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Re: crush distal ttibia
Cory Collinge 06 Ноябрь 2008, 20:55
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First, cases like this are difficult and perhaps inappropriate to comment on definitively from afar. I agree with previous comment that the soft tissues are the key component to success, and we have no ability to accurately assess that component of the injury.
Soft tissue questions that may help make decisions:
1. Your description of the soft tissue injury is unclear. Is this an open or closed injury?….both Gustilo and Tscherne soft tissue grading systems are mentioned.
2. Where is the open wound (if it exists)? Can the wound be used to aid in reduction to allow for an easy early nailing? If so, why stage procedures, just nail it. This is a metadiaphyseal fracture with significant soft tissue trauma and even if MIPO plated it will likely take a longtime to heal with a high% requirement for bone graft.
3. How are the lateral soft tissues? Plating the fibula (or PerQ nailing) may provide assistance for a) tibial reduction and b) construct stability to prevent valgus collapse
4. How are the soft tissues at the medial malleolus? Open vs. perQ screw fixation are options.
5. Finally, and likely most importantly…..are the soft tissues evolving/ progressively dying off? If so, make plans for early soft tissue coverage before it gets infected.
Cory Collinge, MD
cell 817-253-9392
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Re: crush distal ttibia
Marek 07 Ноябрь 2008, 00:34
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This injuris is open Gustilo III A with wound on medial side of tibia, but the mechanism of the injury made a large contusion on anterolateraL side of leg, especially over the fibula - its looks - Tscherne 3. Yes, I think traumatic woun, after exposure make offer possibilty for reduction, bu I,m affraid to make any Inernal fixation- this is 3 day witout tx - so possibility of deep infection is common...
tomorrow I will try debride this, realign and stabilize temporary by external fixator ( spanning ). I Wonder if stbilize fibula in 1st OR ?
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Re: crush distal ttibia
Отправитель: Alexander Chelnokov 07 Ноябрь 2008, 01:17
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M> tomorrow I will try debride this, realign and stabilize temporary
M> by external fixator ( spanning ). I Wonder if stbilize fibula in 1st OR ?
I suppose yes. You can close the gap between the tibia and the fibula either manually or by big clamps (if skin allows), and transfix the distal
malleolus to the talus by 1-2 K-wires. Then after traction and alignment the wires can be added or replaced by 2-3 wires through both bones above the ankle joint level. Maybe a hybrid frame (long tibial bar + ring distally) is most suitable option.
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Re: crush distal ttibia
Отправитель: Nikolaj Wolfson 07 Ноябрь 2008, 18:41
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Marek:
First is soft tissue. In your case it would mean to me irrigation, debridement and temporarily external fixator( we call it traveling frame). Wound should be covered if you can not close it us wound vac, if you have it. Later ( within 6 day) use a flap if there is a problem.
I would not open fibulla. Why to rash, you have ex fix doing for you what you need. Let soft tissues to calm down, swelling to go away and than nail tibia after you ORIF fibula and fix the syndesmosis if needed after your nailing is done. Do CT scan to assess the distal tibia for possible articular extension.
Nik
Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
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