Date post: | 18-Aug-2015 |
Category: |
Documents |
Upload: | selene-g-parekh-md-mba |
View: | 10 times |
Download: | 2 times |
50 year old male diabetic Tripped and fell from a single stair
injuring right ankle Locally treated initially with below
knee cast for 3 weeks Patient told he had “minor” fracture
in ankle Immediate post injury x rays not with
the patient
Swollen, warm, erythematous distal leg, ankle and foot
No pain...patient came walking to the OPD....No stick, no cast
On IV antibiotics for 10 days post cast removal : Meropenem and dalacin
Blood cell counts normal Blood sugar Random 345 HbA1C : 11.5 Peripheral doppler normal Neuropathy
CT report:
• Fracture head, neck and body of talus, displaced fracture fragments extruded medially
• Comminuted fracture around posterior subtalar joint involving both talus and calcaneus with lateral dislocation of the fragments
• Fracture distal medial tibia, superiorly displaced
At 14 weeksAt 10 months: trivial fallAfter surgery
4 days post a closed fracture
Eventually after 3 surgeries
It is good to compare with the normal side
Trivial trauma in a diabetic
In 6 weeks!!
Diabetic fractures
Dr.Rajiv ShahFoot & Ankle OrthopaedicsFoot & Ankle SurgeonPresident, Indian Foot & Ankle Society
Fractures in diabetics: facts ‘Literature’Diabetes affects fracture healing at cellular level 1) deficient production of
growth factors leading to impaired bone formation
2) Deficient osteoclastogenesis
Impaired bone quality rather than impaired bone density leads to higher fracture risk in diabetics at subtle trauma
A history of any previous fracture increasesthe risk of further fracture by at least twofold
Fractures in diabetics took 163% longer time to heal!!
Fractures in diabetics: facts Literature69 years old diabeticX-rays at five months
X-rays at Nine months
8
What is special about diabetic fractures?Whether you operate on them or you conserve them results are universally bad with many complications!
Complications following diabetic ankle fracturesComplication at 90 days
Uncomplicated diabetes
Complicated Diabetes
Infections 2.46 3.85
Revision Surgery 1.84 5.09
Below knee Amputation
6.41 27.6
Ankle fractures in diabetics: ‘Literature’Complication rate in ankle fractures with uncomplicated diabetes is same as control(10%)
Complication rate in ankle fractures with complicated diabetes (neuropathy, nephropathy or vaculopathy)is very high(56%)!!
Surgical treatment of diabetic ankle fractures have shown major complication rate of 43% & infection rate up to 30%
Fractures in diabetics: facts
Diabetic fractures behave differently especially in presence of neuropathy
Bone destruction can be rapid Charcot process may start even
with “chip” fracture
Fractures in diabetics: facts
Many charcot are misdiagnosed as cellulitis / infection and are treated with antibiotics
‘Elevation test’ Rule out un displaced fracture
extensions not seen on the x ray with CT scan
Fractures in diabetics: facts
Diabetic patients need MORE of everything ▪ More investigations : Neuropathy, CT,
Doppler▪ Longer duration of immobilization▪ Longer duration of NWB▪ More fixation : stronger implants▪ May require primary fusions more often
than non neuropathic cases
Adelaide Diabetic Ankle Fracture Algorithm
Ankle Redness / Swelling and/or Pain
DIABETIC?NoRisk Factors?
Yes
Screen for DM
Diabetic RADIOLOGY
FRACTURE / DISLOCATION / CHARCOT
No
Other causes
Non DM
No
Two points each One point each
1. Peripheral Neuropathy / loss of protective proprioceptive sensation
2. Vasculopathy3. Previous history of
charcot at any joint4. IDDM5. Poor control HbA1c more
than 7.5
1.Diabetic more than 20 years
2.Nephropathy / Retinopathy
3.Obesity4.Non Compliant
patient
AFDA Scoring
Adelaide Diabetic Fracture Management Algorithm
Fractures in diabetics‘High Index of Suspicion’
Fractures in diabeticsWhat to ask ? History Mode & severity of traumaCould you walk after trauma?Presentation(delayed) after traumaPrior fractureTingling, numbness, burning, lack of sensibility, feeling of cushioned feet, night painsRenal or visual problems
Fractures in diabeticsWhat to look?
NeuropathySensory element
NeuropathyAutonomic element
NeuropathyMotor element
Fractures in diabeticsWhat to look? VasculopathyPeripheral pulses
VasculopathyToe hair growth
VasculopathyDoplerABI
HBA1C < 7Total lymphocyte >1500Total albumin > 3.0Pinzur criteria( CORR, 1993)
Fractures in diabeticsHow to treat?
Uncomplicated diabetic
fracture
Conservative care
Same as routine
Surgical care Same as routine
Fractures in diabeticsHow to treat?
Complicated diabetic fracture:
Conservative care
Watch for infection,Pressure sores,Frequent visits,
Periodic check X-raysLonger immobilization
Delayed weight bearingProtection if needed
Ankle fractures in diabeticsHow to treat? Complicated diabetic ankle fractures: Surgical guidelineTwo ways
Fractures in diabetics with neuropathyHow to treat? Longer
fixations Stronger
fixation Combination
fixations Crossing &
spanning of joints
Longer protection
Delayed weight bearing
Long time bracing
Do inform patient & relatives
Diabetic male aged 65 years
Fall Injury to
right ankle
Exploration of medial side & suture anchors for deltoid?
Syndesmotic screw?
Follow up
Infection – sinuses – implant failure
what
next?
Stage 1: Debridement, anchor removalStage 2: Ankle fusion with hind foot nail
42 years old male
Plate fixation
4 months –ex-fix removal
Associated with IHD Atherosclerosis Lower limb ischemia Infection Finally required Below Knee Amputation!!
Diabetic female aged 58 years
Fall in bathroom
Injury to left ankle
This is what was done
Comments?What next?
Position after mobilization
Revision fixation Comments?What next?
Mobilization with wound issues Comments?
Was it deemed?
What next?
Non unionInfectionCharcotLower third tibia fracture
Stage 1: Debridement, implant removalStage 2: Ankle fusion with hind foot nail Fracture stabilization with ilizarov fixator
Just 3 weeks post –surgery patient died!!
That’s all…Thank you all..