To The Editor:
I read with disquiet "Bosworth Fracture-Dislocation and Resultant
Compartment Syndrome. A Case Report"
(2003;85:2211-4), by Beekman
and Watson.
They describe the case of a soccer player who sustained a
fracture-dislocation that was reduced with difficulty and treated with a short
leg cast. They also reported substantial soft-tissue swelling and observed
that surgery was 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 the leg could be treated with high elevation and ice packs could possibly
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 the
hospital.
One might ask whether the compartment syndrome might have been noted
earlier and perhaps a fasciotomy would have been done at an earlier stage,
possibly with a better outcome, if the patient had been admitted to the
hospital and the leg had been elevated.
We certainly agree with Mr. Ferris that patients with a severe
fracture-dislocation 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 the
inadequacy of the reduction, given the unusual fracture pattern, led an
inexperienced junior house officer to assume incorrectly that this patient was
suitable for ambulatory management.
Typically at our institution, only ankle fractures that are easily reduced
with a congruent reduction are treated in an ambulatory fashion. Our emergency
department treatment regimen includes appropriate splinting with a bulky
Jones-type dressing, training on the use of crutches, and strict patient
instructions for home care. Patients then return to the ambulatory clinic for
definitive surgical decision-making and scheduling. However, important
injuries such as this one 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.