Case Conference10/10/2016

Ext. Natsuda Tatu Faculty of Medicine, Chiangmai university

Case scenario

• Identification data: ผู้ป่วยชายไทยคู่ อายุ 77 ปี ปัจจุบนัไมไ่ด้ประกอบ อาชพี

ภมูลิำาเนาอำาเภอเมอืง จงัหวดันครราชสมีา• Admission date: 7/10/2559• Source of data: ผู้ป่วย, ญาติ, และบนัทึกทางการแพทย์• Reliability: มาก• Chief complaint: ล่ืนล้ม ปวดขาซา้ย 3 ชัว่โมงก่อนมาโรงพยาบาล

Primary survey

• A: can talk, no stridor• B: clear & equal breath sound both lung• C: BP 188/94 mmHg, PR 70 bpm, no active bleeding• D: E4V5M6, pupil 3 mm RTLBE

Secondary survey

• GA: An elderly Thai man with normal consciousness• V/S: BP 188/96 mmHg PR 70 bpm RR 18/min BT 36.6• HEENT: no pale conjunctiva, no jx, no cervical LN• Heart: regular rhythm, no murmur• Lung: CCT neg, clear & equal BS both lung• Abdomen: soft, no tenderness, normoactive bowel sound• Pelvic: no contusion, no wound, PCT neg• Extremity: affected part Left leg

Affected part

• Left leg:• Swelling at lower leg• Tenderness at lower leg• Can perform ankle dorsiflexion

and plantarflexion• Dorsalis pedis 2+• Sensory intact

Secondary survey

• Allergy: no food and drug allergy• Medication: - Atenolol (50) 1x1 PO pc

- Doxazosin (2) 1xhs• Past illness: HT, BPH, HNP• Last meal: -• Event: 3 ชัว่โมงก่อนมาโรงพยาบาล (16.00 น.) ขณะเดินโดยใช้ walker

ล่ืนล้มเอง ไมไ่ด้วูบ หรอือ่อนแรงก่อนจะล้มลง ขาซา้ยกระแทกพื้นปูน มอีาการ ปวดและบวมขึ้นมาทันที ขาซา้ยไมส่ามารถรบันำ้าหนักได้ ไมม่แีผลเปิด ศีรษะไม่

กระแทกพื้น จำาเหตกุารณ์ได้ จงึไปโรงพยาบาล ป. แพทย์ ได้ x-ray และดามไว้ก่อนสง่มารกัษาต่อท่ีโรงพยาบาลมหาราชนครราชสมีา

InvestigationFilm leg AP, Lat

Film ankle AP, Lat, mortise

Diagnosis

• Closed fracture both bone left leg

Management at ER

• Close reduction• On posterior long leg slab

Tibia and fibular shaft fracturesFracture both bone

Introduction

• Tibia and fibular fractures are relatively common• Bimodal distribution:

• > 50 yr low energy, spiral pattern• < 30 yr high energy, transverse and comminuted fracture

• Mechanism of injury• Low energy: Fall from standing height, sporting injury• High energy: Vehicular trauma (pedestrian > MC > motor vehicle

crash), direct blow, gunshot, fall from height

Assessment

• Mechanism of injury• Associated injuries• Imaging and other diagnostic studies• Classifications

• Fracture configuration• Soft tissue involvement

Mechanism of injury

• Low-energy• Fall from standing height• Sporting injury

• High-energy• Vehicular trauma (Pedestrians > MC > Car crash)• Assault (Direct blow, Gunshot wound)• Fall from height

• Usually open fracture (≥ Gustilo IIIB)

Associated injuries

• Compartment syndrome• Ankle injuries• Floating knee injuries• Fracture extension into tibia plateau• Knee ligamentous injuries• Proximal tibiofibular joint dislocation

Imaging & other diagnostic studies

• X-ray • AP and lateral view, include entire length of tibia & fibular

• CT, MRI• If concern pathologic bone lesion

• Minimal energy mechanism• History of malignancy• Antecedent pain• Irregular appearance on bone x-ray

AO/OTA classification

• Type A Simple fracture

Spiral

AO/OTA classification

• Type A Simple fracture

Oblique>30 degree

AO/OTA classification

• Type A Simple fracture

Transverse

AO/OTA classification

• Type B Wedge fracture

Spiral

AO/OTA classification

• Type B Wedge fracture

Bending

AO/OTA classification

• Type B Wedge fracture

Fragmented

AO/OTA classification

• Type C Complex fracture

Spiral

AO/OTA classification

• Type C Complex fracture

Segmental

AO/OTA classification

• Type C Complex fracture

Irregular

Associated soft tissue injury classification• Useful for determined proper management of tibial and

fibular fx• For closed fracture

• Tscherne classification• For open fracture

• Gustilo classification

Tscherne classification

Simple fx withLittle/no soft tissue injury

Mild-mod fx configSuperficial abrasion

Tscherne classification

Moderately severe fx configDeep contamination c local skin/muscle contusion

Severe fxextensive contusion or crushing of skin or destruction of muscle

Gustilo classification

Anatomy

Treatment option

• Non-operative treatment• Closed reduction• Immobilization cast, slab• Rehabilitation

• Operative treatment• Open reduction/close reduction• Immobilization Intramedullary nail, Plate & screw

Non-operative treatment

• Indications:• Adequate alignment, length, and rotation in a splint or cast• Soft tissue cannot tolerate cast• High anesthetics risk• Patient refused operative treatment

• Contraindication:• Inadequate alignment, length, and rotation after application splint

or cast• Open fracture• Arterial injury• High risk of develop compartment syndrome

Non-operative fixation

• Long leg cast • Partial weight bearing with crutches as soon as tolerated• Full weight bearing at 2nd – 4th wk after injury

• Patella tendon-bearing cast• At 4th – 6th wk after injury

• Average time to union about 16 weeks

Long leg cast

Patella tendon-bearing cast

Operative treatment

• Indications:• Failure to obtain adequate close reduction• Open fracture• Vascular injury• Massive soft tissue damage• Patient who too unreliable for closed treatment• Patient prefer not to have a cast

• Better outcome than non-operative treatment

Operative fixation

• Intramedullary nail• Interlocking nail*• Flexible IM nail

• Plate• External fixator

Intramedullary nail

Plate

Complications

Thank you