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Tue Dec 19 13:18:09 GMT 2006

Rachel,

I'm sorry that you haven't had much of a response to your question.  It's a complex case, and the Trauma-List isn't well populated with orthopedists as far as I know.  Perhaps there's an Ortho-List out there somewhere.

There's lots of info here about your patient's plight, but less about your hospital.  What are your options for a formal consult with someone who specializes in orthopedic complications?  We have a top guy here in Bangor, and there are dozens of other Problem Orthopedics gurus peppered around the U.S., mostly referred by word of mouth.  If this were a patient of ours, we'd probably be aggressively arranging a specialty consult or (if such were not available) an out-transfer.  

Assuming that your patient has years of productive life ahead, there's some urgency in making his legs right with minimal trial and error.  The Trauma-List is hardly up to your (his) needs.

Beyond that, I'm curious about the order for six weeks in a Thomas splint.  I have to say, it's not a recommendation that inspires confidence.  I can't recall this approach in my limited ortho experience.  Is there something going on outside of my paradigm?

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of rachel cher
Sent: Sunday, December 17, 2006 7:13 PM
To: trauma-list at trauma.org
Subject: surgery question.

hello everybody,
i would appreciate an opinion about the following case:

    Report of Dr                The story so far: 

         Fall    of granite slabs on both legs

 X-ray  (R) Femur # lower y3
           (L) Tibial #    (L) Fibular #        (L) Medical Malleolus #

 21.01.06 Operated     SA
   Procedure Done : (R) Femur i K nail and derotation plate
            (L) Fibula     DcP Plating
            (L) Tibia  ext. fixator application i  
            (L) Medial Malleolus fixation I fixator screw

  11.03.06 Developed swelling over (R) leg with severe pain esp. on movement

  13.03.06 X ray (R) Femur slowed broken screws with telescoping of fracture ends
   (R) Leg put in Thomas's splint; and advised to keep the same for 6 weeks

  14.04.06 X rays not very encouraging. Advised to under go review surgery for (R) femur

 17.04.06 Implant removal i revision interlocking nails i  
  Bone graftline done   SA.

  24.04.06 Removal of (L) tibial fixator i  injection of bone marrow at fracture site and above knee scotch cast done  SA

   To stimulate bone growth on both sides advised to use NON INVASIVE BONE GROWTH STIMULATOR for six weeks.   

  06.06.06 (L) Scotelr cast removed to get better view of the X - rays and (L) tibial callus
   On removal of cast, it was seen that the screws of (L) fibular plate had eroded the skin and were visible from outside.

   Thus emergency removal of (L) fibular plate nail nad (L) medical malleolus screws done SA.

  (L) Leg put   below knee POP splint

  28.06.06 Pain at # site and movement prompted to do an x ray of (L) tibia
   Labeled as non union
   Now the dilemma - What to do

   Ilizarov  method

   Interlocking

   Nailing  and Plating

 Past History Bilat Csom (R) Ear operated twice      Both the ears are
      (L) Ear operated thrice     dry at present

 (L) Lung - Emphysymatous bulla rupture leading to (L) lung collapse repairing (L) Upper lobe bullectomy i with (L) pleurectomy done     GA. Post operation developed (L) lung abscess drained   CT guided aspiration

  Allergic History Allergic to Sulphers, Ampicillin, Amoryeillin, Tetracycline, Brufen, Aspirin, Savlon for local application   

  History after 28.06.06

  Underwent interlocking nailing of (L) tibia in the first week of July.06.

 Developed spasms and pain in (R) thigh with growth in size over a period of two weeks, it was observed that there was discharge of sero sanguinous fluid from the sutured wound of surgery. Then underwent I/D with debridement and saucerization of (R) femur after due confirmation of acute Osteomyelitis by blood tests and gallium nuclear scanning.

 The right thigh swelling subsided and spasms decreased over a period of now, the (R) thigh wound require dressing every A/D, as the wound was kept open and is allowed to heal by secondary intention.

 From physical therapy point due to special caliper shoes - it is possible to put 100% weight on (L) leg and 30% weigh on (R) leg.     

 There is full bending of (L) knee but only about 10° bending on (R) knee with pain.

 Repeat x ray to be done around December 20, 2006. Last x ray done on November 5, 2006 showed good bone formation on (L) side with not so satisfactory bone formation on the (R) side.

 Problem at Present (26.11.06) : 1. (R) Knee bending
       2. (R) Knee pain

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