Essentials of Orthopedic Surgery, third edition / 14-Answers to Questions

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FIGURE 3. Postoperative radiographs with healed first metatarsal osteotomy.

Trauma: Open Tibia Fracture

SCOTT T. SAUER

History

A 58-year-old woman was at a social event in the early morning hours. She fell down a flight of stairs and injured her right lower extremity. She presented to an emergency room with extreme pain in her right lower extremity, with some bloody drainage by report. She had no reports of numbness or tingling in the leg itself and no other injuries. She did not lose consciousness at the time of her fall. She describes an achy sharp pain in the right lower extremity just below the knee. She reports the pain as a severity of 9 of 10, with 10 being the worst pain she has felt, and nothing relieves her pain. She has no significant past medical history. She has a past surgical history that includes an open-reduction internal fixation of the right forearm many years ago, as well as strabismus surgery on the right eye in the past 5 years. She takes no medications. She has no drug allergies. Social history includes moderate alcohol consumption, and she is a nonsmoker. Family history and review of systems are noncontributory.

Physical Examination

This is a well-developed, well-nourished female in a moderate amount of distress. She is alert and oriented times three. She is approximately 5 feet 3 inches and 150 pounds. Temperature is 98.7°F. Blood pressure is 125/80, pulse is 95, and respiratory rate is 20. Airway, breathing, and circulation exams are within normal limits. Her secondary survey includes a moderately swollen right lower extremity below the knee, with a small laceration over the anteromedial aspect of the lower leg midtibial region that measures approximately 1 cm. Further examination of her right lower extremity shows good palpable dorsalis pedis and posterior tibial artery pulses, and tenderness over the midshaft of the tibia and proximal fibular region. There is no other tenderness in the knee or hip area or ankle area. Range of motion of the knee and ankle is limited secondary to pain in the midtibial

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region. Hip range of motion internal–external rotation is 45 to 50 degrees without pain. No obvious evidence of ligamentous instability. Ankle dorsiflexion, plantarflexion, inversion, and eversion strength is 4+/5. Sensation is intact on the dorsal, medial, lateral, and plantar aspects of the foot. No pain with passive range of motion of the foot and toes.

X-Rays

Anteroposterior (AP) and lateral radiographs of her right tibia and fibula, AP, lateral, and mortise view radiographs of her right ankle, and AP and lateral radiographs of her right knee show a spiral fracture of the middle shaft to distal third of the tibia with a proximal fibular fracture with moderate displacement. No obvious deformity or fracture is seen in the ankle mortise or around the distal femur.

Laboratory Values

Laboratory values, EKG, and chest X-ray are within normal limits.

Assessment

Right open tibia and fibular fracture with spiral fracture of the midshaft distal third tibia, proximal fibular fracture; no signs of neurologic injury or compartment syndrome.

Treatment

Discussion of the clinical and radiographic findings was done with the patient in regard to the nature of the fracture itself with the small skin opening. The patient was given intravenous antibiotics and was taken immediately to the operating room for irrigation and débridement of the open tibial wound with intramedullary nail fixation. Her postoperative course was uncomplicated. Her wound healed uneventfully with no signs or symptoms of infection and, over the next 3 to 4 months, her tibia fracture healed with excellent results and alignment. Preoperative, postoperative, and healed X-rays are shown in Figures 1, 2, and 3, respectively.

Discussion

This woman presented with isolated right lower extremity trauma after a fall. However, it is important not to be distracted by her presenting symptoms. Patients that are brought to an emergency room who have question-

Trauma: Open Tibia Fracture

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FIGURE 1. Preoperative radiographs show spiral tibia fracture with proximal fibular fracture.

able consciousness or are obviously inebriated should be treated as a multitrauma victim before focusing on an obvious injury. It is important to obtain as complete a history as possible from these patients or family members or friends who have brought the patient to the emergency room to determine exactly the events surrounding the circumstances bringing the patient to the emergency room. In this case, there was alcohol involved, which may cloud the history or judgment of the patient.

It is important to go through the advanced trauma life support (ATLS) protocol, which starts with evaluating the airway, breathing, and circulation. When these parameters are deemed stable, then a secondary survey may be performed. In this patient’s case, although alcohol was involved, her neck was stabilized with a collar appropriately

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FIGURE 2. Immediate postoperative radiograph shows intramedullary nailing.

until she was not intoxicated, which was postoperatively the next day. She was then cleared from the clinical and radiographic standpoint. However, while maintained in the collar, a secondary survey was performed with no obvious other injuries noted and further trauma ruled out with appropriate radiographs, namely of the chest and pelvis, in conjunction with her C-spine radiographs, which had been done on admission.

Once the secondary survey was performed and the isolated injury was identified, in her case an open tibia fracture, appropriate treatment could be applied. In most cases, tibia fractures, if minimally displaced, well aligned, and without evidence of open injury, may be treated conservatively: a long leg cast for 6 to 8 weeks converting to a short leg cast after healing and beginning of weight-bearing between 8 and 12 weeks. In this case, an open injury made it necessary to operatively wash out the wound to prevent infection. Intravenous antibiotics were given immediately in conjunction with the size of the wound. Typically wounds 1 cm or less

Trauma: Open Tibia Fracture

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FIGURE 3. Radiographs of the tibia after healing.

require a cephalosporin, whereas larger wounds may require broader coverage, including gram-positive and gram-negative organisms. With appropriate antibiotics, the patient was taken to the operating room where her wound was irrigated fully. If the wound is small, extending the proximal and distal ends to provide adequate exposure for irrigation may be necessary. These extensions may then be closed after surgery. However, the initial wound should be left open to drain. Treatment in this case included tibial intramedullary nailing with 24 to 48 hours of intravenous antibiotics, namely a gram-positive-covering cephalosporin. She tolerated her procedure well, and the postoperative course was uneventful.

Herniated Nucleus Pulposus

SAM W. WIESEL

History

A 34-year-old lawyer arose with the hope of taking an early-morning run. As he began, he felt sudden back pain to the point where he had to stop running. Walking, the back pain became less intense, but he noticed pain down the leg all the way into the foot with paresthesia (numbness and tingling) into the foot. He had trouble walking and came into the office for an evaluation.

Physical Examination

The patient is a well-nourished young man in moderate distress. He had decreased range of motion of the lumbosacral spine with no palpable spasm. His straight leg raising test was positive in that it produced pain all the way down the leg. He had a weak extensor hallioxic longus (EHL). His hip examination was normal.

Laboratory Studies

A magnetic resonance image (MRI) was obtained (see Fig. 1) that demonstrated a herniated nucleus pulposus at L4–L5.

Treatment

The patient was initially placed on antiinflammatory medication as well as decreased physical activity and some wet heat for comfort. Over a 2- to 4- week period, the patient improved about 30%, but still demonstrated a positive straight leg raising test and a weak EHL. At this point the patient was given epidural steroids, which gave him about 50% overall relief. At

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Herniated Nucleus Pulposus

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FIGURE 1. (A, B) Magnetic reso-
nance imaging (MRI) demonstrates
herniated nucleus pulposus (HNP)
at the L4–L5 level.	B

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the 10-week mark, because the patient was really unable to function, it was recommended that he have a laminectomy with removal of the herniated disk at L4–L5. Patient underwent the procedure, and postoperatively his pain and paresthesias disappeared. He was placed in a rehabilitation program and 1 year later was doing well.

Discussion

This is a classical history for a herniated nucleus pulposus. It generally occurs in the second and third decades of life. This patient had a positive straight leg raising and a positive neurologic in the form of an EHL that coincided with his herniated disk between L4 and L5 involving the L5 nerve root. Conservative treatment was instituted because the simple fact of a neurologic deficit such as a weak EHL does not mandate surgical intervention. If the patient can get good subjective pain relief using nonoperative measures, it is preferred. The patient was treated nonoperatively for a total of 10 weeks. The recommendation is that if one cannot get satisfactory pain relief within 3 months and there is a correlation between the physical examination and an MRI, surgery is indicated. This patient did well with the laminectomy between L4 and L5 and was able to resume all his activities.

Osteomyelitis

STEVEN C. SCHERPING, JR.

History

The patient is an 18-year-old man who is referred to the office for evaluation of a painful and swollen left knee. Two weeks before presentation he suffered a minor twisting injury to the knee while playing soccer. This injury was not associated with any significant pain at the time, and he was able to continue his routine activities, including playing soccer. Over the ensuing 4 to 5 days, the knee and the distal thigh became progressively more painful with some swelling noted in the knee. He denies any givingway or locking of the knee. The pain is present at all times, only slightly worsened with weight-bearing activities. He denies any prior history of injury to the extremity. He denies pain at any other site. He has no history of recent illness other than a laceration to his foot that occurred 3 weeks ago and which was complicated by a local wound infection requiring treatment with oral antibiotics. The laceration subsequently healed without event, and he has no residual swelling or pain in the foot. His past medical history is otherwise benign. On review of symptoms, he has noted a mild sense of fatigue, in association with a sense of a low-grade fever, although he has not taken his temperature and denies any frank rigors or chills.

Physical Examination

This generally healthy-appearing young adult male is afebrile. Gait is antalgic with restricted motion through the left knee. His left knee is swollen in appearance with an effusion. Tenderness is appreciable over the distal femur, more so of the medial condyle. Range of motion of the knee is from 0 to 120 degrees in association with some discomfort. No mechanical block or instability is detected. His neurovascular examination is normal in the extremity. No adenopathy is appreciated in the groin or popliteal fossa. Range of motion of his ankle and hip is painless and symmetrical with the uninvolved extremity.

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