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Abstract

This case report presents the successful management of a rare and complex open ankle fracture-dislocation known as a ‘Logsplitter Injury’, resulting from a high-energy traumatic event. The patient, a Chinese male in his early 20 s, sustained a severe left lower limb injury in a traffic accident. Initial clinical assessments revealed significant swelling, pain and an open fracture with extensive soft tissue damage. The patient underwent an emergency surgical intervention, involving meticulous wound debridement, internal fixation and reconstruction of the lower tibiofibular union, was performed. The use of vancomycin-loaded polymethylmethacrylate bone cement and negative pressure wound therapy contributed to the favourable outcome. Post-operative care encompassed comprehensive analgesia and infection prevention measures, resulting in substantial ankle function recovery. Follow-up assessments revealed healed fractures and excellent joint alignment, with the patient attaining an AOFAS score of 85, indicative of good functional recovery. This case underscores the effectiveness of individualised treatment plans and multidisciplinary teamwork in managing such challenging injuries, offering valuable clinical insights and highlighting the potential for successful outcomes with timely and precise surgical interventions.

Keywords

Logsplitter injury open fracture reduction bone cements negative pressure wound therapy case report

Introduction

Logsplitter injury, a rare and challenging type of injury, is characterised by high-energy traumatic events and is associated with complex fracture lines and severe soft tissue damage.^1,2 This injury poses a significant challenge to clinical management. The existing literature on this subject is limited, with most reports consisting of case studies and small clinical studies.^3,4 These studies underscore the significance of multidisciplinary teamwork and the development of individualised treatment plans for the management of this injury. The objective of surgical intervention is to restore the anatomical structure and function of the ankle joint, while minimising the occurrence of complications. This case report delineates the intricate surgical management of an open ‘Logsplitter injury’ in a patient. The surgical intervention involved several critical steps, including debridement, internal fixation, bone block repositioning and lower tibiofibular union reconstruction, which was combined with the use of vancomycin-loaded polymethylmethacrylate bone cement and negative pressure wound therapy (NPWT).The patient's ankle function exhibited significant improvement as a result of the meticulous handling and comprehensive post-operative management by the surgical team. Notwithstanding the generally poor prognosis associated with such injuries, we present a favourable outcome following the provided treatment, which is substantiated by imaging. This case provides valuable clinical experience and reference for the management of this type of injury, and the reporting of this study conforms to CARE guidelines.⁵

Case

Patient information

A Chinese-origin male in his early 20 s sustained a severe injury to his left lower limb in a traffic accident in December 2020. The patient exhibited significant swelling, pain, bleeding and limitation of movement. There was no other significant medical history and the patient denied any relevant family history or psychosocial influences. The emergency team arrived at the scene of the accident and used a small splint to temporarily immobilise the injured left calf. The patient was then transported to the emergency department of Shenzhen Pingle Orthopedic Hospital, which is located at No.15 Lanjinsi Road, Pingshan District, Shenzhen City, Guangdong Province, China.

Clinical findings

The initial medical examination by the primary physician revealed marked swelling in the left leg and ankle, accompanied by an irregular transverse wound measuring approximately 6 cm in length on the inner ankle and exposure of the distal tibia. This was accompanied by significant bleeding (Figure 1(a)). The patient was conscious and reported experiencing pain, but was unable to perform active or passive ankle movements. A decreased sensation was noted at the base of the left foot, normal pulsation of the dorsal pedis artery and normal peripheral blood flow. To further clarify the diagnosis and assess the extent of the fracture, the emergency physician performed a radiological examination of the patient's ankle.

Figure 1.

Preoperative wound and imaging photos (a) obvious blood oozing was observed in the left medial malleolus of the patient, and the lower end of the tibia was exposed. (b) Preoperative anteroposterior and lateral X-ray films of the left ankle joint: The lower segment of the left fibula and the medial malleolus was fractured with dislocation, and the talus was embedded into the lower tibiofibular syndesmosis, resulting in separation and displacement of the syndesmosis.

Timeline

Table 1 presents a timeline that meticulously organises historical and current information relevant to the patient's care. This timeline encapsulates the key medical events, interventions and outcomes from the day of the accident to one-year post-operation, thereby highlighting the patient's recovery and rehabilitation process.

Table 1.

The timeline of historical and current information from this episode of care organised.

Date/time	Event/Intervention
Dec-20	Patient, a Chinese male in his early 20 s, sustains a severe left lower limb injury in a traffic accident.
Day of accident	Emergency team immobilises the left calf with a small splint and transports the patient to the local hospital's ED.
Day of accident	Physical examination reveals marked swelling, pain and an open fracture in the left ankle.
Day of accident	Radiological examination shows significant fracture displacement and a final diagnosis of an open fracture is made.
Pre-operative	Pre-surgery interventions include swelling reduction, analgesia, anti-tetanus and infection prophylaxis.
Evening of accident	Emergency surgery is performed with wound debridement, fracture reduction and fixation and antibiotic bone cement.
Post-operative day 1	Patient receives post-operative analgesia and infection prevention; limb elevation to reduce swelling.
Post-operative day 2	Morphine is stopped, oral diclofenac is continued, and patient instructed to walk without weight-bearing.
Post-operative day 5	Drainage tube is removed, and patient begins passive ankle flexion and extension training.
3 months post-operative	Kirschner wire, tibiofibular screw, and antibiotic bone cement are removed.
1 year post-operative	Internal fixation is completely removed; X-ray shows healed fracture and anatomical reduction.
1 year post-operative	Ankle range of motion assessed, and AOFAS score is 85, indicating good outcomes.
1 year post-operative	Kellgren–Lawrence grading shows Grade I, suggesting minimal post-traumatic arthritis.

Diagnostic assessment

In addition to the physical examination of the patient, laboratory investigations were performed to assess the risk of infection and to determine the necessity for preoperative preparation. These investigations included blood counts and coagulation tests. In addition, a frontal and lateral X-ray of the ankle was performed to analyse the fracture and dislocation in detail. The results of these investigations revealed a significant fracture displacement of the distal fibula and medial ankle, with the talus embedded in the distal tibiofibular union (Figure 1(b)). Fractures or dislocations not associated with open wounds and Pilon fractures were excluded and the final diagnosis was an open fracture of the left ankle in the ‘Logsplitter Injury’ category.

Therapeutic intervention

Pre-operative

Prior to undergoing surgery, interventions such as the administration of braking agents, reduction of swelling, analgesia, anti-tetanus immunoglobulin and empirical prophylaxis of infection were routinely administered. Following the completion of the preoperative examination and evaluation, the decision was taken to proceed with emergency surgical intervention. With the patient's informed consent, the surgical operation commenced at 20:30 h.

Intra-operative

The patient was positioned supine on the operating table under spinal anaesthesia, with strict aseptic techniques employed for the preparation of the surgical area. The surgical procedure included the following steps: (1) Wound debridement and exploration: The wound at the left medial malleolus and the surrounding skin were thoroughly irrigated with saline to remove contaminants and clots. The surgical area was disinfected and draped with sterile towels. Exploration revealed an intact posterior tibial tendon, posterior tibial artery and tibial nerve, with a palpable pulse in the tibial artery. The anterior tibial artery and deep peroneal nerve were structurally intact, with a palpable pulse in the anterior tibial artery. Necrotic tissue was excised, and the wound was extensively irrigated with saline. (2) Reduction and fixation of medial malleolus fracture: The area was then subjected to a second cycle of disinfection, after which the use of sterile materials and instruments was replaced. The talocrural joint and medial malleolus were reduced and stabilised using cannulated screws, and the medial wound was temporarily closed. The area was then disinfected once more, and the use of sterile instruments, surgical gowns and gloves were replaced. (3) Reduction and fixation of lateral malleolus: A 15-cm incision was made between the peroneus longus and extensor digitorum longus tendons to expose the fibular fracture end and anterolateral tibia. A high transverse-oblique fracture of the lateral malleolus, syndesmotic separation and anterolateral tibial avulsion fragment were identified. The avulsion fragment was then reduced and fixed with the use of cortical screws, while the fibular fracture was aligned and fixed using a plate and screws. C-arm fluoroscopy was used to confirm satisfactory fracture reduction. (4) Syndesmotic reconstruction: A hole was drilled 2–4 cm above the syndesmosis at a 30° anterior angle, and the use of two 45 mm cortical screws was used for fixation. The talocrural joint was reduced and fixed with two 2.5 mm screws inserted from the plantar aspect. C-arm X-ray confirmed equal medial and lateral joint spaces and proper implant positioning (Figure 2). (5) Placement of antibiotic-loaded bone cement: Partial sutures of the medial wound were removed, and polymethyl methacrylate bone cement loaded with vancomycin at a 10:1 ratio was prepared and placed in the anterolateral ankle and medial tibial spaces. (6) NPWT: Vacuum Sealing Drainage sponges were placed in the anterolateral ankle and medial malleolus areas, secured with sutures and film and connected to a drainage tube for negative pressure suction. A sterile dressing was applied to the lateral malleolus. The operation was completed after 4 h, with an intraoperative blood loss of approximately 300 mL, and the patient was transferred to the recovery room in stable condition.

Figure 2.

Intraoperative perspective images (a) anteroposterior film, (b) lateral film: the tibia and fibula fractures had good alignment, the internal fixation device was in a satisfactory position, and the ankle joint space was smooth and symmetric.

Post-operative

Following the procedure, the patient was administered routine post-operative analgesia and infection prevention measures. The affected limb was elevated to reduce swelling, and on the second day after the surgery, the morphine injection was discontinued, with the oral administration of diclofenac (75 mg once daily) being maintained. The patient was instructed to ambulate without weight-bearing. To gain a more comprehensive understanding of the position of internal fixators and the alignment of fracture, we conducted imaging examinations of the post-operative ankle joint, including X-ray and three-dimensional CT. The results showed that the fracture and dislocation of the left ankle joint returned to normal, the joint space of the lower tibiofibular joint did not widen significantly, the fracture block was in good alignment, the corresponding relationship of each joint was good, and the joint surface recovered smoothly (Figure 3). On the fifth day, following a stringent wound dressing change, the drainage tube was removed (with a lead flow of less than 10 ml), and the patient was instructed to commence passive ankle flexion and extension training.

Figure 3.

Images of ankle joint on the first day after operation (a–d) 3D CT scans and reconstructions of the ankle joint: good alignment of the left ankle fracture, good correspondence between the joints and smooth restoration of the articular surface. (e, f) The anteroposterior and lateral radiographs of the left ankle joint on the first day after surgery: the fracture and dislocation of the left ankle joint have returned to normal, the position of the internal fixator is satisfactory, and the bead-{PI}like antibiotic bone cement can be seen between the tibia and fibula.

Follow-up and outcomes

A discharge rehabilitation plan was formulated based on the specific needs and rehabilitation progress of the patient, and he was informed to return to the hospital on time for a follow-up examination to evaluate the healing of fractures. Three months after the operation, the Kirschner wire was removed, and the lower tibiofibular screw and antibiotic bone cement were removed. The X-ray of the left ankle joint was reviewed (Figure 4(a)), and the patient was instructed to walk with weight gradually. One year after the operation, the quality of fracture reduction was evaluated in this patient based on the Burwell–Charnley fracture reduction evaluation criteria, which classify the quality of fracture reduction into three grades: anatomical reduction, acceptable reduction and poor reduction.⁶ An X-ray of the left ankle joint showed that the dislocation of the lower tibia was corrected, the anatomical reduction was performed, and the fracture line of the lower fibula was healed (Figure 4(b)), so we completely removed the internal fixation. The range of motion of the ankle joint was as follows: dorsiflexion 15° and plantar flexion 30°. The AOFAS scoring system, developed by the American Orthopaedic Foot and Ankle Society, is one of the most widely used assessment tools in foot and ankle surgery.⁷ The patient's post-operative evaluation utilised a 100-point scale, with scores above 75 indicating favourable outcomes. The evaluation encompassed various parameters, including pain, ambulatory function, gait characteristics, joint mobility, ankle stability and joint alignment. The patient's AOFAS score was determined to be 85 points. In order to ascertain whether post-traumatic arthritis had occurred after surgery, we employed the Kellgren-Lawrence grading system, which assesses the patient's condition based on the radiographic findings. This system is graded from 0 to IV, with higher grades indicating more severe lesions.⁸ Ultimately, the patient's Kellgren–Lawrence grade was I, indicative of a suspected narrowing of the ankle joint space and the possible presence of osteophytes. It is evident that following the administration of emergency open reduction and internal fixation (ORIF) surgery, in conjunction with active infection prevention during the perioperative period and the implementation of appropriate rehabilitation exercises, the patient's ankle joint attained satisfactory anatomical alignment and functional recovery. This enabled the resumption of daily activities with minimal residual disability.

Figure 4.

Anteroposterior and lateral X-ray films of ankle joint were taken at 3 months and 1 year follow-up after operation (a) the positive and lateral X-ray of the left ankle joint after the removal of the Kirschner wire and the removal of the lower tibiofibular screw and antibiotic bone cement in the third month after the operation. (b) The anteroposterior and lateral X-ray of the left ankle joint one year after the operation and the fracture healed well.

Discussion

The majority of ankle fractures and dislocations are caused by high-energy injuries and generally result in suboptimal functional outcomes.⁹ Logsplitter injury is one of the distinct types, which can be categorised into typical and atypical damage according to the injury mechanism. Research has identified that the majority of typical cases occur in the context of road traffic accidents or falls from height and that the fracture reduction rate and range of motion are poor, with a high incidence of post-traumatic ankle arthritis.¹⁰ Radiological Examination reveals that the medial malleolus fracture is located at the ankle joint level, the lower tibiofibular syndesmosis is separated, and the fibula fracture is located above the lower tibiofibular syndesmosis level. The presence of these signs indicates that the foot is in a pronation position when injured and is subjected to external rotation and axial force, thus indicating a typical injury. Currently, a clear consensus on the treatment of Logsplitter injury is lacking. However, the International Association for the Study of Internal Fixation asserts that the vast majority of displaced ankle injuries are unstable, necessitating reliable internal fixation through open reduction to ensure accurate anatomical reduction. It is therefore hypothesised that ORIF surgery is the optimal treatment for Logsplitter injury. The restoration of stability in the ankle joint can be achieved through anatomical reduction and fixation of the tibiofibular syndesmosis, in conjunction with the repair of the deltoid ligament. This approach has been shown to reduce the incidence of post-traumatic osteoarthritis to a certain extent and has been demonstrated to show significant advantages in the early stabilisation of the fracture, promotion of soft tissue healing and accelerated functional recovery. Post-operative results showed that the patient's AOFAS score was 85, indicating a favourable clinical outcome.

Recent studies have focused on the management of open ankle injuries, with the traditional ‘Fix and Flap’ protocol emphasising delayed internal fixation after initial damage control.^11,12 However, studies have shown that under certain conditions, emergency definitive treatment can achieve similar results to delayed surgery,¹³ especially if the operator has a high level of skill and the patient's condition permits. The present case further validates this view, suggesting that emergency open reduction and internal fixation may serve as a viable alternative in young, uncomplicated and highly compliant patients. In the present case management, NPWT and antibiotic bone cement appeared to play a positive role in preventing infection. This assertion is further substantiated by extant studies that support their role in promoting wound healing and reducing the risk of infection.^14,15 However, it is also acknowledged that the positioning and technique of intraoperative internal fixation devices require further optimisation. For instance, it is noted that the elevated position of the transverse ligament screws may have an impact on post-operative healing outcomes, a matter that requires attention in future studies.

With this case report, we recognise the importance of individualised treatment plan. This case report serves to underscore the significance of two factors in the management of complex open ankle injuries: individualised treatment plans and multidisciplinary teamwork. The findings of this study demonstrate that the precision of surgical technique and comprehensive post-operative management exerts a direct influence on the healing outcome of patients. Consequently, future studies should endeavour to optimise surgical techniques and enhance post-operative management, with a view to further improving treatment outcomes.

Conclusion

This study demonstrates the feasibility and efficacy of emergency definitive treatment in a specific clinical context and highlights the critical role of intraoperative technical details and post-operative management in achieving good functional recovery. The case provides a new perspective and valuable experience in the individualised treatment of open logsplitter injury.

Patient perspective

The initial impact of the injury, as well as the severity of the accident, was significant. However, the emergency team's prompt response and professional demeanour provided immediate relief and reassurance, instilling a sense of confidence in the care I was receiving. During the surgical intervention, I was thoroughly informed about the procedures and the anticipated outcomes, which contributed to alleviating my anxiety. The surgical team's meticulous approach and the use of advanced techniques such as antibiotic bone cement and NPWT assured me that I was receiving cutting-edge care tailored to my specific needs. Post-operatively, the pain management plan was effective, allowing me to gradually regain mobility without undue discomfort. The rehabilitation process, although demanding, was crucial in aiding my recovery. The provision of comprehensive post-operative follow-up care and clear instructions regarding post-surgical exercises was also beneficial in restoring function to the patient's ankle. The multidisciplinary team's dedication and the personalised treatment plan were instrumental in the patient's recovery, and the support and expertise they provided enabled a return to daily activities with minimal limitations. This experience serves as a testament to the effectiveness of modern medical interventions and the importance of patient-centred care.

Informed consent

The patient has provided written informed consent for the treatment and procedures described in this case report, including surgical interventions, post-operative care and rehabilitation. The patient was thoroughly informed about the nature of the injury, the proposed treatment plan, potential risks and expected outcomes. Additionally, the patient consented to the use of their medical data and images for this publication, understanding that all identifying information will be kept confidential to maintain privacy. We have obtained the patient's written informed consent (Chinese version).

Footnotes

Acknowledgments

The authors would like to thank Shenzhen Pingle Orthopedic Hospital for its help in retrieving case data.

Author contributions

Ruize Huang and Yangting Cai were credited as co-first authors, having made equal contributions to the conception, design, and drafting of the manuscript. Tingqu Zheng was involved in the clinical management of the patient and provided critical revisions to the manuscript. Qiang Lin supervised the project, coordinated the research team and approved the final version for publication. All authors have read and agreed to the published version of the manuscript.

Data availability statement

The data supporting the findings of this study are available within the article. Additional data related to this case report may be obtained from the corresponding author, upon reasonable request, and with appropriate permissions, while ensuring patient confidentiality is maintained.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Ethics approval

This case report was conducted in accordance with the ethical standards laid down in the Declaration of Helsinki and local institution does not require ethical approval for reporting individual cases. But the patient provided written informed consent for the treatment procedures and for the publication of this case report, including the use of medical data and images, with the assurance that all personal identifying information would be kept confidential. The authors adhered to CARE guidelines to ensure the ethical and transparent reporting of this case.

ORCID iDs

Ruize Huang

Yangting Cai

Tingqu Zheng

Qiang Lin

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A case report on the successful treatment of a specific type of open ankle fracture-dislocation called logsplitter injury

Abstract

Keywords

Introduction

Case

Patient information

Clinical findings

Timeline

Diagnostic assessment

Therapeutic intervention

Pre-operative

Intra-operative

Post-operative

Follow-up and outcomes

Discussion

Conclusion

Patient perspective

Informed consent

Footnotes

Acknowledgments

Author contributions

Data availability statement

Declaration of conflicting interests

Funding

Ethics approval

ORCID iDs

References