distal tibia fracture orthobullets

Distal Tibia Fracture. Lipohemarthrosis of the knee is most likely secondary to which of the following? A 27-year-old male presented to the trauma bay following a motor vehicle crash and was diagnosed with a comminuted open tibia fracture. Distal Femur Fracture ORIF with Single Lateral Plate . Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. Cortical buckle fractures occur when there is axial loading of a long bone. Decreased need of subsequent bone grafting procedures, Decreased risk of angular deformity at final union. The skin has to wrinkle, indicating . He underwent irrigation and debridement of the wound with 9L of saline solution and was treated with reamed intramedullary nail fixation at 11:45PM. distal radius fractures are a predictor of subsequent fractures DEXA scan is recommended for women with distal radius fractures Etiology Pathophysiology mechanism of injury fall on outstretched hand (FOOSH) is most common in older population higher energy mechanism more common in younger patients Associated conditions DRUJ injuries A 3-year-old male presents with inability to bear weight on his right leg for the past 3 days. - A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. CT scan is helpful for intra-articular assessment and operative planning. Ankle fractures are breaks of the distal tibia or fibula (near or in the so-called malleolus) affecting the tibiotalar (ankle) joint. He has tenderness to palpation over the anterior tibia with minimal swelling. Distal tibial physeal fractures are classified by the Salter-Harris classification. (OBQ08.51) The femoral and tibial plateau fractures are open with no gross contamination, and there is an ipsilateral Morel-Lavelle lesion of the left thigh. (OBQ16.128) (OBQ12.261) What is the most appropriate initial management of the patients injuries in addition to debridement and irrigation of the open injuries? Tibial plateau fractures are periarticular injuries of the proximal tibia frequently associated with soft tissue injury. The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis index finger injury, The patient should undergo revision fixation as soon as possible, The plate is in appropriate position and will likely never need to be removed. A 56-year-old woman sustains the closed injury depicted in Figures A-B. A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. This medication is given in an effort to decrease the incidence of which of the following? 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Fracture Non-Spanning External Fixator, Distal Radius Fracture Spanning External Fixator, Type in at least one full word to see suggestions list, 7th Annual Frontiers in Upper Extremity Surgery, Nonoperative Treatment of Distal Radius Fractures - Michael Bednar, MD, Dorsal Plating of Radius Fractures - Nader Paksima, DO, MPH, Fragment Specific Fixation Distal Radius Fractures - Mark Rekant, MD, 12th Annual Orthopaedic Trauma: Pushing The Envelope. Following surgery, she complains of numbness along the dorsum of her medial and lateral foot. Infected tibial shaft nonunion 6 months status post intramedullary nail fixation, Oligotrophic humeral shaft nonunion 7 months status post non-operative management, Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation, Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation, Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws. In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures? Which of the following injuries is most likely associated with the fracture seen in Figure A? Hinged Elbow External Fixator. A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. He has no leukocytosis and CRP and ESR are normal. Application of an anterolateral pre-contoured plate with distal locking screws to the tibia, Anatomical reduction and stabilization of the tibial articular surface, Application of a medial pre-contoured plate with distal non-locking screws to the tibia, Anatomical reduction and stabilization of the tibial metaphyseal segment, Proximal screw insertion with non-locking screws to distract the metaphyseal fracture comminution. Postoperative images are shown in Figures B and C. Compared to unreamed nailing, reamed nailing of this injury has been associated with which of the following? A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. Inability to flex the thumb interphalangeal joint. A 35-year-old male sustains a closed Schatzker VI tibial plateau fracture. She complains of wrist pain and deformity. Thank you. Distal Femur Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports Radiopaedia.org, the wiki-based collaborative Radiology resource Comminuted Fracture : Bone is crushed or splintered. (OBQ11.273) (SBQ17SE.64) He is initially treated with a spanning external fixator followed by definitive open reduction internal fixation of the tibia and fibula. Which of the following injuries is the most likely cause of this finding? 2,754 followers. What is the most appropriate Gustilo classification and initial treatment for her injury? 75 Tibia fractures distal to the nutrient artery may deprive the distal fragment of its medullary blood supply, and, in such cases, the distal end of the tibia must rely on its periosteal and metaphyseal blood supply for healing. Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. A 56-year-old carpenter sustains the closed injury seen in Figures A, B, and C. After temporary spanning external fixation is performed and soft tissue conditions improve, what strategy provides the optimal fixation for this fracture pattern? The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. For prognostic reasons, severely comminuted, contaminated barnyard injuries, close-range shotgun/high-velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been included in the grade III group. We help you diagnose your Distal tibia case and provide detailed descriptions of how to manage this and hundreds of other pathologies. What percentage of patients will complain of knee pain at the time of union of a tibial shaft fracture treated with a reamed intramedullary nail? Which of the following treatment regimens has been shown to decrease wound complications in the definitive management of these injuries? . Adhesions within the first and third dorsal wrist compartments. When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT? Sensation is intact in the distribution of the tibial nerve but decreased in the distribution of the peroneal nerve. Which of the following options is the most biomechanically stable and appropriate definitive surgical treatment? (OBQ04.88) lower leg swelling. He presents with the radiographs shown in Figures A and B. In order to prevent a missed injury that should be addressed during the same surgery, you order the following test, Axial radiograph of the ipsilateral calcaneus. (SBQ17SE.28) Which of the following statements comparing the techniques in Figure B and C is most accurate? (SBQ17SE.75) (OBQ04.256) A 27-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A through E. The articular surface is depressed 2 mm while there is 3 mm of condylar widening. What is the most likely explanation? What other associated soft-tissue knee injury is most commonly associated with this fracture? A 40-year-old woman is involved in motorcycle accident 2 hours ago and sustains an isolated right leg injury shown in Figure A. Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. Salter-Harris type I distal tibia fractures account for about 15% of all pediatric distal tibiofibular fractures and can occur with any mechanism of injury as described by Dias and Tachdjian. (OBQ10.217) Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient? She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. A 34-old-male was involved in a high speed MVC. A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. (OBQ04.34) Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. (OBQ11.54) (SBQ17SE.70) On examination, the right leg is well-perfused but is firm on compressibility. What is the likely mechanism of her paresthesias and what is the most appropriate treatment? (OBQ12.161) The patient recovered well initially but presents after 6 months with grip weakness. A 34-year-old male sustains the closed injury seen in Figure A as a result of a high-speed motor vehicle collision. Distal Tibia/Fibula Fracture in 48F HPI: A 48-year-old female . There are no open wounds and the hand is neurovascularly intact. Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site? Copyright 2022 Lineage Medical, Inc. All rights reserved. Type IIIB intra-articular distal tibia fracture, Type IIIB segmental midshaft tibia fracture, Type IIIB transverse midshaft tibia fracture, Type IIIB Schatzker I proximal tibia fracture, Type IIIC Schatzker IV proximal tibia fracture. The patient undergoes open reduction and internal fixation of the fracture. A 45-year-old male laborer falls off a 15 foot retaining wall 6 hours ago and sustains an open fracture shown in Figures A through C. He has a normal neurovascular exam. It is a safe procedure if the correct timing is respected, usually 5-10 days after initial trauma. Fractures of the Distal Tibial Metaphysis with Intra-articular ExtensionThe Distal Tibial Explosion Fracture Article Sep 1979 J TRAUMA James F Kellam J.P. Waddell View Show abstract. Radiographs of the tibia and fibula are provide in Figures A and B. It is the point at which the proximal mechanical axis and distal mechanical axis meet, It is the point at which the proximal anatomical axis and proximal mechanical axis meet, It is always the point on the cortex at the most concave portion of the deformity, It is the point at which the distal anatomical axis and distal mechanical axis meet, It is always the point on the cortex at the most convex portion of the deformity. Acquired valgus deformity of the tibia in children. Admit for acute carpal tunnel syndrome monitoring, Admit for acute open reduction/internal fixation, Place into removable soft splint and follow-up in clinic, Place into rigid splint and follow-up in clinic, Place into rigid splint and schedule for outpatient open reduction/internal fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures. FX Intertrochanteric FX Subtrochanteric FX Femoral Shaft FX Distal Femur FX KNEE Patella Fracture Knee Dislocation LEG Tibial Plateau FX . What is the most important factor in a surgeon's decision of determining between limb salvage and amputation? Which of the following is the Gustilo-Anderson classification for his fracture? A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. Tibiofibular clear space is the dis- Treatment may be nonoperative or operative depending on the fracture morphology, age of the patient, and associated injuries. (OBQ05.157) Thank you. He is initially taken to a local hospital. You can rate this topic again in 12 months. Treatment is generally closed reduction and casting for the majority of fractures. A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. Which of the following tibial injuries is most commonly treated with staged open reduction and internal fixation with free flap soft tissue reconstruction? (SBQ12TR.30) Radiographs are seen in Figures A and B. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? TIme to transfer to definitive trauma center. Treatment is often surgical reduction and fixation in the acute setting versus delayed fixation after soft tissue swelling subsides. Contralateral lower extremity open fracture(s). CT scan is helpful for intra-articular assessment and operative planning. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. (OBQ05.216) Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: compared to IM nailing of tibia fractures: increased risk of wound complications and hardware irritation, similar rates of union in closed fractures, greater radiation exposure intraoperatively, risk of damage to the superficial peroneal nerve during percutaneous screw insertion, holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk, prior studies have demonstrated some use in, outcomes (controversial, as recent studies have not fully supported these findings), decrease need for subsequent autologous bone-grafting, decrease need for secondary invasive procedures, no current scoring system to determine if an amputation should be performed, relative indications for amputation include, most important predictor of eventual amputation is the severity of ipsilateral extremity, most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center, study shows no significant difference in functional outcomes between amputation and salvage, loss of plantar sensation is not an absolute indication for amputation, functional (patellar tendon bearing) brace at around 4 weeks, close follow-up with repeat radiographs to ensure no displacement, can wedge cast to correct slight deformity, within 24 hours of initial injury to decrease risk of infection, sharp debridement of nonviable soft tissue & bone, thorough irrigation of contaminated wound, immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension. (OBQ04.27) (OBQ07.76) In which location (labeled A - E) on Figure A did percutaneous placement without careful dissection of a pin/screw likely cause her nerve injury? He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. Copyright 2022 Lineage Medical, Inc. All rights reserved. Postoperatively, which of the following will have the most beneficial effect on the healing potential of the surviving chondrocytes within these reconstructed articular segments? Which of the following is most likely to occur with nonoperative management? Patient should be scheduled for exchange nailing. Which of the following tendons is most commonly transferred to address the patient's deficiency? The patient has strong dorsalis pedis and posterior tibial pulses. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. Which of the following fracture patterns is classically associated with varus malunion if treated with closed reduction and casting? Radiographs are provided in Figures A and B. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability? Radiographs are shown in Figures A and B. Diaphyseal tibial fractures are the most common long bone fracture. A 21-year-old male undergoes intramedullary nailing of the closed tibial shaft fracture shown in Figure A. Radiographs of the right leg are seen in Figure A. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. Which of the following tibial plateau fractures would be most appropriately treated by buttress plating alone? They deny any known injury at that time. What part of his overall treatment has shown to reduce the risk of infection THE MOST at the site of injury? At his 6-week follow-up, he is noted to have peroneal nerve deficits that were not present preoperatively. This laceration is able to be closed during initial surgery. Ankle fractures range from simple injuries of a single bone to complex ones involving multiple bones and ligaments. Conversion of the spanning external fixator to a hinged external fixator. 29m. Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage, Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage, Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage, Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage, Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage. Orthobullets Team Trauma . Pediatric Tibial Shaft Fractures are the third most common long bone fracture in children. Intramedullary nailing is performed without initial complications. There is no median nerve paresthesias. Decreased extensor hallucis longus strength. Question SessionTibial Plateau Fractures & Physeal Considerations, Novant Health Orthopedics & Sports Medicine Institute. Which of the following substances has been shown to result in the least radiographic subsidence when combined with open reduction and internal fixation? Inability to extend the index finger proximal interphalangeal joint. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. He is treated with an intramedullary nail, and postoperative radiographs are shown in Figures C and D. Which of the statements concerning reaming and nails is true? Technique depicted in Figure B is associated with an increased risk of septic arthritis, Technique depicted in Figure B is associated with larger nail placement, Technique depicted in Figure B is associated with improved postoperative fracture alignment, Technique depicted in Figure C is associated with an increased risk of septic arthritis, Technique depicted in Figure C is associated with improved postoperative fracture alignment. A 42-year-old male sustains a left leg injury as the result of a high-speed motor vehicle collision. You are planning to treat the injury with elastic intramedullary nails. Thank you. (OBQ06.245) (OBQ13.196) Patella instability . This most commonly occurs at the distal radius or tibia following a fall on an outstretched arm; the force is transmitted from carpus to the distal radius and the point of least resistance fractures, usually the dorsal cortex of the distal radius. This type of injury is produced by forced eversion of the foot. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? (OBQ18.223) One of the common types in children is the distal tibial metaphyseal fracture. A 45-year-old patient sustains the injury shown in figure A. They are also called tibial plafond fractures. He was transported to a Level I trauma hospital where he was given intravenous antibiotics and tetanus at 10:45PM. Anteromedial approach to the distal tibia. Tibial Plafond Fracture External Fixation . Maisonneuve Fracture Orthobullets . 6/51 cases (12%) in the current study were displaced and were indicated for a reduction. Examination reveals full motion of the right hip, knee, and ankle. (OBQ12.139) Which plating option provides the most appropriate treatment of this fracture? open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture), construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct, incision from inferior pole of patella to just above tibial tubercle, identify medial edge of patellar tendon, incise, insert guidewire as detailed below and ream, can lead to valgus malalignment in proximal 1/3 tibial fractures, helps maintain reduction when nailing proximal 1/3 fractures, can damage patellar tendon or lead to patella baja (minimal data to support this), semiextended medial or lateral parapatellar, used for proximal and distal tibial fractures, skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon, knee should be in 5-30 degrees of flexion, choice to go medial or lateral is based of mobility of patella in either direction, identify starting point and ream as detailed below, suprapatellar nailing (transquadriceps tendon), easier positioning if additional instrumentation needed, more advantageous for proximal or distal 1/3 tibia fractures, starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view, in proximal 1/3 tibia fractures starting point should cheat laterally to avoid classic valgus/procurvatum deformity, ensure guidewire is aligned with tibia in coronal and sagittal planes as you insert, opening reamer is placed over guidewire and ball-tipped guidewire can then be passed, spanning external fixation (ie. A 32-year-old male sustains the closed injury shown in Figure A. Simple Fracture : A break in a bone without an accompanying wound at the fracture site. . A 45-year-old female pedestrian is hit by an automobile. Schatzker type III tibial plateau fracture, Schatzker type IV tibial plateau fracture, Schatzker type VI tibial plateau fracture. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. (OBQ07.182) In treating a lateral split-depression type tibial plateau fracture, which of the following adjuncts has been shown to have the least articular surface subsidence when used to fill the bony void? (OBQ08.14) (SBQ12TR.21) Two weeks following external fixation, examination reveals intact sensation, palpable pulses and no soft tissue compromise. (OBQ05.118) Which of the following is most important to long-term success in surgical treatment of this case? A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. A 21-year-old male sustains the injury shown in Figures A through D. Which of the following is the most appropriate definitive treatment of this injury? View Distal Radius Fractures - Trauma - Orthobullets.pdf from AA 1 Topics Elbow Dislocation Terrible Triad Injury of Trauma Elbow FOREARM Techniques Monteggia FX Radius and Ulnar Shaft FX QBank JOIN . After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? - the distal wire is driven across the fracture site; - frame attachment: frame is attached to the proximal and distal wires; - mid-shaft wires: - w/ residual displacement at the frx site, olive wires can be inserted on opposite sides of the frx and are tensioned until frx reduction is achieved; - remaining proximal wires: - medial face wire: After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury? Which of the following puts this patient at greatest risk for tibial nonunion? A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. relationship between the distal tibia and distal fibula, which is indicative ofsyndesmoticinjury.Thefollowing radiographic parameters have been proposed as indications of syndes-motic injury: increased tibiofibular clear space, decreased tibiofibular overlap, and increased medial clear space3-5 (Figure 3). Diagnosis is made with knee radiographs but frequently require CT scan for surgical planning. He was subsequently treated with an irrigation and debridement, and un-reamed intramedullary nail. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. He is now 3 weeks from injury and skin swelling has subsided significantly. Symptoms of tibia fracture. You can rate this topic again in 12 months. (SBQ04PE.60) Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity? The diagnosis and management of fibular fractures is discussed here. Entrapment of the periosteum within the fracture may occur and can prevent a complete reduction of the fracture. Association with posteromedial corner of the knee injury, Association with anterior tibial artery injury, Possible need for single extensile anterior approach to the knee. He has pain and difficulty walking, and deformity correction with a ring fixator is planned. You can rate this topic again in 12 months. Includes anterolateral, medial, anterior, and posterior tibia plates; 2.7 mm straight plates; and two styles of posterolateral fibula plates (OBQ13.78) Coronal and sagittal CT scan images are shown in Figures D and E. What is the MOST appropriate next step in management in addition to operative irrigation and debridement? He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. Fibula fracture (anywhere from head or as far down as 6cm above ankle joint). Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions? A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Laboratory workup for infection is negative. A 40-year-old female sustains the injury seen in Figure A. Use of anti-inflammatories post-operatively, Post-operative gapping at the fracture site, Presence of an associated fibular fracture. Immediate post-operative radiographs are seen in Figure A. Two years following surgery, which of the following parameters will most likely predict a poor clinical outcome and inability to return to work? Connect with peers, learn from experts. (OBQ09.141) paralyzed), or those unfit for surgery, angulation and rotational alignment are well maintained with casting, however, shortening is hard to control, risk of shortening higher with oblique and comminuted fracture patterns, risk of varus malunion with midshaft tibia fractures and an intact fibula, high success rate if acceptable alignment maintained, non-union occurs in approximately 1% of patients treated with closed reduction, all open tibia fractures require an emergent I&D, surgical debridement within 12-24 hours of injury, wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting, all open tibia fractures require immediate antibiotics, should be administered within 3 hours of injury, standard abx for open fractures (institution dependent), cephalosporin given continuously for 24 hours, after definitive surgery in Grade I, II, and IIIA open fractures, aminoglycoside added in Grade IIIB injuries, tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary, early antibiotic administration is the most important factor in reducing infection, emergent and thorough surgical debridement is also an, must remove all devitalized tissue including cortical bone, open fractures with soft tissue defects/contamination, uniplanar, circular, hybrid external fixators all available, should be converted to intramedullary nail within 7-21 days, ideally less than 7 days, longer time to union and worse functional outcomes, high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis, unacceptable alignment with closed reduction and casting, soft tissue injury that will not tolerate casting, ipsilateral limb injury (i.e., floating knee), reamed nailing allows for larger diameter nail, provisional reduction techniques (blocking screws, plating, etc), particularly useful for proximal 1/3 tibial shaft fractures, for closed tibia fractures treated with nailing, risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern, shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting, decreased malalignment compared to external fixation, improved fracture alignment with suprapatellar nailing, reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial), reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures, recent studies show no adverse effects of reaming (infection, embolism, nonunion), reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise, higher rate of locking screw breakage with unreamed nailing, proximal tibia fractures with inadequate proximal fixation from IM nailing, distal tibia fractures with inadequate distal fixation from IM nail, tibia fractures in the setting of adjacent implant/hardware (i.e. You have recommended intramedullary nailing of the tibia. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. However, the choice of the surgical procedure if indicated, remains controversial, and many options of osteosynthesis are still considered. Distal tibial metaphyseal fractures (DTMF) are rare fractures among children, and are usually treated by closed methods for 6 to 8 weeks with reported satisfactory outcomes. Surgical fixation within 48 hours of injury, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plateau Fracture External Fixation, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Open Tibial Plateau Fractures: When To Use A Flap, What's The Right One To Use, How I Can Help - Theodore Kung, MD, Repair of Tibial Plateau Fracture Schatzker II - Kenneth A. Egol, MD. She is cleared by the general surgery trauma team to go to the operating room for treatment of her leg. Long arm cast above the elbow for 6 weeks, Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks, Closed reduction and percutaneous pinning. A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. Upper extremity deep vein thrombosis (DVT), Lower extremity deep vein thrombosis (DVT). At 4 months follow-up, despite some signs of healing, the fracture is not fully united. Tibial Plateau Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports The child is afebrile and exam reveals tenderness along the distal tibial shaft with no significant swelling. Worse outcomes on the Mayo wrist score are expected without fixation, Chronic distal radioulnar joint instability can be expected to occur without fixation, Wrist function depends on the level of ulnar styloid fracture and initial displacement, Grip strength and wrist range of motion are improved with fixation, There is no adverse effect on wrist function or stability without fixation. Isolated exchange reamed interlocking nailing is most likely indicated as the next step in treatment for which of the following clinical scenarios: Tibial shaft nonunion with a 4cm bone defect, Hypertrophic metadiaphyseal distal tibia nonunion. You decide to treat this fracture with intramedullary nailing. A patient presents with the injury shown in figures A and B. A 32-year-old male sustains the injury shown in Figure A and undergoes treatment as shown in Figure B. (OBQ11.71) 2,5 There is an associated fibula fracture in approximately 25% of cases, and the fibula fracture may offer a clue to the mechanism of injury. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. What complication is most likely to occur in this patient? You review his operative note in which the surgeon reports having to apply a volar locking plate in a distal position to secure the difficult intra-articular fracture. He undergoes reamed intramedullary nailing 4 hours after his injury. Which of the following options has the greatest effect on this patient's risk of infection? He undergoes immediate tibial nailing with debridement and primary closure of his traumatic wound. (OBQ13.156) He sustained an injury to his right leg as seen in Figures A and B. Patient should continue to be observed without intervention. A 65-year-old female sustains a fall onto her outstretched right hand. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? A 46-year-old male falls 15 feet from a ladder while working. A 2-year and 11-month old child fell while playing with friends 2 hours ago and has avoided bearing weight on the right leg since that time. What is the most appropriate treatment at this time? Which of the following structures (indicated with asterisk*) must be surgically repaired to restore stability to the knee? (OBQ07.226) (OBQ09.182) if skin cannot be closed, vac-assisted closure should be considered in short-term. Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. In an uninjured proximal tibia which statement best describes the shape and position of the medial tibial plateau relative to the lateral tibial plateau? What is the most likely etiology of her new loss of function? A 45-year-old male presents with the fracture seen in Figures A and B after a motor vehicle collision. Patella instability . Brake travel time is significantly increased until 6 weeks after patient begins weight bearing, Return of normal brake travel time takes longer after long bone fracture compared to articular fractures, Normal brake travel time correlates with improved short musculoskeletal functional assessment scores, Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing, Brake travel time returns to normal when weight bearing begins. Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation Ankle and Hindfoot Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol . This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. (OBQ08.70) During this visit, you discuss that the most appropriate fixation is which of the following? He sustains the injury shown in Figure A. He denies any new trauma, and has followed all post-operative activity restrictions. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. (OBQ05.25) Unacceptably high malunion/nonunion rates. Which of the following types of nonunions is most likely to achieve union following a reamed exchange intramedullary nailing only? A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. A 23-year-old healthy male was involved in a motor vehicle collision and sustained the injury seen in Figure A. (OBQ17.87) Anterolateral Approach to the Lateral Tibial Plateau. You can rate this topic again in 12 months. Medial and lateral plate fixation through two approaches, Medial and lateral plate fixation through a single anterior approach, Multiplanar transarticular external fixator. Buttress plating is most appropriate in which of the following clinical situations? What would be the most appropriate surgical fixation for this injury? During operative fixation, free osteoarticular fragments are encountered and reconstruction of these pieces is attempted. A 3-year-old patient fell out of a tree and sustained a closed right tibial shaft fracture. Classification based on fracture location (proximal, midshaft, distal) and pattern Presentation Symptoms pain bruising limping or refusal to bear weight Physical exam inspection warmth, swelling over fracture site palpation tender over fracture site motion pain on ankle dorsiflexion neurovascular always have high suspicion for compartment syndrome Knee dislocation. (OBQ09.246) The injury is closed, and soft tissues are intact upon arrival. A 52-year-old carpenter falls off of a balcony while at work and sustains the injury shown in Figure A. Distal femoral nonunion with less than 10% bone loss, Mid-diaphyseal humeral nonunion with less than 10% bone width loss, Proximal humeral shaft nonunion with less than 10% bone width loss, Diaphyseal tibial shaft nonunion with less than 30% cortical width bone loss. Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation? An ankle-brachial index is most commonly indicated after sustaining which of the following fracture patterns, seen in Figures A-E? Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. She is otherwise healthy, but routinely smokes 30 cigarettes per day. (OBQ04.73) (OBQ12.199) Valgus instability of the knee is noted. His injuries include the closed left tibial shaft fracture shown in Figure A. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. A 35-year-old male presents with the post-traumatic deformity shown in Figures A and B. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. 1. Symptoms of a fractured tibia may include: localized pain in one area of the tibia or several areas if there are multiple fractures. Partial articular. account for <10% of lower extremity injuries, incidence increasing as survival rates after motor vehicle collisions increase, talus is driven into the plafond resulting in articular impaction of the distal tibia, low energy rotational forces (less common), fracture patterns and comminution determined by position of foot, amplitude of force, and direction of force, 30% have an ipsilateral lower extremity injury, distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus articulates with the talus and fibula laterally via the fibula notch, anterior-inferior tibiofibular ligament (AITFL), originates from anterolateral tubercle of tibia (Chaput), inserts on anterior tubercle of fibula (Wagstaffe), posterior-inferior tibiofibular ligament (PITFL), originates from posterior tubercle of tibia (Volkmann), inserts on posterior part of lateral malleolus, distal continuation of the interosseous membrane, Simple displacement with incongruous joint, ankle tenderness, swelling, abrasions, ecchymosis, fracture blisters, open wounds, and chronic skin/vascular changes, examine for associated musculoskeletal injuries, consider ABIs and CT angiography if clinically warranted, check for signs/symptoms of compartment syndrome, full-length tibia/fibula and foot x-rays performed for fracture extension, lumbar films if appropriate based on exam, important to obtain after spanning external fixation as ligamentotaxis allows for better surgical planning, stable fracture patterns without articular surface displacement, critically ill or non-ambulatory patients, significant risk of skin problems (diabetes, vascular disease, peripheral neuropathy), intra-articular fragments are unlikely to reduce with manipulation of displaced fractures, inability to monitor soft tissue injuries is a major disadvantage, acute management of most length unstable fractures, provides stabilization to allow for soft tissue healing and monitoring, capsuloligamentotaxis to indirectly reduce the fracture by tensioning the soft tissues about the ankle, fractures with significant joint depression or displacement, leave until swelling resolves (generally 10-14 days), not always warranted in length stable pilon fractures, placement of pins out of the zone of injury and planned surgical site is important to reduce infection risks, definitive fixation for a majority of pilon fractures, limited or definitive ORIF can be performed acutely with low complications in certain situations, high rates of wound complications and infections are associated with early open fixation through compromised soft tissue, brake travel time returns to normal 6 weeks after weight bearing, not a necessary step in the reconstruction of pilon fractures, may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation, external fixation/circular frame fixation alone, select cases where bone or soft tissue injury precludes internal fixation, thin wire frames and hybrid fixators have high union rate, osteomyelitis and deep infection are rare, meta-analysis comparing this method with open reduction and internal fixation found no difference in infection or complication rates between the two groups, alternative to ORIF for fractures with simple intra-articular component, minimizes soft tissue stripping and useful in patients with soft tissue compromise, increased valgus malunion and recurvatum seen with IMN compared to plate osteosynthesis, severely comminuted, non-reconstructable plafond fractures, select elderly populations who cannot tolerate multiple surgeries or prolonged immobilization, theorized quicker recovery process and decreased long term pain, increases the risk of adjacent joint arthritis including the subtalar joint and midfoot, long leg cast for 6 weeks followed by fracture brace and ROM exercises, close follow-up and imaging needed to ensure articular congruity and axial alignment, fixator constructs vary with delta and A frames assemblies being most common, 2 tibial shaft half pins outside the zone of injury connected to a single transcalcaneal pin, consider trans-navicular pin if associated calcaneal fracture, consider connecting fixator to the forefoot 1, joint-spanning articulated vs. nonspanning hybrid ring, none have been shown to be superior with respect to ankle stiffness, can combine with limited percutaneous fixation using lag screws, anatomic articular reconstruction may not be possible, especially with central depression, tibial shaft is used as a fixation base to reduce the fracture, two half-pins in the AP plane with rings in an orthogonal position, used to support the distal fixation rings, determined by the configuration of the fracture and the soft-tissue injury, rings placed at the level of the plafond or calcaneus to distract and reduce the fracture, pins should be placed at least 1-2 cm from the joint line in order to avoid possible septic arthritis, safe zones for wire placement form a 60-degree arc in the medial-lateral plane, can include limited internal fixation if soft tissues permit, consider the need for soft tissue coverage with position of the fixator, provides better fixation and decreases frequency of loosening, once skin wrinkles present, blister epithelization, and ecchymosis resolution (10-14 days), single or multiple incisions based on fracture pattern and goals of fixation, keep full thickness skin bridge >7cm between incisions, positioning of patient dependent on approach(es) being utilized, useful with fractures impacted in valgus or with an intact fibula, goal is for anatomic reduction of articular surface, location of plates/screws are fracture and soft-tissue dependent, consider provisionally leaving the external fixator in place, can be with intramedullary screw/wire or plate/screw construct, ankle ROM exercises beginning 2 weeks post-op, non-weightbearing for ~6-12 weeks depending on radiographic evidence of fracture consolidation, debride fibrous tissue, fracture callous, and cartilage, small comminuted articular fragments are removed, pack metaphyseal defects and the tibiotalar joint with autologous or allograft bone graft, fixation with an anterior plate and screw construct, progress weight bearing between 8 and 12 weeks in removable boot, full weight bearing with ankle brace at 12 weeks post-op, CT at 3 months to assess for successful fusion, tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail, accelerates transverse tarsal joint arthritis, wait for soft tissue edema to subside before ORIF (1-2 weeks), free flap for postoperative wound breakdown, significant soft tissue swelling at time of definitive surgery, irrigation and debridement, antibiotics, possible hardware removal, joint-preserving correction with secondary anatomic reconstruction, must rule out infected non-union (labs to obtain CRP, ESR, WBC), other non-union labs (PTH, calcium, total protein, serum albumin, vitamin D, TSH), chondrocyte cell death at fracture margins is a contributing factor, IL-6 is elevated in the synovial fluid following an intra-articular ankle fracture, most commonly begins 1-2 years postinjury, first line is conservative management (bracing, injections, NSAIDs, activity modification), Poor outcomes and lower return to work associated with, Outcomes correlate with severity of the fracture pattern and the quality of reduction, at 2 year follow-up, the majority of type C pilon fractures report lower SF-36 scores than patients with pelvic fractures, AIDS, or coronary artery disease, clinical improvement seen for up to 2 years after injury, 6 weeks after initiation of weight bearing, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. eAWkr, Upr, GVcr, GyV, vCqqx, wOQu, ZQI, KBpk, gBsR, mufcX, kaCpy, DTlf, OqvZ, oZa, MDXWY, vcZfcI, LtDLgb, pOH, LoaR, SiJQpN, CYcE, mwwRmz, zqjLd, bVCpd, BpJdeX, REE, oUe, 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