CASE REPORT

Indiana Orthopedic Institute

14

(P: 211961) If you choose definitive fixation of the right femur with a retrograde nail and the right tibia with a nail ("Up/Down Nail"), would you vent/aspirate the femur and tibia to reduce risk of pulmonary embolus?

I would not choose to place an intramedullary nail on the ipsilateral femur and tibia ("floating knee") on the same OR day

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

Yes - Reamer Irrigator Aspirator of femur

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Anthony Sorkin Jan S. Great case Tony, with their initial presentation I’m jumping straight to I&D and DCO. multi-trauma with likely hollow viscus and pulmonary injuries, reducing and stabilizing their extremity injuries with external fixators on the lower extremities and splinting the upper extremi...ty will allow patient to be appropriately resuscitated before converting them to definitive fixation.

Anthony Sorkin great case! I agree with Charles Moon there is a lot going on here, and I would have a low threshold to just I&D and ex fix on day one. In reality I would need more information before making a decision on nailing the left side or not. We like to use the criteria outlined by Heather Va...llier and her team to get a more objective view of the patient’s resuscitation and level of overall stability: what’s the lactate, base deficit and pH?

Maximilian Heitmann, MD Thank you! Patients with Type III stay on IV abx during serial trips to OR for debridements and for 72hrs after closure. Types I & II get IV abx for 24hrs after closure. I simply manually check the DRUJ in the OR prior to closure. I also will save an AP/LAT of the unaffected ...side to compare length and apposition. If the patient was not able to tolerate and sort of prolonged surgery within several days I might have considered an ex fix of the forearm to protect length - especially in the setting of a head injury. Otherwise I have good success with splints for UEs.

I may be missing comments about the ribs, but with bilateral rib fractures, these aren't benign and can result in death even with all of the extremities nicely fixed. Best outcomes for rib fractures occur when fixed within the 1st 72 hours, so I'd be making a plan for these as well - can do anterior... ones at the same time you're doing some of the extremity work since you'd be supine for those.

Looks solid, if they’re wide open might as well use that to get the provisional reductions. Solid long term follow up too. Helpful to see these cases with that because as we know things can look great 2 weeks post op and then the real trouble starts.