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HPI

A 64-year-old male presents to the trauma bay after sustaining a fall from a ladder. The patient reports he was approximately 10 feet high when he lost his balance. He reports isolated left ankle pain and denies hitting his head or losing consciousness. He denies numbness/tingling in the left foot.

PMH

PMH: HTN, HLD

PE

Focused exam of the left lower extremity demonstrates moderate swelling to the left ankle without open wounds or blisters. The skin does wrinkle. Motor grossly intact EHL/FHL/GSC. Sensation intact to all distributions of the foot. PT/DP pulses are palpable and foot is warm and well perfused.

Poll
1 of 12
1. Would you obtain any imaging in addition to standard ankle films to guide management?
No - current radiographs are sufficient
13%
190/1382
Yes - additional radiographic views (aXR)
0%
12/1382
Yes - CT scan of the ankle (CT)
76%
1061/1382
Yes - MRI of the ankle (MRI)
0%
9/1382
Yes - aXR + CT
4%
64/1382
Yes - aXR + MRI
0%
5/1382
Yes - CT + MRI
0%
13/1382
Yes - aXR + CT + MRI
0%
6/1382
Outside my area of expertise - best if I dont vote
1%
22/1382
2. Would you use a classification system to guide management?
No - a classification would not help me
36%
480/1327
Yes - Ruedi and Allgower
15%
208/1327
Yes - Lauge-Hansen
5%
69/1327
Yes - Danis-Weber
3%
41/1327
Yes - AO/OTA
33%
439/1327
Outside my area of expertise - best if I don't vote
6%
90/1327
3. How would you definitively manage this injury?
Nonoperative
0%
10/1343
Operative
97%
1315/1343
Outside my area of expertise - best if I don't vote
1%
18/1343
4. If you choose Operative management, would you temporize this patient with an external fixator?
I would not choose Operative management
0%
2/1353
No - I would fix this acutely
29%
401/1353
Yes - for 5-7 days
23%
319/1353
Yes - for 8-14 days (1-2 weeks)
38%
518/1353
Yes - for > 15 days (2 weeks)
5%
70/1353
Yes - for > 21 days (>3 weeks)
0%
10/1353
Outside my area of expertise - best if I don't vote
2%
33/1353
5. If you choose Operative management, what definitive fixation technique would you use?
I would not choose Operative management
0%
1/1328
External fixation (ExFix) only (includes monoplanar, ringed circular fixation, etc)
2%
33/1328
Percutaneous screw fixation only
0%
10/1328
Open reduction internal fixation (ORIF) with plate and screws (includes MIPO)
88%
1181/1328
Intramedullary nailing (IMN) only
0%
2/1328
IMN + ORIF
1%
23/1328
IMN + percutaneous screw fixation
0%
4/1328
ExFix + percutaneous screw fixation
3%
40/1328
Outside my area of expertise - best if I don't vote
2%
34/1328
6. If you choose Operative management, would you include fixation of the fibula?
I would not choose Operative management of the tibia
0%
3/1171
No - I would not fix the fibula
9%
115/1171
Yes - I would fix the fibula
88%
1032/1171
Outside my area of expertise - best if I don't vote t
1%
21/1171
7. If you choose to Fix the fibula, what type of fixation would you use?
I would not choose to fix the fibula
1%
22/1173
ORIF - separate approach from the tibia
49%
581/1173
ORIF - same approach as the tibia
33%
393/1173
Intramedullary fixation (includes screw, flex nail, wire)
13%
160/1173
Outside my area of expertise - best if I dont vote
1%
17/1173
8. If you choose ORIF and made the patient non weight bearing after surgery, what DVT prophylaxis would you prescribe?
I would not choose ORIF
0%
5/1105
None - I would not prescribe DVT prophylaxis
6%
76/1105
Aspirin
23%
257/1105
Low molecular weight heparin (Lovenox)
50%
560/1105
Heparin
3%
35/1105
Xa inhibitors (Xarelto etc.)
14%
156/1105
Outside my area of expertise - best if I don't vote
1%
16/1105
9. If you choose ORIF with plate and screws of the tibia AND fibula, when would you fix the fibula?
I would not ORIF with plate and screws of the tibia AND fibula
1%
18/1156
Fix fibula Before the tibia
70%
813/1156
Fix fibula After the tibia
26%
303/1156
Outside my area of expertise - best if I don't vote t
1%
22/1156
10. If you choose Operative Management and attained the construct shown below, when would you allow the patient to begin weight-bearing postoperatively?
I would not choose Operative management with the construct below
0%
0/1101
Immediately (1-6 days)
1%
20/1101
7-14 days (1-2 weeks)
2%
24/1101
15-28 days (3-4 weeks)
5%
58/1101
29-42 days (5-6 weeks)
26%
296/1101
43-56 days (7-8 weeks)
34%
375/1101
57-70 days (9-10 weeks)
9%
110/1101
71-84 days (11-12 weeks)
11%
127/1101
> 84 days (>12 weeks)
6%
72/1101
Outside my area of expertise - best if I don't vote
1%
19/1101
11. If you choose ORIF, which posterior based approach(es) would you utilize to treat the tibia?
I would not choose ORIF with a posterior based approach
1%
13/1191
I would not utilize a posterior based approach
24%
295/1191
Posteromedial only
15%
183/1191
Posterolateral only
39%
473/1191
Modified Posteromedial
7%
89/1191
Posteromedial + posterolateral
6%
77/1191
Outside my area of expertise - best if I don't vote
5%
61/1191
12. If you choose ORIF, which anterior based approach(es) would you utilize to treat the tibia?
I would not choose ORIF with the construct below
0%
5/1273
I would not utilize an anterior based approach
2%
30/1273
Medial
2%
28/1273
Anterolateral
24%
311/1273
Direct Anterior
11%
142/1273
Anteromedial
24%
315/1273
Medial + Anterolateral
21%
274/1273
Anteromedial + Anterolateral
8%
111/1273
Outside my area of expertise - best if I don't vote
4%
57/1273
PROCEDURE #1

ORIF L pilon fracture (CPT 27827). APPROACH: The patient was initially positioned prone. A posterolateral approach was carried out and posterior buttress plate applied followed by posterior fibula fixation. The patient was then positioned supine. An anteromedial approach was carried out. The anterior plafond was reduced and fixed provisionally followed by fixation to the posterior segment and plating.

Intra-procedure P1
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OUTCOMES
Post-procedure P1
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