Extern conferenceOrthopedics nakornratchsima

Ext. Chansinee Sunawinworarat

case

• Patient Profile : ผปวยชายไทยอาย 35 ป• Chief Complaint : ปวดขาซาย 1 ชวโมงกอน

มาโรงพยาบาล

case

• Chief complaint : 1 hrPTA ผปวยประสบ อบตเหตขบรถจกรยานยนตลม มอาการปวดขา

ซาย มขาซายผดรป มบาดแผลถลอกทขาซาย ไมม บาดแผลฉกขาด สลบ จำาเหตการณไมได

Primary survey

• Airway – can talk, c-spine not tender, full motion of neck• Breathing – equal breath sound both lungs, CCT – negative• Circulation – BP 120/65mmHg , P 89 bpm , no external

bleeding• Disability – E4V5M6 , pupil 3mmRTLBE• Exposure –abrasion wound Left leg 3x3 Cm

Secondary survey

General appearance – a thai man , good consciousHEENT – no pallor , no facial wound Chest & Lungs – good air entry equally both side, no adventitious sound,CCT negativeCardiovascular - full regular pulses all extremities, normal s1 s2,no murmur

Secondary survey

Abdomen - no distension, no bruising, soft , not tender, pelvic compression negativeExtremities abrasion wound Left leg 3x3 Cm ,swelling tenderness,limit active and passive ROM due to pain no deformities Neurological – conscious, orientated, motor power grade V, no numbness

case• Allergy – none• Medication – none• Past history – unknown underlying disease, • Last meal – 17.00

case

• Event –ผปวยประสบอบตเหตขบรถจกรยานยนตลม มอาการปวดขาซาย มขาซายผดรป ไมชา มบาดแผลถลอกทขาซาย ไมมบาดแผลฉกขาด สลบ จำาเหตการณไมได ดมสรา

Investigation• Film Lt leg AP , Lateral

diagnosis

• Closed Fractures Tibia Lt leg• Mild Head injury (moderate risk)

Management

• On Lt Posterior long leg slab

CLOSED FRACTURES TIBIA

-EPIDEMIOLOGY-MECHANISM-PRESENTATION-IMAGING-TREATMENT -COMPLICATIONS

Overview

EPIDERMIOLOGY

most common long bone fx account for 4% of all fx seen in the Medicare population

Mechanism-low energy fx pattern

result of torsional injuryindirect trauma results in spiral fxfibula fx at different levelTscherne grade 0 / I soft tissue injury

Mechanism-high energy fx pattern

direct forces often result in wedge or short oblique fx and sometimes significant comminutionfibula fx at same levelsevere soft tissue injuryTscherne II / IIIopen fx

SYMPTOMSPAININABILITY TO BEAR WEIGHTDEFORMITY

Presentation

Physical exam

deformity / angulation / malrotationcontusionsopen woundsLimit passive motion of toes

Imaging-Flim full length AP and lateral views of affected tibia AP, lateral and oblique views of ipsilateral knee and ankle-CTindications

intra-articular fracture extension or suspicion of joint involvement

Treatment of Closed Tibia Fractures-Nonoperativeclosed reduction / cast immobilization indicationsclosed low energy fxs with acceptable alignment< 5 degrees varus-valgus angulation< 10 degrees anterior/posterior angulation> 50% cortical apposition< 1 cm shortening< 10 degrees rotational malalignmentif displaced perform closed reduction under general anesthesia

techniqueplace in long leg cast and convert to functional brace at 4 weeks

outcomeshigh success rate if acceptable alignment maintainedrisk of shortening with oblique fracture patterns risk of varus malunion with midshaft tibia fractures and an intact fibula non-union occurs in 1.1% of patients treated with closed reduction

functional brace

Operativeexternal fixation

-indicationscan be useful for proximal or distal metaphyseal fxs-complications pin tract infections common-outcomeshigher incidence of malalignment compared to IM nailing

external fixation

IM Nailingindications

unacceptable alignment with closed reduction and castingsoft tissue injury that will not tolerate castingsegmental fxcomminuted fxipsilateral limb injury (i.e., floating knee)polytraumabilateral tibia fxmorbid obesity

contraindicationspre-existing tibial shaft deformity that may preclude passage of IM nailprevious TKA or tibial plateau ORIF (not strict contraindication)

outcomesIM nailing leads to (versus external fixation) decreased malalignmentIM nailing leads to (versus closed treatment) decrease time to uniondecreased time to weight bearingreamed vs. unreamed nails reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)recent studies show no adverse effects of reaming (infection, nonunion)reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial shaft

ComplicationsKnee painMalunion NonunionMalrotation Nerve injury

ReferenceOrthobulletsเอกสารประกอบการเรยนวชาออรโธปดกส