At medical school, we’re often told to present patients in front of colleagues and a Consultant. This particular Tuesday was no different. So, I trotted along to orthopaedics for something which I’d be able to remember, where I examined a young patient with a simple fracture of his right fibula, following a football tackle.
Any patient who presents with trauma must be assessed for their ABCs before further examination. Yes, the ABCs you learned in all of the first aid courses you did for your UCAS form. It’s easy to forget the simple things, but they get you marks in examinations and brownie points from Consultants. This patient was talking readily (A+B) and his foot didn’t look pale or feel cold to touch (C). So all’s well.
When taking histories, it’s important to have a structured approach. And orthopaedics is no different. I initially just ask him “What happened?” since it’s a quick and easy way to get relevant information. He mentions that he was tackled playing football and that he was unable to weight bear on the right foot thereafter. This is good: mechanism of injury and weight bearing is extremely important with lower limb orthopaedic histories. Immediately after the injury, he felt a sharp pain in his right ankle which was managed by painkillers, along with swelling on the lateral aspect of the distil fibula and associated redness. He wasn’t bleeding following the injury which is important considering “open” fractures are associated with higher rates of infection. Which makes sense. He was also unable to walk without the use of crutches or a wheelchair, an important point to ask considering immobility can be a cause of DVT in elderly patients following prolonged hospital stay. It’s also wise to ask about a patients housing situation, as many people who live in houses with stairs will find it difficult to mobilise around the house if they have a dodgy ankle joint and may require extra care.
When examining joints, it’s always good to examine the unaffected side first so that you have a “normal” baseline with which to compare the affected side. It also makes you look smarter in your OSCEs. This patient still had swelling and redness present on the affected side and slight numbness around the lateral malleolus. His toes weren’t pale and felt warm to touch, which reassured me that there was no sign of neurovascular compromise following the injury. Since this was a traumatic injury, an AP and lateral X-Ray were indicated. These were as follows:
As is clearly seen on the wonderful and totally authentic X-Ray images, a fracture (see: a black or white line) is clearly seen on the distal aspect of the right fibula. It’s important to check for a fracture in the tibia if one is seen in the fibula, and vice versa, as it’s not uncommon for these injuries to present with fractures of both the tibia and fibula. Classifying these fractures (by virtue of Denis-Weber classification) is also important, and they’re done by the position of the fracture relative to the syndesmosis, a fibrous joint between the distil tibia and fibula. It’s important to ascertain this information because fibula fractures above the syndesmosis (Type C) are unstable and require surgical intervention. As is seen on the XR, the fracture occurs above the syndesmosis and therefore this patient underwent ORIF (Open reduction, Internal fixation) to stabilise the joint. Injuries at the level of the syndesmosis or distal to it may or may not require surgery depending on the degree of damage and its consequence on overall ankle stability. Conservative management, such as immobility agents such as a cast, can often be useful for stable fractures considering that they avoid complications associated with major surgery. Septic arthritis immediately springs to mind, and it’s very problematic.
This patient went ahead with the ORIF, which went swimmingly, and is now able to weight bear on his right foot following the use of crutches for a few months after the operation.