ORTHOPAEDIC CASE RECORD

I. ADMINISTRATIVE INFORMATION

II. CLINICAL CONTENT

1. Reason for Admission

2. History of Present Illness

• Skin and mucous membranes: pink, well-perfused
• Severe pain at the left ankle (T)
• Left lower limb: unable to grip/close properly
• Open wound over the left ankle, approximately 1 cm, with minimal bleeding
• Decreased sensation over the left foot and toes
• Pulse: 80 beats/min | Temperature: 37°C | Blood pressure: 120/70 mmHg | Respiratory rate: 20 breaths/min
• Abdomen: soft, no focal tenderness

3. Past Medical History

• Comorbidities: Gastroesophageal reflux disease (GERD) - ICD K21 noted on admission record. No history of diabetes mellitus, hypertension, or coagulopathy documented.
• Habits/risk factors: Occupation in construction work (high-energy trauma risk). No history of smoking, alcohol use, or drug use documented.
• Residual musculoskeletal impairments: None documented prior to this admission.

4. Condition on Admission

• Level of consciousness: Alert and oriented (GCS not explicitly recorded; patient communicating coherently per history)
• Vital signs: HR 80 bpm | BP 120/70 mmHg | Temp 37°C | RR 20 breaths/min | SpO2 not documented
• Key physical findings on admission:
  • Deformity of left ankle and foot
  • Reduced active and passive range of motion of the left ankle
  • Open wound ~1 cm over the left ankle, minimal bleeding
  • Decreased sensation of the left foot toes
  • Unable to weight-bear on left lower limb
  • No neurovascular compromise documented beyond sensory changes

5. Clinical Diagnosis (Pre-operative)

1. Left ankle dislocation with open wound - Trat khop co chan trai, vet thuong co chan trai
2. Probable ligamentous injury left ankle
3. R/O fracture left ankle (pending imaging)
4. GERD (co-morbidity)

6. Investigations and Results

Laboratory Investigations (08/07/2026, 16:06 - blood drawn by Lam Thi Kim Hai):

• PT (Prothrombin Time): Reference 13.5 sec / 70-120% activity / INR 0.96 (ref 0.8-1.2) - Normal
• APTT (Activated Partial Thromboplastin Time): 22 sec - Normal

Imaging Investigations:

• Bony structures: No abnormal image detected (Chua ghi nhan hinh anh bat thuong)
• Joint spaces: Widening of the left tibio-talar (talar mortise) joint space (Rong khe khop chay - san trai) - indicating ligamentous disruption/dislocation
• Soft tissues: Difficult to assess (Kho khao sat)
• Other: Left ankle cast shadow visible (Chong anh bot co chan trai)

• Bony structures: No fracture identified
• Joint spaces: Widened talo-crural joint space left
• Soft tissues: Not fully assessable
• Conclusion: Casting image over the left ankle - post-reduction with cast applied

7. Definitive Diagnosis

• Ligamentous injury left ankle (widened talo-crural joint space)
• Decreased sensation left foot toes (possible transient neurological compromise)
• GERD (co-morbidity)

8. Operative Report

9. Postoperative Course (Symptoms only)

10. Clinical Examination (Current - Post-operative)

a. General Examination

• General appearance: Alert, conscious, cooperative; lying comfortably in bed
• Build: Average (BMI 22.04)
• Nutrition status: Well-nourished
• Skin and mucous membranes: Pink, warm, well-perfused; no pallor or icterus
• Vital signs (post-operative):
  • HR: ~80 bpm, regular
  • BP: 120/70 mmHg
  • Temperature: 37°C (afebrile)
  • RR: 20 breaths/min
• Lymph nodes: Not enlarged (not specifically documented)
• No signs of systemic distress

b. Systemic Examination

• Below-knee cast in place, well-moulded, not too tight
• No evidence of excessive swelling beyond cast margins
• Capillary refill in left toes: assessed and satisfactory (per post-cast check protocol)
• Sensation left toes: present and improving
• Wound: ~1 cm laceration over left ankle, closed, covered with dressing; no signs of active bleeding or dehiscence
• Active movement of left ankle: not possible (immobilized in cast)
• Passive movement of left ankle: not tested (cast in situ)
• Left foot toes: patient able to perform flexion/extension
• Neurovascular status of left foot: intact

• Cast shadow visible over left ankle
• Talo-crural joint space: restored to normal alignment following reduction
• No residual dislocation
• No fracture identified
• No hardware (consistent with closed reduction only, no internal fixation)

11. Case Summary

• History of acute trauma with direct mechanism (construction site injury)
• Immediate onset of left ankle deformity, severe pain, and inability to weight-bear
• Open wound ~1 cm over left ankle
• Decreased sensation in left foot toes at presentation
• X-ray: widened tibio-talar (talo-crural) joint space left, no fracture - confirming pure ligamentous dislocation

• Small (<2 cm) wound overlying the dislocation site
• Minimal contamination (indoor/outdoor construction environment)
• Minimal bleeding

• Decreased toe sensation on left foot at presentation
• Likely secondary to traction/compression on peroneal or tibial nerve branches by the dislocated talus
• Improving after reduction (favourable sign)

• No tense compartments described
• No escalating pain beyond expected level
• No neurological deficit progressing

12. Conclusion

• Primary injury: Closed (with small open wound) left ankle dislocation, pure ligamentous type - no fracture
• Treatment method: Closed reduction under spinal anaesthesia + wound debridement and closure + below-knee cast immobilization
• Current outcome: Satisfactory - joint reduced, wound closed, haemodynamically stable, sensory function improving in left foot

13. Further Treatment

a. Treatment Plan

1. Immobilization: Continue below-knee cast for approximately 6 weeks
2. Analgesia: Oral analgesics for pain control
3. Antibiotics: Short course for open wound prophylaxis
4. Wound care: Regular dressing changes; monitor wound healing
5. Thromboprophylaxis: Assess risk (young patient, lower limb immobilization)
6. Physiotherapy: Non-weight-bearing mobilization; range-of-motion exercises for toes and knee; progress to partial weight-bearing as tolerated post-cast removal
7. GERD management: Continue existing treatment (proton pump inhibitor)
8. Follow-up X-ray: Repeat ankle X-ray at 2-3 weeks to confirm maintained reduction

b. Specific Treatment

• Paracetamol 500 mg, 2 tablets orally every 8 hours (three times daily), total 3 g/day
• If pain not controlled: add NSAIDs (e.g., Ibuprofen 400 mg orally every 8 hours with food) - with caution given GERD history; consider adding PPI cover

• Cefazolin 1 g IV every 8 hours for 24-48 hours, then step down to oral Cefalexin 500 mg every 6 hours for 5 days total (covering Staphylococcus aureus and skin flora)
• Tetanus prophylaxis if vaccination history unknown (tetanus toxoid 0.5 mL IM)

• Omeprazole 20 mg orally once daily before breakfast (also provides gastric protection if NSAIDs are co-prescribed)

• Wound dressing change every 48-72 hours; remove sutures at day 10-14
• Below-knee cast: maintain for 6 weeks; remove if neurovascular compromise suspected

• Non-weight-bearing crutch ambulation from day 1 post-operatively
• Commence gentle active toes and knee range of motion exercises
• At 6 weeks post-cast removal: progressive weight-bearing with physiotherapy-guided ankle rehabilitation

• Closed reduction is the first-line treatment for ankle dislocation without fracture. It is performed under anaesthesia (spinal in this case) to achieve full muscle relaxation, minimizing further soft tissue damage during the reduction manoeuvre.
• Immobilization in below-knee cast maintains the reduced position and allows ligamentous healing (primary ligament healing takes 6-8 weeks).
• Open reduction and internal fixation is not indicated because no fracture was identified and closed reduction was successful.
• Short-course antibiotics are indicated for the open wound (even Gustilo Type I) to reduce the risk of surgical-site/wound infection.

14. Prognosis

• Risk of wound infection: the open wound, though small, was sustained at a construction site with potential for contamination. Proper wound debridement and antibiotics reduce but do not eliminate this risk.
• Risk of cast-related complications: pressure sores, skin maceration, or circulatory compromise if swelling increases post-operatively. The patient should be monitored with regular neurovascular checks.
• Risk of re-dislocation: if the patient weight-bears prematurely or the cast becomes loose before ligamentous healing is complete.
• GERD may be exacerbated by perioperative stress, NSAIDs, and opioid analgesics; PPI cover is important.
• Spinal anaesthesia: minor risk of post-dural puncture headache or urinary retention in the immediate postoperative period.

• Ankle instability: lateral ligament complex injury is common in ankle dislocation; if the ligaments heal with laxity, chronic ankle instability may result, predisposing to recurrent sprains and dislocation.
• Post-traumatic ankle osteoarthritis: uncommon after pure dislocation without fracture, but cartilage injury during the dislocation event (chondral damage) can lead to early joint degeneration.
• Peroneal nerve injury: if the transient sensory deficit does not fully resolve, a peroneal nerve traction injury may result in persistent sensory impairment or foot drop (though this is uncommon with prompt reduction).
• Stiffness: prolonged cast immobilization (6 weeks) will result in some ankle stiffness; physiotherapy rehabilitation is essential for full return of range of motion and function.
• Return to work: construction work involves uneven terrain and heavy lifting; the patient should be advised regarding graduated return to full duties over 3-6 months, with ankle strengthening exercises.

15. Preventive Measures

1. Infection prevention: Continue perioperative antibiotics; strict aseptic wound dressing technique; monitor wound for signs of infection (erythema, purulent discharge, fever). Ensure tetanus prophylaxis is up to date.
2. Cast complications: Educate the patient to report any numbness, tingling, increasing pain, or colour change in the toes immediately. Elevate the left lower limb above heart level for the first 48-72 hours to reduce oedema. Perform neurovascular checks every 4-6 hours in the first 24 hours post-casting.
3. Re-dislocation prevention: Strict non-weight-bearing instruction with crutches until cast removal. Educate the patient on the importance of compliance. Repeat X-ray at 2-3 weeks to confirm maintained reduction.
4. GERD flare prevention: Use PPI cover (Omeprazole) throughout the analgesic course; avoid NSAIDs if possible or use the minimum effective dose with meals.
5. DVT prevention: Although the patient is young with no documented risk factors, below-knee cast immobilization increases DVT risk. Consider low-molecular-weight heparin (e.g., Enoxaparin 40 mg SC once daily) for the duration of immobilization, particularly if mobility is limited.
6. Chronic instability prevention: After cast removal at 6 weeks, commence structured ankle rehabilitation with a physiotherapist including proprioception training, peroneal muscle strengthening, and balance exercises to prevent chronic lateral ankle instability.
7. Occupational safety: Advise the patient and employer on appropriate footwear and safe working conditions at construction sites to prevent recurrence.
8. Long-term follow-up: Schedule outpatient follow-up at 2 weeks (wound check), 6 weeks (cast removal + X-ray), 3 months (functional assessment), and 6 months (return-to-work evaluation).

16. Comments

• Mechanism of injury: The mechanism (direct trauma/fall at a construction site) is consistent with the injury pattern of a pure ankle dislocation. High-energy direct trauma to the foot in a plantarflexed and rotated position is a recognized mechanism for ankle dislocation, particularly when there is no fracture (the ligaments fail before the bone).
• Initial management: Pre-hospital management was not formally documented. Ideally, the injured limb should have been immobilized with a splint at the scene, the wound covered with a clean dressing, and ice applied to reduce swelling. The absence of documented field immobilization is a common deficiency in workplace trauma management in Vietnam and represents a gap between theory and practice.
• Imaging approach: Two sets of ankle X-rays were appropriately ordered (AP and lateral views). No fracture was identified, which is consistent with a pure dislocation. Theoretically, a CT scan of the ankle could be considered to rule out occult osteochondral injury (not documented as having been performed - this may represent an area where the workup could be enhanced).
• Surgical management: Closed reduction under spinal anaesthesia was an appropriate choice for this injury. The procedure was performed promptly on the day of admission, which is important to minimize the risk of avascular necrosis of the talus and neurovascular compromise. This is consistent with current orthopaedic guidelines recommending urgent (within 6 hours) reduction of ankle dislocations.
• Operative duration of approximately 79 minutes is somewhat prolonged for a closed reduction + wound closure; this may reflect difficulty of reduction requiring multiple attempts, or time taken for wound assessment and debridement.
• No internal fixation was performed, which is appropriate since no fracture was identified. This is consistent with the principle that pure ligamentous ankle dislocations are managed with closed reduction and immobilization rather than surgery.
• Anaesthetic choice: Spinal anaesthesia is appropriate for lower limb orthopaedic procedures and provides better muscle relaxation for reduction than local anaesthesia alone, which is consistent with standard practice.
• Documentation gap: The specific values of the complete blood count are not fully legible in the available records, and post-operative vital signs after 24 hours are not documented in the available pages. A more complete post-operative nursing chart would be expected in a full medical record.