Injuries around leg

Dr Abhishek Pathak
Asst. Prof
Deptt of Orthopaedics & traumatology
Gandhi Medical college Bhopal
Bones
TIBIAL PLATEAU

DIAPHYSIS

PLAFOND/ PILON
Tibial plateau fracture
 Caused by high-energy mechanisms
 associated with neurological and vascular
injury, compartment syndrome
 caused by motor vehicle accidents or bumper
strike injuries KNOWN AS BUMPERS
FRACTURE.
 Classified by SHATZEKAR
CLASSIFICATION
SHATZEKAR CLASSIFICATION
BUTRESS PLATING HYBRID FIXATURE
TIBIAL SHAFT FACTURE
 Tibia major weight bearing bone
 Fibula transmits only 10% of body weight

 Both bones are joined together by

1. Ligaments at upper and lower ends
2. Interosseous membrane
Mostly both bones fractures together
 Very common injury
 High speed RTA
PECULIARTIES
1. Subcutaneous bone
2. Lack of muscle cover
3. Precarious blood supply b/c of decreased
periosteal blood supply
Mode of injury
1. Direct most common

2. Indiect twisting injury

spiral or oblique #
 Most of the tibial shaft fractures are open

1. Difficult to manage
2. Increased morbidity
Diagnosis
1. History
2. Pain
3. Swelling
4. Deformity
5. Wound :- if compound #
6. Crepitus.
History …… AMPLE
A Allergies
M Medications
P Past illnesses
L Last meal
E Events / Environment
What to do??
 In all trauma cases first look for
1. A
2. B
3. C
What to do??
 In all trauma cases first look for
1. A AIRWAY
2. B BREATHING
3. C CIRCULATION
What to do??
 In all trauma cases first look for
1. A AIRWAY
2. B BREATHING
3. C CIRCULATION
4. D DISABILTY
5. E EXPOSURE
LOOK FOR OTHER INJURIES

ALWAYS CHECK DISTAL PULSES,

MONITER VITALS

RADILOGICAL EXAMINTION AFTER PATIENT

STABLIZATION
 POSTERIOR TIBIAL ARTERY
DORSAL PEDIS ATRERY
TREATNENT
 PAIN CONTROL
Splinting by A/K Plaster Slab

Analgesic SOS

Skeletal traction in tibial plateau fracture

Patient complaining of excessive pain
after # BB leg
 Open slab immediately
 Watch for tense compartment of leg

COMPARTMENT SYNDROME
 Compartment syndrome as an elevation of
the interstitial pressure in a closed
osseofascial compartment that results in
microvascular compromise
COMPARTMENT SYNDROME
 FIVE Ps
1. Pain: pain out of proportion to that expected
with the injury
2. Pallor
3. Paresthesias
4. Paralysis.
5. Pulselessness A VERY LATE SIGN
 If compartmental pressures are greater than
30 mm Hg in the presence of clinical findings,
immediate fasciotomy is indicated.

 Difference between compartment pressure

and diastolic pressure more imp indicator of
tissue perfusion.
 Not all signs need to be present
 Only clinical basis is enough is sufficient to do
a fasciotomy
 All compartment of leg should be released
Treatment.
Treatment
 Conservative
 Operative
Conservative treatment
 closed #
 Undisplaced or minimally displaced
 In children
 Poor surgical risk
Method
 Above knee cast
 PTB cast
Cast bracing
 sarmiento
operative
 Method of coice
 Early mobilisation
Many methods
Interlocking nails
ORIF with DCP
External fixature
 Mainly for open fracture
INFECTION
NONUNION
ARDS
MASSIVE PULMONARY
EMBOLISM
Phemister grafting
 Used for treatment of nonunion of tibial shaft
fracture
Tibial plafond fracture
 Lower end tibial fracture
 Associated with soft tissue injury.
Crush Injury “syndrome”
 Crush syndrome first
recorded in bombing
of London during
WWII: 5 people who
were crushed
presented in shock
with swollen
extremities, dark
urine.
 Later died from renal
failure.
MESS
 Mangled extremity severity score
 Type Characteristics Injuries
Points
SKELETAL/SOFT TISSUE GROUP
1. Low energy Stab wounds, simple closed fractures, 1
small-caliber gunshot wound
2. Medium energy Open or multiple-level fractures, 2
dislocations, moderate crush injuries
3. High energy Shotgun blast (close range), high-velocity 3
gunshot wounds
4. Massive crush Logging, railroad, oil rig accidents 4

SHOCK GROUP
1 Normotensive hemodynamics
2 Transiently hypotensive
3Prolonged hypotension
Blood pressure stable in field and 0
in operating room
BP unstable in field but responsive to 1
intravenous fluids
Systolic blood pressure less than 90 mm 2
Hg in field and responsive to intravenous
fluid only in operating room
ISCHEMIA GROUP
1 None A pulsatile limb without signs of ischemia 0†

2Mild Diminished pulses without signs of ischemia 1†

3Moderate No pulse by Doppler, sluggish capillary refill 2†

paresthesia, diminished motor activity

4Advance Pulseless, cool, paralyzed and numb 3†

without capillary refill

AGE GROUP
1<30 years 0
2 >30 <50 years 1
3 >50 yrs 2
 limbs with scores of 7 to 12 ultimately
required amputation, whereas scores of 3 to 6
resulted in viable limbs.