Posted: Oct 19 2021 #(C101821)

Tibial Plafond Fracture in 73F

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HPI

A 73-year-old female presented to the ED after being involved in an MVC. She is unable to bear weight on her right lower extremity. She does report a loss of consciousness during the accident. She denies any numbness or tingling to the right lower extremity.

PMH

PMH: Hypertension, hyperlipidemia, and prior CVA (on eliquis)

Focused physical examination of the right lower extremity demonstrates mild swelling and pain about the ankle without any open wounds. Skin wrinkling is present. Bony crepitus is noted about the ankle. She is neurovascularly intact. Compartments are soft and compressible.

Poll

1 of 12

Would you obtain any imaging in addition to standard ankle films to guide management?

No - current radiographs are sufficient

10%

(77/725)

Yes - additional radiographic views (aXR)

(7/725)

Yes - CT scan of the ankle (CT)

79%

(578/725)

Yes - MRI of the ankle (MRI)

(6/725)

Yes - aXR + CT

(36/725)

Yes - aXR + MRI

(4/725)

Yes - CT + MRI

(6/725)

Yes - aXR + CT + MRI

(3/725)

Outside my area of expertise - best if I dont vote

(8/725)

How would you definitively manage this injury?

Nonoperative

(6/714)

Operative

97%

(699/714)

Outside my area of expertise - best if I don't vote

(9/714)

If you choose Operative management, what definitive fixation technique would you use?

I would not choose Operative management

(3/709)

External fixation (ExFix) only (includes monoplanar, ringed circular fixation, etc)

(18/709)

Percutaneous screw fixation only

(0/709)

Open reduction internal fixation (ORIF) with plate and screws (includes MIPO)

88%

(628/709)

Intramedullary nailing (IMN) only

(2/709)

IMN + ORIF

(16/709)

IMN + percutaneous screw fixation

(7/709)

ExFix + percutaneous screw fixation

(26/709)

Outside my area of expertise - best if I don't vote

(9/709)

If you choose ORIF with plate and screws, would you temporize this patient, and how?

I would not choose ORIF with plate and screws

(7/705)

No - I would fix acutely

33%

(233/705)

Yes - External Fixation for 3-7 days

16%

(119/705)

Yes - External Fixation for 8-14 days (1-2 weeks)

24%

(176/705)

Yes - External Fixation for > 14 days (2 weeks)

(18/705)

Yes - Splint or Cast for 3-7 days

10%

(74/705)

Yes - Splint or Cast for 8-14 days (1-2 weeks)

(44/705)

Yes - Splint or Cast for > 15 days (2 weeks)

(22/705)

Outside my area of expertise - best if I don't vote

(12/705)

If you choose ORIF with plate and screws, would you do the tibia alone, or tibia and fibula?

I would not choose ORIF

(5/700)

ORIF of tibia alone

12%

(87/700)

ORIF of fibula alone

(9/700)

ORIF of fibula and tibia

84%

(589/700)

Outside my area of expertise - best if I don't vote

(10/700)

If you choose ORIF with plate and screws of the Tibia Alone, how many incisions would you make, and from what plane?

I would not choose ORIF of the tibia alone

24%

(161/666)

One - Anterior Incision (Ant) Alone (includes Anteromedial, Anterolateral, Direct Anterior)

25%

(169/666)

One - Medial Incision (Med) Alone

(53/666)

One - Posterior Incision (Pos) Alone (includes Posterolateral, Posteromedial, Achilles split)

(26/666)

Two - Ant + Med

15%

(101/666)

Two - Ant + Post

(56/666)

Two - Med + Post

(60/666)

Three - Ant + Med + Post

(20/666)

Outside my area of expertise - best if I don't vote

(20/666)

If you choose ORIF with plate and screws of the Tibia Alone with ONE Anterior Incision, what approach would you use?

I would not choose ORIF of the tibia with One Anterior Incision

18%

(116/624)

Anterolateral (AL)

27%

(174/624)

Anteromedial (AM)

43%

(270/624)

Direct anterior (DA)

(48/624)

Outside my area of expertise - best if I don't vote

(16/624)

If you choose ORIF with plate and screws of the Tibia Alone with ONE Anteromedial approach, what plate(s) location would you use?

I would not choose ORIF with plate and screws of the Tibia Alone with One Anteromedial approach

16%

(87/541)

Single Anterior Plate (A)

(31/541)

Single Anterolateral Plate (AL)

15%

(86/541)

Single Medial Plate (M)

32%

(177/541)

A + M Plates

13%

(71/541)

AL + M Plates

12%

(68/541)

A + AL Plates

(7/541)

Outside of my area of expertise - best if I don't vote

(14/541)

If you choose ORIF with plate and screws of the tibia AND fibula, when would you fix the fibula?

I would not ORIF with plate and screws of the tibia AND fibula

(18/597)

Fix fibula Before the tibia

71%

(424/597)

Fix fibula After the tibia

23%

(143/597)

Outside my area of expertise - best if I don't vote t

(12/597)

If you choose ORIF with plate and screws of the Tibia AND Fibula, what fixation technique would you use for the fibula?

I would not choose choose ORIF with plate and screws of the Tibia AND Fibula

(14/540)

Plate and Screws

82%

(447/540)

Intramedullary screw

(29/540)

Intramedullary nail

(45/540)

Outside my area of expertise - best if I don't vote

(5/540)

If you choose Operative Management and attained the construct shown below, when would you allow the patient to begin weight-bearing postoperatively?

I would not choose Operative management with the construct below

(3/557)

Immediately (1-6 days)

(11/557)

7-14 days (1-2 weeks)

(8/557)

15-28 days (3-4 weeks)

(51/557)

29-42 days (5-6 weeks)

29%

(167/557)

43-56 days (7-8 weeks)

34%

(191/557)

57-70 days (9-10 weeks)

(47/557)

71-84 days (11-12 weeks)

(42/557)

> 84 days (>12 weeks)

(28/557)

Outside my area of expertise - best if I don't vote

(9/557)

If you choose ORIF and obtained the construct below, and made the patient non-weight bearing after surgery, what DVT prophylaxis would you prescribe?

I would not choose ORIF with the construct below

(5/564)

None - I would not prescribe DVT prophylaxis

(36/564)

Aspirin

21%

(119/564)

Low molecular weight heparin (Lovenox)

52%

(298/564)

Heparin

(11/564)

Xa inhibitors (Xarelto etc.)

14%

(82/564)

Outside my area of expertise - best if I don't vote

(13/564)

Would you obtain any imaging in addition to standard ankle films to guide management?

Yes - CT scan of the ankle (CT)

If you choose Operative management, what definitive fixation technique would you use?

Open reduction internal fixation (ORIF) with plate and screws (includes MIPO)

If you choose ORIF with plate and screws, would you temporize this patient, and how?

Yes - Splint or Cast for 8-14 days (1-2 weeks)

If you choose ORIF with plate and screws, would you do the tibia alone, or tibia and fibula?

ORIF of tibia alone

If you choose ORIF with plate and screws of the Tibia Alone, how many incisions would you make, and from what plane?

One - Anterior Incision (Ant) Alone (includes Anteromedial, Anterolateral, Direct Anterior)

If you choose ORIF with plate and screws of the Tibia Alone with ONE Anterior Incision, what approach would you use?

Anteromedial (AM)

If you choose ORIF with plate and screws of the Tibia Alone with ONE Anteromedial approach, what plate(s) location would you use?

AL + M Plates

If you choose Operative Management and attained the construct shown below, when would you allow the patient to begin weight-bearing postoperatively?

43-56 days (7-8 weeks)

If you choose ORIF and obtained the construct below, and made the patient non-weight bearing after surgery, what DVT prophylaxis would you prescribe?

Low molecular weight heparin (Lovenox)

If you choose ORIF with plate and screws of the Tibia Alone with ONE Anteromedial approach with an anterior and/or anterolateral plate(s), what type would you use?

Locking - Precontoured Plate

Would you use a classification system to guide management?

Yes - Ruedi and Allgower

Post-procedure P1

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