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crush distal tibia
Ортопедия и травматология Отправлено Marek Kolasniewski 06 Ноябрь 2008, 11:47
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, Tscherne 3 ) 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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    Re: crush distal ttibia
    Alexander Chelnokov 06 Ноябрь 2008, 12:21
    As i realize skin condition now is crucial. Images of its appearance are not provided. Until skin problems are solved, temporary ex-fix is most safe and reliable solution. Monolateral fixator would be more friendly for soft tissue procedures. When the skin problems are solved (free flap, split grafting or whatever is suitable/available) nailing becomes the best definitive fixation.

    The fibula is broken, syndesmosis disrupted - it would be better to repair the mortise by ex-fix. Then with nailing the proper length of the fibula along with closed tibia/fibula gap can be maintained by a single "position" screw.
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    Re: crush distal ttibia
    Ivan Petrov 06 Ноябрь 2008, 14:37
    Due to soft tissue coverage about distal tibia and ankle has a poor blood supply, in high-energy fracture there is high frequency and severe consequences of complications secondary to early ORIF.
    I recomend next options (subject to Your skill in handling):
    1. Ilizarov frame as definitive managment (it is crucial to perform high-quality about ankle fixation for early distal ring removing and ROM restoration) - see photo.
    2. Cross-Ankle external fixation - 1 stage.
    After severe soft tissue edema and necrosis resolving - tibial nailing, percutaneous syndesmosis and medial malleolus screw fixation.



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    Re: crush distal ttibia
    Alex Lerner 06 Ноябрь 2008, 16:43
    Dear Marek,
    I am fully agreed with d-r Alexander Chelnokov that the skin and soft tissue condition are crucial at these stage of the treatment and also in the future. The treatment process must be staged due to high-energy trauma with severe soft tissue damage.
    By my opinion, at this stage the lower limb must be fixed using unilateral Ex Fix (tibio-calcaneal bridging due to severe trauma to the ankle joint) or using hybrid Ex Fix (unilateral proximal half-pins tibial fixation combined with distal ring / 5/8ring with thin wires).
    Sorry, we haven't clinical pictures. Is a radical repeat wound debridement needed?
    Then, the early free microsurgical flap is a good option for closure the exposed tibial bone fragments and the fracture site. Temporary acute limb shortening or/and angulation for diminishing of the extensive soft tissue wound can be also performed.
    The final skeletal stabilization may be performed using IM nailing with additional medial malleolus fixation and also positional screw for syndesmotic fixation.
    Or, you can perform conversion of primary unilateral EX.Fix to finally Ilizarov frame fixation (trans-ankle), especially if the temporary acute shortening or/and angulation was chosed at early stage of the treatment. Graduate re-alignment and length restoration using Ilizarov method must be performed after wound healing.
    With best wishes
    D-r Alex Lerner
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    Re: crush distal ttibia
    Dr. A.Liberson 06 Ноябрь 2008, 16:44
    Ex Fix!!!!!!!!! The soft tissue is the important bit.
    AL
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    Re: crush distal ttibia
    Nikolaj Wolfson 06 Ноябрь 2008, 20:51
    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
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    Re: crush distal ttibia
    Cory Collinge 06 Ноябрь 2008, 20:55
    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
      Отправитель: Marek 07 Ноябрь 2008, 00:34
      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
        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
        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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    Re: crush distal ttibia
    W.P.Zuidema 06 Ноябрь 2008, 22:56
    Dear collegae,

    With this bad soft tissue I would opt for a staged approach. First uni lateral ex fix for stabilization untill soft tissue injury calms down. Than you still have the option if the soft tissues improve to perform a intra -medullairy osteosynthesis of the tibia and a thick k-wire in de distal fibula. Or in case of continuing bad soft tissue , transform your ex fix into a hybrid ex fix..


    succes

    W.P.Zuidema, trauma-surgeon

    dept. of Trauma-surgery

    VU Medical Center

    De Boelelaan 1117

    1081 HV Amsterdam

    The Netherlands
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    Re: crush distal tibia
    DR ASSAD MUGHAL 07 Ноябрь 2008, 01:18
    hi there. interesting case, very challenging
    for a background, in our setting we comfortably nail the 3a tibias with a nail. now he came 2 day late but as u said no signs of infection. my only concern would be the soft tissue. if u are happy with them, nail it.
    if not id slap on an exfix and hold this out to lenght and once the tissues are settled , id drop a nail in and address the ankle too.. plate the fibula and fix that malleolus.
    alternatively..depending on your tissues, if it allows u to, id ORIF the ankle and get the fibula out to lenght and then mua that tibia (seems it will lock into each other based on the # configuration) and manage him in a pop with a window for wound care. all really depends on how the tissue injury is and what part is affected.

    assad
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    Re: crush distal tibia
    Tom Toal 07 Ноябрь 2008, 01:19
    A photograph of the wound following the latest debridement, and a statement about the patient's medical history would help you get some specific, rather than generic advice.

    Tom Toal
    Portland, Oregon
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    Re: crush distal tibia
    emal wardak 07 Ноябрь 2008, 18:48
    dear
    the best option is hybrid external fixation,, that too under c arm , it will give u space for dressing of the wound and act as a definetive
    treatment too,,
    all the best,,

    --
    May Almighty bless us all

    Dr Emal Wardak
    MBBS "SMS, Jaipur"
    MS "Ortho" {Bronze medalist} PGI Chd, India, Dip. SICOT
    Member of NZIOA,IAA "India"
    AADO "Hong Kong", SICOT
    Orthopaedic Surgeon
    Kabul
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    Re: crush distal tibia
    Odessky Jacob 08 Ноябрь 2008, 23:13
    Dear colleague! Do you use in yours practice Ilizarov apparatus? If yes, his technique is a method of choice for this case.
    I agree with the doctor Wolfson that soft tissue more important than fracture at the first stage of management of patient. Therefore good debridement of the wound with removal of all devitalized tissues is extremely important.
    How can you use Ilizarov techniques for soft tissues? You can essentially decrees the sizes of the wound by dublication of bone fragments having created shortening and \or angular deformity.With the subsequent restoration of length and an axis of a segment by Ilizarov apparatus.
    This technique is well described by doctor Lerner in his book – A. Lerner · D. Reis · M. Soudry
    “Severe Injuries to the Limbs. Staged Treatment”
    If you need more recommendations about this technique, you may address to me.
    All the best.
    Odessky Jacob M.D.
    Orthopedic Division
    Assaf Harofeah Medical Center
    Zerifin, Israel
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    Re: crush distal tibia
    Jeff Brooks 08 Ноябрь 2008, 23:15
    My strong preference would be IM nailing in this case, with plate fixation of the fibula with syndesmosis screw as well --if lateral soft tissues allow, and perc the medial mall.

    CT scan showing articular injury will be helpful.

    I have never understood when folks refer to external fixation in severe soft tissue trauma (IIIc tibias...) "to allow access to the wound"... I can't think of a better way than IMN to "allow access to the wound".

    Jeff
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    • Re: crush distal tibia
      Отправитель: Odessky Jacob M. D. 12 Ноябрь 2008, 13:05
      Dear Jeff! I did not understand too how it is possible to treat the soft tissue damages accompanied fracture, applying an external fixators, until have got acquainted with Ilizarov method.
      Jacob

      [ Ответить ]
    Re: crush distal tibia
    Marek Kolasniewski 13 Ноябрь 2008, 01:45


    Dear colleagues!
    I've sent you picture of the leg. I have problem with this patients because he has had dyspnoea, hemoptysis. We have made, ABG, X-Ray, etc and finally angio-CT of thorax. Our diagnosis is fat embolus syndrome with some kind of acute lung injury (moderate hypoxia)
    Now, he has had 3rd debridement in medial part of the leg, but his problem is also in lateral part - Morel - Lavalle Lesion...
    In Friday I hope to stabilize ankle fracture. And then I plane to make acute shortening after remove all necrotic tissue from lateral and posterior compartment.

    Best regards

    Marek Kolasniewski
    Orthopedic and Trauma Unit
    Military Hospital
    Poznan
    Poland
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