Chapter 21
F R A C T U R E S O F T H E
T I B I A A N D F I B U L A
K E Y F I G U R E S:
Calf anatomy Longstanding open
How to do fasciotomy fracture
初中物理知识大全Gastrocnemius and Gastrocnemius flap
neighboring structures
Fractures of the tibia and fibula are a special concern becau missing early warning signs can result in a uless leg.
胆小鬼原唱
The tibia and the fibula are the two long bones of the calf. Fractures of the bones often result from a sport-related injury or motor vehicle ac-cident. Most fractures of the tibia and fibula (tib-fib fractures) he
al without complication, and the patient is able to resume his or her normal activities.
However, potentially rious complications can develop, and you must be aware of their early warning signs. With this knowledge, you can intervene before permanent tissue damage develops. Early interven-tion may make the difference between a normally functioning patient with a well-healed fracture and disaster.xps是什么格式
C a s e E x a m p l e
An 18-year-old boy was playing football and collided with another player, injuring his right leg. He tried to keep playing, but becau the pain was so inten he could not place any weight on the leg. He sat out the rest of the game and then came in for evaluation.
The calf was swollen and tender, and the x-ray showed a minimally displaced mid-shaft tib-fib fracture. No orthopedic surgeon was avail-able. After finding the fracture in Campbell’s Orthopaedics, you placed him in a cast, gave him crutches and pain medications, and nt him home.
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He returns a few days later in horrible pain. You remove the cast. His calf is very tight and swollen, and except for the lateral aspect he has no nsation in his foot. When you move his ankle, the pain intensifies in his calf. You check for puls in his feet, and they are prent.
A general surgeon takes one look at the patient, and immediately nds him to the operating room. Incisions are made in the calf, and much of the calf muscle is dead.
The boy’s leg will never function as it did before the injury. He will have a life-long disability.
What happened? First you need some basic background information.
C l o s e d v s.O p e n F r a c t u r e s
Fractures are usually classified as clod or open.
A clod fracture means that the skin around the fracture site is intact. In terms of bone healing, clod fractures have a favorable prognosis becau of the low risk for infection of the bone (osteomyelitis) at the fracture site. However, complications may ari, as illustrated by the ca example.
一畦春韭绿
In an open fracture, also called a compound fracture, the skin around the fracture site has been punctured. Open fractures are more rious injuries becau it generally takes greater forces to disrupt the skin and fracture the bones. An open fracture greatly increas the risk for the development of osteomyelitis, and osteomyelitis increas the risk for poor healing.
The quality of the soft tissue around the fractured bones plays a role in fracture healing. Feel your own calf. The anterior surface of the tibia is covered only by skin; there is not much padding around this bone. Significant injury to the skin around the tibia can result in exposure of the bone and thus a greater risk for poor healing of the fracture.
香港男歌星The higher the energy of the injury, the more significant the injury to the soft tissue and the greater the potential for problems. Falling off a step results in a low-energy injury; being hit by a car results in a high-energy injury.
E s s e n t i a l E l e m e n t s o f t h e P h y s i c a l E x a m i n a t i o n
1.Is the skin intact? (open vs. clod fracture)
2.If the skin is punctured, what can you e in the wound? Foreign ma-
terial must be removed, and dead muscle or skin should be cut out.
If the fracture site is expod, soft tissue coverage may be needed.
Fractures of the Tibia and Fibula207 3.What is the vascular status of the leg? Check capillary refill. Check
the puls on the top of the foot (dorsalis pedis) and behind the medial malleolus (posterior tibial artery). If capillary refill or puls are not prent, the patient may have a rious arterial injury.
4.What is the neurologic status of the leg? Evaluate the patient for ev-
idence of nerve dysfunction or injury. Check nsation in the follow-ing areas:
•The first web space on the dorsum of the foot between the great toe and the cond toe: deep peroneal nerve
•The plantar surface of the foot: posterior tibial nerve
•The lateral aspect of the foot: sural nerve
Check active ankle motion and toe motion:
•Plantarflexion of the ankle and toes (pointing of toes and foot): posterior tibial nerve
•Dorsiflexion of the ankle and toes (bringing the toes and foot upward toward the front of the calf): anterior tibial nerve
•Eversion (elevating the lateral side of the foot): peroneal nerve 5.What are the radiographic findings? A single break in each of the
bones usually heals with fewer complications than when the bones are broken into many pieces (a comminuted fracture). A large number of fragments indicates a higher-energy injury, which is as-sociated with a higher rate of complications.强化使命担当
6.Evaluate the patient for signs and symptoms of compartment syn-
drome. If they are prent, you have a surgical emergency on your hands (e below).
栀子花有毒吗
C o m p a r t m e n t S y n d r o m e
A compartment syndrome develops when pressure builds up within a fixed, well-defined space. The increa in pressure prevents venous and lymphatic outflow, and fluid build-up leads to a further increa in pressure in the tissues. High pressures can cau tissue injury and death.总经理任命书
High pressures also prevent blood and nutrients from reaching the tis-sues, causing further injury. Without appropriate intervention to re-lieve pressure build-up, a vicious cycle develops. This is esntially the definition of a compartment syndrome.
Muscle and nerve are the tissues most prone to injury. If a compartment syndrome remains untreated even for a few hours, the result is muscle death, which translates into tissue loss and permanent disability.
The death of muscle tissue can also be a very rious problem for the patient’s overall health. A muscle breakdown byproduct, myoglobin,
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Fractures of the Tibia and Fibula 209
Signs and Symptoms
It is important to be aware of the potential development of compart-ment syndrome and to warn patients about the early warning signs.The key is to catch the problem early so that intervention can prevent permanent damage. An untreated compartment syndrome can lead to vere morbidity, extremity loss, and potentially life-threatening com-plications. The following signs and symptoms should be kept in mind:•Severe pain in the calf, out of proportion to that expected from the injury
•Significant calf tightness
•Pain with passive stretch of a muscle group; for example, pain in the front of the calf with pointing of the toes and plantarflexing the ankle, or pain in the back of the calf with dorsiflexion of the ankle.•Tingling or numbness in the foot, along the peroneal and posterior tibial distribution, but not necessarily along the lateral aspect of the foot.
Note:Puls in the foot and ankle may be completely normal even with a significant build-up of pressure in the calf compartments.Axial ction through the middle third of the calf showing the four compart-ments. (From Jurkiewicz MJ, et al (eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 1990, with permission.)
