nswolfso at usc
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Nov 6, 2008, 4:52 AM
Post #3 of 14
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Re: [ORT-L] crush distal tibia
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Marek:
Her what I would do:
1. make sure there is no compartment syndrome. If yes: fasciotomy. If no:
I would make sure full length x rays of tibia and fibula is done, including ankle x rays, and even CT scan of the distal tibia, to assess possibility of intraarticulat extension of the tibial fracture. I also would take x rays of the foot.
2. Soft tissue is my first priority.
A. I stage my treatment.
1. Temporary ex fix ( traveling frame): one pin or wire into calcaneus and one pin ( or wire) into proximal tibia. Try to stay away from the IM canal. You can safely put proximal pin or wire into mataphyseal bone. ( if Morell lesion ( not likely) decompress with I@D )
2. After the swelling is down and soft tissue condition declared itself ( hopefully no major skin problems), it may take between few days up to 2 weeks or sometimes more) my next step would be to address the fractures. CT scan will give you more info on possible intraarticular extension of the tibial fracture and if there is a large fragment you may reduce and stabilise it prior to the IM nail insertion.
I would use IM nail with at least 2 distal locking screws, and ORIF of the ankle: reduce and plate lateral malleolus, medial malleolus, stress syndesmosis under X ray ( C arm, fluoro) and, if unstable address it as well. If CT scan shows postesrolateral fragment fractured and displaced you may have to address this based on stability of your ankle/syndesmosis. You can work around your nail.
It sounds you have experience with Ilizarov. It would not be my choice. make sure you address the ankle injury.
Good luck
Nik
Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery
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----- Original Message -----
From: Marek Kolasniewski <kolix@wp.pl>
Date: Thursday, November 6, 2008 1:36 am
Subject: [ORT-L] crush distal tibia
To: ORT-L@www2.aaos.org
> Dear
> Could You give us an advice ?
> 48 yo male, crush injury ( esp. Gustilo IIIA ) of distal tibia managed
> nonoperatively ( cast ! ABX) for 2 days, was transferred to us.
> There,s no
> signs of infection but condition of skin is bad ( large contusion,
> Tscherne3 ) What kind of treatment: definitivly or staged ?
> Internal fixation (
> plate ) or maybe nail + screws ? Ilizarov is an option...
> Best regards
> Marek Kolasniewski
> Orthopedic Trauma Unit
> Military Hospital
> Poznan
> Poland
>
---
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