These cases are are to get you to start thinking and questioning your beliefs ahead of the next webinar on ankle fractures and Lisfranc injuries.

We are joined for this webinar by:

Case 1

43 yrs male publican tripped over a step.  Inversion injury to left ankle.  Seen in ED and put in a backslab (injury view not available).  The ED records report that he was diffusely swollen and painful medially.
No fractures are seen around the ankle on XR 

How would you proceed in clinic?

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If you were to get further imaging, what would you go for?

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The treating doctor decided to do a weight-bearing view in cast:

What now?

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Case 2

32 yrs male, sustained a twisting injury to his left ankle 2-days ago and sustained the injury above.
He was put in a backslab in ED and is now in fracture clinic.

What would you do now?

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The doctor in clinic took this X-ray (Image 2 - lateral looks fine). What now?

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If the doctor in clinic had instead taken this X-ray in clinic (Image 3.), what would you now do on the lateral side?

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What do you do about he medial side of the joint?

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Case 3

A 24 yrs car salesman sustained this injury while playing football.  The doctor in fracture clinic removed the backslab and took this weight-bearing X-ray (Image 1).  The patient is happy to go with whatever treatment you recommend.

What would you do at this point?

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While you were pondering what to do, the helpful SHO goes and gets a CT of the ankle anyway (Image 2).

Does this CT change your management or opinion of the fracture management?

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This case ends up on your trauma list for fixation.  Regardless of your initial feelings on the case (discussed above), you’ve  agreed to carry out ORIF (imagine one of the other consultants you owe a favour to has asked you specifically).

How would you approach and fix?

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Case 4

54 yrs female solicitor twisted her ankle getting out of the car.  Plain X-rays and CT are shown.

Same as previous case. Does the CT add anything to this case for you?

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Same as for case 3. If you were going to fix it, how would you do it?

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Surgical Approaches

Lyndon Mason explains how to use the CT scan to plan the surgical treatment of the posterior malleolus. Based on this you can select your surgical approach. Lyndon then talks us through how to perform the posterolateral, medial posteromedial, and posteromedial approach to the posterior malleolus.

Case 5

29 yrs, fit and healthy store manager presents to fracture clinic having tripped whilst walking a week ago.  He’s complaining about right midfoot pain. 

Do you see any radiographic abnormality?

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She is able to weight bear in a boot but she finds it painful.  Clinically she is painful and swollen over the midfoot.  Some midfoot swelling but no plantar ecchymosis.

How would you proceed now?

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The doctor in clinic decides to do a set of weight bearing x-rays (Image 2). Does this change your management at all?

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The doctor in clinic decides to do a CT of the foot. What is your reading of these (albeit limited) views?

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The lady asks you, 'If it were your foot, what would you have done?' Time to decide, what's your treatment?

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If you were to treat her non-op, what would be your normal regimen (pick the closest option)?

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If you were to decide to fix her lis frank, complex, how would you normally do it?

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Please do post your thoughts about these cases in the comments section below.

For the answers to these questions and much more join our webinar this week, Wednesday at 8pm BST.

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11 Responses

  1. Good cases
    I’m interested to see how aggressive the faculty are in weightbearing the examples you had with a lateral and posterior malleolar fractures in the context of a normal weightbearing x-ray. I’d assume you’d just get them going in a boot – but i often feel a little apprehensive about doing this and keep a closer eye on them!

    • Good staff!!I just replied with our practice in my DGH which based by our foot ankle team iy looks work ,thanks still not sure if suspected lisfranc should we get this package straightaway ie WB XRAY PLUS CT or that should be sequntial !!

      • Hi Waleed, join us live on the webinar tonight and we will go through the answers to those questions.

        We will post a video response too over the next week.

  2. Very helpful to look through these cases indeed. Looking forward to lis Frank injuries discussion. Many thanks
    Kind regards
    Olga Jones

  3. These are very common cases and have seen varied treatments. I would like to attend webinar and listen to expert on current evidence.

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