(Disclaimer: This article is for general use only. To protect Ms. Zhang’s privacy, the information in the following content has been processed)
Abstract: Ms. Zhang described herself: 1 week ago, she accidentally stepped off the stairs and injured her right ankle, resulting in swelling, pain and restricted movement. In order to seek further treatment, she came to our hospital and was admitted with “right external ankle fracture”. After completing the CT 3D reconstruction and preoperative examination, the diagnosis was clarified and the right external ankle fracture was internally fixed under lumbar anesthesia.
Basic information】Female, 39 years old
Type of disease】Ankle fracture
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】May 2021
Treatment plan】Surgical treatment (right external ankle fracture incision and internal fixation) + medication (flurbiprofen ester injection)
Treatment period】8 days of inpatient treatment, 1 month and 3 months of outpatient follow-up
Treatment effect】Good fracture repositioning, good wound healing
I. Initial consultation
Ms. Zhang reported that one week ago, she stepped off the stairs and injured her right ankle, resulting in swelling, pain and restricted movement. On examination: the right ankle joint was swollen, local pressure pain was positive, bone rubbing sensation could be detected, active movement of the right ankle joint was limited, passive movement pain was obvious, peripheral blood flow, sensation and movement were not abnormal. She was admitted to our department as “right external ankle fracture”.
Treatment history
After completing the preoperative routine examination, CT 3D reconstruction and other tests, the diagnosis of right external ankle fracture was made clearly. The fracture was repositioned and the plate was satisfactorily positioned. Extensive damage to soft tissues such as skin was avoided, and flurbiprofen injection was given postoperatively to relieve pain and other symptomatic treatments.
III. Treatment effect
Ms. Zhang underwent internal fixation of right external ankle fracture with incision and repositioning. The fracture was repositioned and the position of the plate was satisfactory. The fracture healed well, the plate was in good position, and there was no obvious discomfort when moving to the ground. Ms. Zhang and her family were very satisfied.
(3 months review image)
IV. Notes
We are glad that Ms. Zhang’s symptoms have improved after treatment. After discharge, we still recommend Ms. Zhang to have regular review at 1 month, 3 months, 6 months, 1 year and 3 years. In the early stage, she should pay attention to the wound healing, change the medication every 3 days, avoid weight-bearing activities for 3 months, exercise the joint function to prevent thrombosis, and gradually resume normal activities after 3 months, and regularly review and observe whether the plate is displaced, if it is displaced, early treatment should be carried out. There is no contraindication to diet, you can have a high calcium diet or a healthy diet according to your eating habits.
V. Personal insight
For the diagnosis and treatment of ankle joint disease, X-ray films should be read carefully and detailed examination should be done to avoid missing the diagnosis. The operation should be performed as gently as possible because the soft tissue in the ankle joint is less, commonly known as skin and bone, which can easily lead to poor skin healing, so gentle operation can reduce postoperative complications. For example, Ms. Zhang was given strong internal fixation during surgery, and rehabilitation exercises were performed early after surgery, and the ankle joint function recovered well later. In conclusion, for patients, early treatment and rehabilitation are more conducive to recovery.