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 ExtremityLeft Right

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

Left Right

Movement (+) LOM on active motion of the L ankleFull 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 independently 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 Nailing Castin Immobilization

1.) shorter time to healing early mobilization with or without weight bearing

2.) better rate of healing short hospital stay

3.) improved functional score

less risk of infection

Disdvantages

IM Nailing Castin Immobilization

1.) infection does not preclude further surgical treatment

2.) wound problems residual deformity

3.) possible contractures knee 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.”