, and closure in layers.
7. Wound closed primarily. Left ankle immobilised in a below-knee cast in the neutral position.

9. POSTOPERATIVE COURSE

• Postoperative day 0 (08/07/2026, ~19:50): Patient alert and stable. Transferred to ward. Left ankle in below-knee cast (back slab). Ordered: IV fluids, IV Paracetamol 10 mg/mL, IM Meloxicam (Brosiral) 10 mg/1.5 mL. Vital signs stable. No nausea or vomiting reported.
• Postoperative day 1 (09/07/2026, 07:30): Patient alert and cooperative. Vital signs stable. Wound dressing intact with minimal drainage. Movement of toes preserved bilaterally. Dorsalis pedis pulses palpable bilaterally. Lower extremity numbness from spinal anaesthesia resolved. Wound dressing changed, sutures inspected (wound < 15 cm).
• Postoperative day 2 (10/07/2026, 07:30): Patient alert. Vital signs stable. Wound with minimal serous discharge. Active toe movement intact. Bilateral dorsalis pedis pulses strong. Wound dressing changed, sutures intact.
• Postoperative day 3-4 (11-12/07/2026): Patient stable. Continued wound care. Antibiotics, analgesics, and esomeprazole maintained.

10. CLINICAL EXAMINATION (POSTOPERATIVE - Examination date: 14/07/2026, Postoperative Day 6)

• Conscious, alert, fully oriented (GCS 15/15)
• Comfortable at rest; able to communicate clearly
• Skin and mucous membranes: pink, well-perfused, no pallor, no jaundice
• Nutritional status: BMI 22.04 kg/m² - normal
• No peripheral oedema of the unaffected limb
• Temperature: afebrile (36 - 37°C range on all postoperative days)
• Heart rate: 78 bpm, regular
• Blood pressure: 120/70 mmHg
• Respiratory rate: 20 breaths/min
• SpO2: 98% on room air

• Left ankle in below-knee posterior plaster cast, neutral position
• Cast intact, no areas of breakdown over bony prominences
• Wound site: Medial aspect of left ankle, surgical wound approximately 1 cm (original wound) extended intraoperatively - wound dressing in place, minimal serous discharge, no signs of erythema, warmth, or purulent discharge observed around cast edges
• Left toes: Pink, warm, capillary refill < 2 seconds
• Sensation of left toes: Preserved (patient reports normal sensation to all toes)
• Active dorsiflexion and plantarflexion of left toes: Intact
• Left dorsalis pedis pulse: Palpable (confirmed by clinical assessment)
• Left posterior tibial pulse: Palpable
• No compartment syndrome signs: toes warm, sensation intact, passive stretch does not elicit severe pain
• Right lower limb: Fully normal; full weight bearing

• Motor: Active toe movement preserved bilaterally
• Sensation: Intact to light touch in all toe webspaces bilaterally
• No evidence of common peroneal nerve palsy (dorsiflexion of toes intact)

• Left ankle AP and lateral X-rays (post-reduction/post-operative): Ankle joint space normalised. No residual dislocation. No fracture identified. Hardware not used. Cast in appropriate position.
• Left chest X-ray: Normal (no changes from admission).

11. CASE SUMMARY

• History of forced plantarflexion/inversion injury at a construction site (industrial machinery entanglement)
• Left ankle deformity on admission
• Left ankle pain and reduced range of motion
• Widening of the talo-fibular joint space on X-ray (AP and lateral ankle views)
• Successful closed reduction with restoration of pulse and SpO2

• Medial left ankle wound (~1 cm), with suspected joint communication
• Intraoperative confirmation: Joint capsule laceration, articular cartilage injury of the talus, delta ligament tear
• Wound located adjacent to joint line
• Intraoperative finding of yellowish fluid (possibly synovial fluid) from the wound at closed reduction stage

• Absent left dorsalis pedis pulse on initial admission
• Restoration of pulse immediately after closed reduction
• SpO2 100% and pink, warm toes post-reduction - no permanent vascular injury

• Normal CBC, coagulation, renal function, liver enzymes, glucose, electrolytes
• No diabetes, no anaemia, no coagulopathy
• No systemic signs of infection (afebrile throughout)

12. CONCLUSION

1. Left ankle open dislocation with penetrating joint injury (open joint wound, delta ligament tear, talar cartilage injury) - occupational trauma - Postoperative day 6, stable
2. Gastro-oesophageal reflux disease (GORD) - under treatment with esomeprazole

13. FURTHER TREATMENT

• Continue antibiotic therapy (completing the course)
• Analgesics: oral and IV paracetamol, celecoxib
• GI prophylaxis: esomeprazole
• Wound care: regular dressing changes, suture removal at appropriate time
• Cast maintenance: left ankle below-knee cast for approximately 6 weeks total
• Early passive toe and foot exercises
• Non-weight bearing on the left lower limb with crutches

• Ceftazidime + Levofloxacin (dual antibiotic cover): The wound penetrated the joint cavity, making this an open joint injury. This carries a high risk of septic arthritis, which is catastrophic for cartilage. Broad-spectrum cover targeting Gram-negative organisms (including Pseudomonas with ceftazidime) and atypical organisms (levofloxacin) is appropriate for a construction-site contaminated wound. Dual therapy is justified by the high-risk nature of the injury.
• Paracetamol (IV then oral): First-line analgesic - effective, safe, no GI side effects, appropriate for postoperative pain.
• Celecoxib (selective COX-2 inhibitor): Provides additional anti-inflammatory and analgesic effect for postoperative pain and soft tissue swelling with reduced GI risk compared to non-selective NSAIDs.
• Esomeprazole 40 mg: GI mucosal protection - indicated given the patient's underlying GORD and concurrent NSAID use; prevents NSAID-induced peptic ulceration.
• Below-knee cast in neutral position: Provides mechanical stability to the repaired ligament complex, prevents re-dislocation, and protects the articular surface during the healing phase.

14. PROGNOSIS

• Risk of septic arthritis: This is the most critical short-term risk. The joint was open and exposed to construction-site contamination. Despite thorough intraoperative irrigation and broad-spectrum antibiotics, there remains a risk of joint-space infection, which could destroy the articular cartilage and result in permanent joint destruction. Warning signs include fever, increasing pain, erythema, warmth over the joint, and purulent wound discharge.
• Risk of wound infection/wound dehiscence: The wound was contaminated at the time of injury. Despite adequate debridement, superficial or deep wound infection may occur, particularly given the mechanism of injury (industrial machinery, likely contaminated wound).
• Risk of neurovascular compromise: Absent dorsalis pedis pulse was documented at admission. Although it was restored after reduction, vascular spasm or intimal injury may lead to delayed vascular compromise. Close monitoring of toe perfusion, capillary refill, and pulse is required.
• Deep vein thrombosis (DVT): Immobility, cast, and lower limb venous stasis increase DVT risk. Active toe exercises and early ambulation with crutches should be encouraged.
• Pressure injury under cast: With prolonged cast use, skin breakdown over bony prominences (lateral malleolus, heel) is possible; the patient should be instructed to report any pain, numbness, or skin changes.

• Post-traumatic ankle osteoarthritis: Intraoperative damage to the talar articular cartilage is a direct risk factor for post-traumatic osteoarthritis of the ankle joint. This may manifest as chronic ankle pain, stiffness, and reduced function over 5 - 15 years.
• Ligamentous instability/chronic ankle instability: Even with repair, the delta ligament and surrounding ligamentous structures may not fully regain pre-injury strength, leading to chronic lateral or medial instability, recurrent sprains, and difficulty with uneven ground.
• Avascular necrosis (AVN) of the talus: Although pure ankle dislocation carries lower risk than talar neck fractures, vascular disruption cannot be fully excluded. AVN may develop in the talar body within 6 - 12 months.
• Stiffness: Post-immobilisation ankle stiffness is expected and will require dedicated physiotherapy.
• Return to work: The patient works in construction, which requires physical labour and prolonged standing. Full return to pre-injury occupation may take 4 - 6 months minimum and may not be achievable at the same level if significant osteoarthritis or instability develops.

15. PREVENTIVE MEASURES

• Complete the full 7-day course of dual IV antibiotics as prescribed; do not shorten the course.
• Daily wound inspection for signs of infection (erythema, warmth, swelling, discharge, fever).
• Strict aseptic technique during all wound dressing changes.
• If fever develops or CRP rises, urgent joint aspiration and culture should be performed.

• Surgical wound care with sterile dressing changes every 1 - 2 days as per protocol.
• Suture removal at 10 - 14 days postoperatively (once wound is adequately healed).
• Patient and family education on keeping the wound and cast dry.

• Encourage active ankle (toe) exercises within the cast.
• Early mobilisation with non-weight-bearing crutch walking as soon as the patient is able.
• Adequate hydration; avoid prolonged bed rest.
• If clinically indicated (high-risk features), low-molecular-weight heparin prophylaxis should be considered.

• Educate the patient to report any pain, numbness, tingling, colour change, or swelling of toes immediately.
• Elevate the limb above heart level to reduce swelling.
• Schedule cast check at 1 - 2 weeks post-application.

• After cast removal (approximately 6 weeks), commence formal physiotherapy including range-of-motion exercises, progressive weight bearing, proprioceptive training, and peroneal muscle strengthening.
• Avoid premature weight bearing, which could disrupt ligament healing and damage the repaired capsule.
• Follow-up ankle X-rays at 6 weeks, 3 months, and 6 months to monitor joint space, alignment, and for early signs of AVN or osteoarthritic change.

• Continue esomeprazole throughout the duration of NSAID (celecoxib) use to prevent NSAID-related gastropathy in the context of GORD.

• After full recovery, the patient should be counselled regarding safe working practices at construction sites. Proper protective footwear (steel-capped boots) and training on the safe operation of machinery would reduce the risk of recurrent occupational ankle injuries.

16. COMMENTS

1. Mechanism of injury and pathology: The mechanism is consistent with the injury pattern. Entanglement of the lower limb in construction machinery produces the rotational/forced plantarflexion force required to dislocate the ankle joint and tear the surrounding ligamentous structures (delta ligament, joint capsule). The wound's position on the medial ankle and its penetration into the joint are fully explicable by the mechanism documented.
2. Initial management: The pre-hospital management is not clearly documented in the record (no mention of splintage at the scene). Ideally, the injured ankle should have been splinted in a neutral position before transport to prevent further neurovascular compromise and additional soft tissue injury. The absent dorsalis pedis pulse on arrival suggests significant displacement was present during transport.
3. Closed reduction before surgery: Performing urgent closed reduction under local anaesthesia (ankle block) upon presentation was appropriate and correct. The immediate restoration of the dorsalis pedis pulse confirms that the vascular compromise was positional (due to stretch or kinking) rather than structural. Reducing the dislocation emergently is the standard of care to protect the neurovascular structures and the overlying skin.
4. Decision to proceed to open surgery: Theoretically, a pure closed ankle dislocation without fracture may be treated with closed reduction and cast immobilisation alone. However, in this case, the wound was suspicious for joint penetration, which was confirmed intraoperatively (joint capsule tear, cartilage damage, delta ligament avulsion). Open joint injuries require mandatory surgical exploration, irrigation, and debridement, making operative management both indicated and appropriate. The decision to proceed to theatre was correct and is consistent with established orthopaedic principles for open joint injuries.
5. Antibiotic regimen: The use of dual broad-spectrum antibiotics (ceftazidime + levofloxacin) for an open joint contaminated wound at a construction site is rational and consistent with infection-prevention guidelines for open orthopaedic injuries.
6. Cast position: Immobilisation in a below-knee cast in neutral position protects the repaired structures while keeping the foot in a functional position, consistent with standard management of ankle ligamentous injuries after repair.

• Patient: Nguyen Duc Long, Male, DOB 16/09/1989, Nghe An Province
• Admitted: 15:47, 08/07/2026 - Emergency Dept
• Injury: Left ankle dislocation + penetrating wound from construction machinery entanglement, same day as admission
• Closed reduction: 16:10, 08/07/2026 (under local anaesthesia)
• Multidisciplinary consult: 18:00, 08/07/2026 - diagnosis confirmed, surgery planned
• Surgery: 18:50, 08/07/2026 - open debridement, joint washout, delta ligament + capsule repair
• Postoperative transfer to Orthopaedic Ward (Room K24, Bed 11.02)
• Date of this examination: Postoperative Day 6 (14/07/2026)