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Bosworth Fracture-Dislocation and Resultant Compartment SyndromeA Case Report
Ryan Beekman, MD1; J. Tracy Watson, MD2
1 Department of Orthopaedic Surgery, Wayne State University, 4707 St. Antoine Boulevard, Suite 1-South, Detroit, MI 48201 E-mail address: rabeekman@hotmail.com
2 Department of Orthopaedic Surgery, Saint Louis University, 3735 Vista Avenue, 7th Floor, St. Louis, MO 63110. E-mail address: watsonjt@slu.gov
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Wayne State University, Detroit, Michigan

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2003 Nov 01;85(11):2211-2214
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Extract

Compartment syndromes after ankle fractures are exceedingly rare, as are Bosworth fracture-dislocations of the ankle. A high degree of vigilance must be maintained when managing these fractures in order to avoid complications and long-term morbidity. We report a case in which a Bosworth fracture-dislocation resulted in anterior, lateral, and deep posterior compartment syndrome. The patient was informed that data concerning the case would be submitted for publication.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Ryan Beekman, M.D.
    Posted on April 12, 2004
    Dr. Beekman responds:
    4707 St. Antoine Boulevard, Suite 1-South, Detroit, MI 48201

    We certainly agree with Dr. Ferris that patients with severe fracture dislocations of the ankle should be admitted for observation and close monitoring of their neurovascular status, even if emergent surgical intervention is not planned. The point of this case report was to highlight the fact that a poor outcome may result if the magnitude of an injury is underestimated. Failure to appreciate the severity of this injury and inadequacy of the reduction given the unusual fracture pattern, led an inexperienced junior house officer to incorrectly assume that this patient was suitable for ambulatory management.

    Typically at our institution only ankle fractures which are easily reduced with a congruent reduction are treated in an ambulatory fashion. Our emergency department treatment regimen includes appropriate splinting with bulky Jones type dressing, crutch training and strict patient instructions for home care. Patients then return to the ambulatory clinic for definitive surgical decision making and scheduling. However, significant injuries such as this do not fall into that category.

    We would like to reassure our colleague from Great Britain that immediate discharge following a high energy ankle fracture is certainly not the standard of care in the United States, and we hope this case report highlights this point.

    Barry Ferris, MS, FRCS
    Posted on January 15, 2004
    Treatment of Bosworth Fracture-Dislocation of the Ankle
    Barnet General Hospital, Wellhouse Lane, Barnet, Herts, EN5 3DJ, England

    The Editor:

    I read with disquiet 'Bosworth fracture-dislocation and resultant compartment syndrome. A case report' (2003; 85-A: 2211-2214 by Beekman and Watson).

    They describe a fracture-dislocation in a footballer that was reduced with difficulty and treated in a short leg cast. They also describe substantial soft tissue swelling and observe that surgery is inevitably going to be required. I would ask why the patient was discharged home to elevate the leg?

    Surely there is a very strong case to be made for admitting the patient so that high elevation and possible ice packs could be applied.

    Is it the case that the pressures are such that patients are not admitted unless it is absolutely necessary? This is certainly the route that we are going down in the United Kingdom and many orthopaedic surgeons have a certain amount of disquiet about the early discharge of patients from hospital.

    One would ask had the patient been admitted to hospital and the leg elevated that maybe the compartment syndrome would have been noted earlier and perhaps a fasciotomy would have been done at an earlier stage, possibly with a better outcome.

    Yours sincerely,

    Mr Barry Ferris, MS, FRCS Consultant Orthopaedic Surgeon

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