Trauma SGD Week 2 August 2, 2011

Patient Profile Remeius Emata, 44/M San Isidro, Nueva Ecija R-handed, farmer Seen 5 days post-injury

History of Present Illness DOI: July 27, 2011 TOI: 4:00 am POI: San Fernando Sur, Cabuyao, Nueva Ecija MOI: Pt was about to ride his tricycle when a motorcycle hit him from behind. Pt fell on his left leg, and hit the pavement. (-) Bleeding, open wound, loss of consciousness Brought to PGH for management.

Review of Systems (-) cough, colds, fever, headache (-) dizziness (-) BOV (-) dysphagia (-) nausea/vomiting (-) DOB, palpitations (-) bladder and bowel changes (-) polyphagia, polydipsia, polyuria

Past Medical History (-) DM, HPN, CA, TB, BA, allergies, heart/liver/kidney disease (-) prior history of trauma

Family Medical History (+) HPN, leukemia, bone CA (-) DM, TB, BA, allergies, heart/liver/kidney disease

Personal & Social History (+) smoking - 1 pack/day for 14 years (+) occasional alcoholic beverage drinker (-) illicit drugs Works as a farmer

Physical Examination Awake, alert, coherent, NICRD BP 110/80 HR 76 RR 18 afebrile AS, PC, (-) CLAD/NVE/ANM ECE, CBS AP, NRRR, DHS, (-)m/h/t Soft and round abdomen, NABS, (-) masses/tenderness

Skin/Extremities FEP, PNB, (-) cyanosis/edema Bilateral UE - full ROM on active & passive movement, (-) sensory deficit, DTR +2, (-) pain, tenderness, swelling, warmth RLE - full ROM on active & passive movement, (-) sensory deficit, DTR +2, (-) pain, tenderness, swelling, warmth

Left Lower Extremity LeftRight Inspection(+) swelling (-) open wound, pallor, cyanosis, deformity, deviation (-) swelling, deformity, deviation (-) open wounds, pallor, cyanosis Palpation FEP, no sensory deficits (+) tenderness, warmth - anterior aspect of the leg FEP, no sensory deficits (-) tenderness, warmth

LeftRight Movement(+) LOM on active motion of the L ankle Full toe flexion and extension. Full ROM on both active and passive movement

Assessment Leg Fx, closed, complete, comminuted, displaced, MD3, tibia L Fx, closed, complete, comminuted, displaced, MD3, fibula L

Plan At the ER: RICE WOF: Compartment Syndrome, Fat Embolism, ARDS, DVT Definitive: IM nailing, L leg

RICE Principle Rest- Walk with crutches if you cannot bear weight. Ice- Use an ice pack for 20 minutes every two to three hours during the first 72 hours. Compression- Wrap the leg. Start at the bottom of the toes and wrap up past the knee. Elevation- Keep the injured ankle above the level of your heart when sitting or lying down

Goal of Treatment The goal of any treatment is to allow the fracture to heal in an acceptable position with minimal negative effect on the surrounding tissues or joints.

Fibular fracture The fibular fracture usually heals independentl y of the reduction achieved. Tibial Fracture Close Open

Close treatment for Tibial Fractures Close reduction under GA patient is immobilized in a long leg non-weight–bearing cast Weekly radiographs for the first 4 weeks

If with displacement, angulation can be corrected by "wedging" the cast At 6 weeks, some shaft fractures are stable enough to be put in a short leg weight-bearing cast Protected weight bearing should be continued until clinical and radiologic healing is evident.

Surgical Options for Tibial Fractures IM Nailing Plates & screws

Surgical Management (Intramedullary Nailing) For the fixation of unstable closed tibial shaft fractures Stabilizes and aligns the tibial shaft Union rates of greater than 95% and excellent alignment Indications: high-energy fx; modereate to severe soft-tissue injury; unstable fracture pattern; open fx; compartment syndrome; ipsilateral femur fx; inability to maintain reduction;

Intramedullary nails are introduced from a proximal starting point anterior to the tibial tubercle across the fracture site under fluoroscopic control without opening the fracture site Dynamic or static interlocking can be achieved with transfixing screws on both ends of the nail

Surgical Management (Plates & Screws) Open reduction and internal fixation with plates and screws using minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques,

Avoids direct exposure of the fracture site Decreases soft- tissue dissection Decrease devascularization of the bone

Decrease risk of infection Decrease risk of delayed union This technique is useful in periarticular fractures with diaphyseal extension

Cast immobilaztion VS IM nailing Advantages IM NailingCastin Immobilization 1.) shorter time to healingearly mobilization with or without weight bearing 2.) better rate of healingshort hospital stay 3.) improved functional score less risk of infection

Disdvantages IM NailingCastin Immobilization 1.) infectiondoes not preclude further surgical treatment 2.) wound problemsresidual deformity 3.) possible contracturesknee or ankle joint stiffness more difficult wound care

What do we do with the Fibula?  The fibular fracture usually heals independently of the reduction achieved.  The fibula only bears 17% of the body weight.  Surgery to place a rod, or plates and screws may sometimes be recommended.

Conclusion: “Fibular plating in addition to tibial IM fixation of distal third tibia and fibula fractures leads to slightly increased resistance to torsional forces. This small improvement may not be clinically relevant.”

“In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia- fibular fracture.”