case of the week august week 3 (Full Version)

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Dr.Wagner -> case of the week august week 3 (August 23, 2007 6:49:47 PM)

20 year old male involved in a MVA
Restrained, car vs tree

Describe this fracture (as if giving a report), give the name of this fracture, and describe the mechanism.




[image]local://2287/A58757F81BDA41A9A312E8ECF0238C23.jpg[/image]



Dr.Wagner -> RE: case of the week august week 3 (August 23, 2007 6:50:24 PM)

picture 2


[image]local://2287/EF2B19662502497D8D4BF002B1E681DC.jpg[/image]



Chocco -> RE: case of the week august week 3 (August 23, 2007 7:10:41 PM)

Radiology is not my strong point, but is it  closed comminuted fracture of the distal tibia. The distal fibula doesn't look to be fractured but seems to be too lateral from the mortise ( ? Trimaleolar fx). Either way it looks like a crush type injury like his foot was braced against something ( pedal or dashboard. etc) when he hit the tree. Like i said radiology isn't my strong suit, but i think these are fun so i thought i would give it a try.



jma -> RE: case of the week august week 3 (August 23, 2007 9:05:17 PM)

The first one looks like an oblique displaced comminuted closed fracture of the left distal tibia.
The second is a lateral displaced comminuted closed fracture of the left distal tibia. Hope they are right.



USAPT -> RE: case of the week august week 3 (August 23, 2007 10:01:45 PM)

closed, displaced comminuted spiral fx of distal tibia. Pt may have tried to brace himself with his L foot next to the pedals. The force of the collision may have forcefully internally rotated his L LE. Just a thought. Thanks Doc.



Dr.Wagner -> RE: case of the week august week 3 (August 23, 2007 10:08:20 PM)

Should've added this...one hand on the foot, other on the camera...it really isn't as gross as the picture seems...remember this fracture has a NAME


[image]local://2287/A66243328F0A44CCA2D26D046DECEEEC.jpg[/image]



JCOY -> RE: case of the week august week 3 (August 24, 2007 7:15:45 AM)

Spiral fracture of distal left tibia with posterior displacement.



FLAOrthoPT -> RE: case of the week august week 3 (August 24, 2007 10:09:34 AM)

Fracture name:
ugonnalimpawhile
or
mayajustalosedefoot



Shill -> RE: case of the week august week 3 (August 24, 2007 11:35:33 AM)

How about a MESS, group 2 sprial oblique comminuted open distal tibial fx?  Am I getting close? (Mangled Extremity Severity Score)  Finally, an acronym that makes sense.

Or maybe a Tscherne grade C II sprial oblique comminuted open distal tibial fx?   Shouldnt be a Weber, as the fibula is OK(?)

That all Ive got.



Dr.Wagner -> RE: case of the week august week 3 (August 24, 2007 7:09:57 PM)

Open communuted oblique fracture of the distal tibia with minimal anterior displacement...


This type of fracture (open or closed) is called a PILON fracture (pronounced peelon).  Happens via axial load as the talus is forcefully directed into the tibia...like in a car accident.

Wicked cool.

Thanks for playing, I will try to get them posted on monday with answers on Friday.



JCOY -> RE: case of the week august week 3 (August 26, 2007 3:49:27 PM)

I am curious as to "anterior displacement..."  per above.

Paul and Juhl state:
"When describing displacement of fracture fragments, it is usual to refer to the displacement of the distal fragment in relation to the proximal, the latter being considered as the stationary part.  Thus one speaks of a posterior displacement of the distal fragment of the tibia on the proximal fragment, rather than an anterior displacement of the proximal on the distal."
 
On the lateral film above, the distal tibial fragment appears posterior to the proximal.  

Thoughts?



Dr.Wagner -> RE: case of the week august week 3 (August 27, 2007 7:34:01 AM)

To be honest with you, displacement probably is the least important part of this.  As this is a communuted fracture, you could probably say anything and it matters little...specifically because this is an open fracture...fun.



JCOY -> RE: case of the week august week 3 (August 27, 2007 8:41:52 AM)

>>>To be honest with you, displacement probably is the least important part of this.<<<<
That is probably true if one has the films to look at, which would be the case, for the attending doc pinning this back together.

However- you posted:
>>>"Describe this fracture (as if giving a report),...."<<<.

I've seen/read,  good and HORRIBLE rad reports.  AND-  universal frame of reference in a report is absolutely essential in a quality report.   Reports are read by many that do not neccessarily have the films in front of them.  Communicating the information in a report is paramount.  Non-adherence to a univeral reference can create many problems. 

Do you think the  "anterior displacement" discriptor on this image study fits with the standard of image/radiology reports/ing? 



Dr.Wagner -> RE: case of the week august week 3 (August 27, 2007 9:24:56 AM)

I understand your point, but this description, when given to a orthopedist taking call, the description of the displacement of the communuted fragment is most helpful.  In a closed fracture of the wrist, giving displacement is great because it helps with discussion of immediate vs delayed reduction.
In the case of an OPEN communuted fracture in trauma, the surgeon wants to have an idea of the complexity of the surgery he is entering.  If I would say to him, "Hey Joe, I have an open communuted pilon fracture of the left ankle with neurovascular involvement" he knows to call the OR pretty quickly...I reduce and splint the fracture, then he operates.

Thanks for all the imput guys, enjoy the next case already posted!



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