Ortho Case of the Week – Tibia and Fibula ANSWERS

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Source: Radiopaedia (case)

1. Describe the x-ray above.

There is displaced comminuted tibial mid-shaft fracture with displaced butterfly fragment.

Transverse fracture is present at the proximal fibular diaphysis with anterior angulation of the distal fracture component. 

A fracture is also seen at the lateral tibial plateau with depressed/displaced component (Schatzker II)


2. What is the most concerning complication of this injury?

Compartment syndrome


3. How would that complication present and how would you test for it?

Compartment syndrome classically presents with the 5 Ps:

  1. Pain (early)
    • Severe, out of proportion to physical exam findings
    • Worse with passive stretch
  2. Paresthesia (early)
    • Occurs in sensory distribution of affected nerve
  3. Pallor
  4. Paralysis (late)
  5. Pulselessness: (late)

Assessment:

  • Clinical suspicion, especially with pain out of proportion to exam
  • Compartment Pressure:
    • Traditionally, >30 mm Hg
    • More recently 
      • ΔPressure = [Diastolic Pressure] – [Compartment Pressure]
      • ΔPressure < 30 mm Hg is suggestive of compartment syndrome

Case 2: : A 7-year-old male BIBEMS after an MVC with the exam findings and imaging below.

Source: Radiopaedia

This patient has comminuted segmental fractures of the upper/mid third of tibia and fibula with the tibial shaft exposed externally and a high grade soft tissue laceration.

1. How would you manage this injury if you didn’t have orthopedics at your hospital? What type of splint would you use?

Management of open fractures:

  • Reduction
  • Thorough irrigation
  • Cover with a sterile dressing
  • Splinting: posterior long leg splint (video)
  • Antibiotics (Initiate as soon as possible. Increased risk of infection when started >3 hours post-injury.)
    • Generally Ancef (2g for most adults)
    • If severe (Gustilo type III – high-energy fractures with large wounds and extensive soft tissue damage ), add an aminoglycoside
    • If concern for Clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add high-dose PCN (4 million units for most adults)
    • For freshwater wounds, use a fluoroquinolone or 3rd or 4th generation cephalosporin
    • For saltwater wounds, use a fluoroquinolone or doxycycline + ceftazidime
  • Update tetanus vaccination
  • Transfer to a hospital with orthopedics for surgical debridement and washout (to be performed within 24 hours).

Further Reading:
https://www.orthobullets.com/trauma/1001/leg-compartment-syndrome

https://wikem.org/wiki/Compartment_syndrome

https://www.orthobullets.com/trauma/1004/open-fractures-management

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