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Trauma SGD Week 2

Trauma SGD Week 2

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Trauma SGD Week 2

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  1. Trauma SGD Week 2 August 2, 2011

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

  3. 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.

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

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

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

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

  8. 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

  9. 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

  10. Left Lower Extremity

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

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

  13. 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

  14. 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.

  15. Close treatment for Tibial Fractures

  16. Surgical Options for TibialFractures • IM Nailing • Plates & screws

  17. 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;

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

  19. Cast immobilaztion VS IM nailing

  20. 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.

  21. 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.”

  22. “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.”