Dr. Omar Bibiano Escalante

Dr. Omar Bibiano Escalante
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viernes, 5 de diciembre de 2014

Discuson entre pares / 11yrs male presented with closed displaced fracture distal 1 / 4th tibia with displaced ...


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Indian-Orthopaedic Research-Group 

11yrs male presented with closed displaced fracture distal 1 / 4th tibia with displaced communited fracture distal 1 / 4th fibula. Patient was treated with orif with 3.5mm recon plating for fibula + CRIF with TENS nailing tibia. Does it require revision? Kindly opine

  • Ujagar Singh YES, Rahul....
    8 horas · Me gusta · 1
  • Rahul B Tanga Does distal tibia needs revision?
    8 horas · Me gusta
  • Ujagar Singh Yes that's what I meant. Distally the nail seems to be protruding anteriorly and reduction is not proper .....,.
    8 horas · Me gusta · 1
  • Srinivas Daravathu in lateral it appears like tibia fracture is being distracted by nails?if so remove them and keep medial contoured plate to tibia
    8 horas · Me gusta · 1
  • Rahul B Tanga Srinivas medial plating at this age?
    8 horas · Me gusta
  • Ketas Mahajan Better to go for medial plating and protect it for 4-6 weeks....
    8 horas · Me gusta · 1
  • Rahul B Tanga On table carm pics looked Ok. But check xray different
    8 horas · Me gusta
  • Rahul B Tanga Is it advisable to wait till 6weeks and then plan if no signs of union then revise.
    8 horas · Me gusta · 1
  • Srinivas Daravathu do u think alignment is good inlateral ?u can do medial plate by mipo sparing physis
    8 horas · Me gusta · 1
  • Rahul B Tanga Even I am not happy lateral view reduction.but paediatric case exposing him for one more procedure?
    8 horas · Me gusta · 1
  • Srinivas Daravathu i had seen my friends going for mipo with dcp for similar case with good result
    8 horas · Editado · Me gusta · 1
  • Walid Salah Eldin The elastic nail guidelines. The curve should be in fr site not the crossing. This against. It is not secure fixation for the tibia
    8 horas · Me gusta · 2
  • Srinivas Daravathu u might get bridging callus,being closed procedure done for tibia fracture,but that wud take time
    8 horas · Me gusta
  • Khaled Gh I think if you put the plate on tibia and rash nail for fibula,you will get a good result. I'm not agree with you in your decision.
    8 horas · Me gusta · 1
  • Jayant Sharma I would have done a closed reduction and well molded cast for 3 weeks followed by ptb for another 2 weeks. Would not have bothered about fibula as suprasyndesmotic..
    8 horas · Me gusta · 6
  • Rahul B Tanga Dr Khaled Gh you mean to say violate fibular physis and put rusch nail.i don't agree with you.
    8 horas · Me gusta · 4
  • Rahul B Tanga Dr Jayant Sharma in this type of scenario where fibula is has comminution and impaction component and distal 1 / 4th displaced fracture tibia.is closed reduction successfully?
    8 horas · Me gusta · 1
  • Khaled Gh I had a same case before, and I've got good results.
    8 horas · Editado · Me gusta · 1
  • Rahul B Tanga Dr Khaled Gh literature doest it support rusch nail in 10yrs
    8 horas · Me gusta · 1
  • Ahmad Ayaz I think it is better to b revised...I think tibia should b open n reduce n fix with interfrag screw n k wire...n cast
    8 horas · Editado · Me gusta · 1
  • Rimon Lazar Sliwa If you got good lateral view the debate will be less!!
    8 horas · Editado · Me gusta · 1
  • Rahul B Tanga As lateral view was not good that's the reason debate is going , whether to wait or revise? What do you suggest?
    8 horas · Me gusta
  • Rimon Lazar Sliwa I think you wait this will unite with no problem
    8 horas · Me gusta
  • Priyank Banker Dr Rahul B Tanga in the given case fibula plating was necessary..
    What u did in this case was alright except about the entry of Tens nail in lateral view..
    This is the reason for distraction at # site coz of elasticity of nails..
    Do one thing that keep this in situ & insert 1 more tens from centre of tibia in lateral view and get those multiple tens jammed in canal of tibia at # site..
    This will definitely aid in acceptable reduction and early union..
    8 horas · Editado · Me gusta · 1
  • Srinivas Daravathu distal tibia seems to be in rotation?what do u say rahul?
    7 horas · Me gusta
  • Srinivas Daravathu any thought of adding external fixator or LRS for tibia fracture compression now?
    7 horas · Me gusta
  • Pav Lohan Wait this is kid and will unite definitely
    7 horas · Me gusta
  • Srinivas Daravathu i think we need to pull back the nail protruding anterior cortex and see
    7 horas · Me gusta · 1
  • Narayan Bs I personally feel fibula fixation is good but tibial nails are distracting the fracture instead of alligning..removing the nails and close reduction under c arm and applying AK cast vil give good result...
    7 horas · Me gusta · 4
  • Srinivas Daravathu that wud be easiest way to deal
    7 horas · Me gusta · 2
  • Bansal Ajay Re surgery needed
    7 horas · Me gusta · 1
  • Drmahesh Dama Revise tibia
    7 horas · Me gusta · 1
  • Rajiv Goyal Sir... Remove nail nd give cast under c arm fr tibia under shory ga
    7 horas · Me gusta · 1
  • Rahul B Tanga Dr Priyank Banker I agree with you that's the ideal it has to be done.in my case entry point was more anterior .but ideal way fixation is possible in middle 3rd and distal 3rd tibia fractures.but it's always an issue with distal 1 / 4th tibia and fibula fractures .what is your opinion regarding revision of tibia?
    7 horas · Me gusta · 1
  • Rahul B Tanga Dr Narayan Bs and dr Rajiv Goyal fibula is already fixed and do you feel so it will allow closed reduction of tibia now?
    7 horas · Me gusta · 1
  • Awadhesh Yadav Dear Rahul B Tangai appreciate u r concern for the best result for child....in my exp....there r 2.3 planning mistakes...1.i would have always put k wire im in fibula....open or closed...not more than 2mm dia...it snuggly fits the canal....as good as plate....2.the principle of tens/enders not working here...rather it has displaced it further....the ant .wire itself is acting as stress riser for the #displacement here......removing the tens....and even putting a modular ex fix will reduce it nicely with fibula plate in situ.... I will not accept this...revise minimally...even 2.3 cortical screws will hold reduction in tibia nicely....not in for plating tibia.....
    7 horas · Me gusta · 2
  • Rahul Arora Fibula is ok,just remove tens n put ex fix for1n 1/2- 2 month then ptb cast for anather month
    7 horas · Me gusta · 2
  • Rahul Arora I have done 2 similar cases with good result
    7 horas · Me gusta · 1
  • Aung Naing Win thanks so much 4 ur shar knowelage .
    7 horas · Me gusta · 1
  • Narayan Bs There is no much of overlapping here, with traction and percutaneous shanz pins I feel reduction can be achieved....
    7 horas · Me gusta · 1
  • Narayan Bs Shanz pins just to reduce the fracture...I appreciate ur reply to almost every comments...many people post a photo n disappear...
    7 horas · Me gusta · 1
  • Rahul B Tanga Thanks Dr Narayan Bs that's the way we learn and grow
    7 horas · Me gusta · 1
  • Rajiv Goyal Yes sir... I think reduce tibia as much possible.... Child bone ll unite even when fr site is far distance
    7 horas · Me gusta · 1
  • Rajiv Goyal Sir or fic with screw nd cast
    6 horas · Me gusta
  • Priyank Banker Revision as a whole is not required at present..
    U can make this fixation stable by adding 1 more TENS nail with a central entry point..
    6 horas · Me gusta · 1
  • Alok Jain What I feel...
    Pull back the nails...
    Reduce..
    Hold...
    Re insert, with optional add on of another nail, in reduced position...
    One possibility, if u r unable to reduce, put ex fix or MIPPO...
    6 horas · Me gusta · 2
  • Rahul B Tanga Dr Priyank Banker I don't think so one more tense will lead to more distraction than aid in reduction.what do you say?
    6 horas · Me gusta
  • Rahul B Tanga I would like to invite dr taral nagda for his valuable opinion.
    6 horas · Me gusta
  • Rahul B Tanga Dr kir pat kindly opine.
    6 horas · Me gusta
  • Bansal Ajay In my opinion either this sh have been managed conservatively or two nail in tibia and one in fibula
    No need of fibula plating
    6 horas · Me gusta · 1
  • Kuldip Nandani U need to revise it sir. The problem here is wrong entry into distal fragment. Now u need to withdrow d post nail upto#site 1st. Withdrow ant nail a bit and rotate 180deg. Bowing of this nail will help reduce d ant translation. Then insert d post nail into d medullary cavity which in ur case is through d cortex. Plz Correct me if I m wrong.
    6 horas · Me gusta · 1
  • Vinoth Kumar I don't think it's possible to revise jus tibia. Malreduction of fibula could b a cause. I would suggest u to 1. Remove tens 2. Check for more reduction possibilities even if it requires revision of fibula or opening tibia to see periosteal interposition. 3. Redo tens from prox + pop or multiple k wires and pop
    5 horas · Me gusta · 3
  • Naresh Chodha Why everytime nailing why plating was not done in this case.was there any need for plating fibula.simple k wire could have worked
    5 horas · Me gusta · 2
  • Tarek Elsaidy Reduction of tibia is unaccepted in lateral view.it need revision.
    5 horas · Me gusta
  • Priyank Banker Dr Rahul B Tanga if it was my case then i would have opted for removal of both tens only till i get reduction and after holding the reduction insertion of another tens nail(smaller diameter) with a central entry point so that distraction is avoided..
    And if reduction is better achieved then u can remove the tens having anterior entry point..
    4 horas · Me gusta · 1
  • Yogendra Nehete Rahul please post true lateral view.i don't think it's true lateral view to comment
    4 horas · Me gusta · 1
  • Priyank Banker Dr Rahul B Tanga lower tibia # are never easy to reduce by close method especially in children..
    But in children margin of safety is high potential of remodeling even with unacceptable reduction many a times..
    So now after getting these much opinions u have to perform the best for the given patient keeping in mind the growth potential..
    Don't bother and go ahead..
    U hav already done the best u could do in this case..
    It is complexity of this case which has turned out in this way(malreduction)..!!
    4 horas · Me gusta · 1
  • Rahul B Tanga Dr Kuldip Nandani I tried doing this on table but ap translation was increasing.
    4 horas · Me gusta
  • Rahul B Tanga Dr Yogendra Nehete it's true lateral view
    4 horas · Me gusta
  • Rahul B Tanga I do not have any other view
    4 horas · Me gusta
  • Gopal Goel i would have preferred a plate LCP
    4 horas · Me gusta · 1
  • Rahul B Tanga Dr Gopal Goel in 10 yrs old lcp is not overkill?
    4 horas · Me gusta
  • Srinivas Daravathu Rahul ur plan?now
    4 horas · Me gusta
  • Pramod Lamichhane That is acceptable in child. Will unite and nicely remodel. The main thing is angulation and joint alignment. By the way that is not a true post op lat xray.
    4 horas · Me gusta · 1
  • Gopal Goel Rahul B Tanga LCP is only a principle. Since distal tibia is mostly cancellous i would have preferred 3.5 mm LCP and used MIPO technique is possible. This # site is notorious for poor reduction by closed methods. I make 2 3mm incisions along tibia in such a way that i can hold both fragments with reduction forceps and slide the plate. Distally 3 screws are adequate
    4 horas · Me gusta · 3
  • Kir Pat TENS crossing at # site will keep # distracted in all ready distracted reduction ..as it will lack nancy principle collapse/spring along with fibular fixation,with seq of protruded .. and there is rotational element also?REMOVE TENS and and cast or refix.
    4 horas · Me gusta · 4
  • Rahul B Tanga Thanks Dr kir pat. Is there any harm in waiting for 6weeks?
    4 horas · Me gusta
  • Kir Pat Why,? and waiting > 6wks will req bg or longer immobilistion..opinion..
    4 horas · Me gusta · 1
  • Rahul B Tanga I would like to say this case was operated by me 4 months back.i dint revise this case as keeping in mind a paediatric case and thought waiting for 6weeks and protected him with b/k slab for 4weeks and rom knee after 4weeks and nwb for 2months.after 6weeks I saw some callus on lateral aspect in ap view. I thought I should wait for 4weeks more .at the end of 10 weeks callus was seen even in lateral view.at 4months I was surprised to see this.i learn a lesson in paediatric cases as uniting and remodeling capacity is high and no harm in waiting for 4 to 6 weeks with parents consent and explain them that he might need revision in future.i could succeed without any intervention.it was a great discussion thank you all for your valuable inputs.
    4 horas · Me gusta · 1
  • Rahul B Tanga 4months post op.patient is walking fwb without support.
    4 horas · Me gusta · 1
  • Rahul B Tanga I was amazed seeing this.
    4 horas · Me gusta · 3
  • Kir Pat Gr8
    3 horas · Me gusta · 1
  • Priyank Banker Dr Rahul B Tanga this is the potential of paediatric age group..!!
    3 horas · Me gusta · 1
  • Jay Sharma I wrote comment reading half the story .
    Agree with Dr priyank
    3 horas · Me gusta · 2
  • DrSuresh Parmar I think remove nails and open reduction n do plating Dcp 3.5
    3 horas · Me gusta
  • Alhamwi Talal The plate should be to the tibia not the fibula
    Reduction is bad
    2 horas · Me gusta
  • Rahul B Tanga Rightly said Priyank Banker that's what even I was trying to emphasise on it
    1 hora · Me gusta · 2
  • Rahul B Tanga AlhamwiTalal kindly go through my previous comments and you can see good result at 4months post op
    1 hora · Me gusta
  • Srinivas Daravathu So that is the reason why ,u are telling plating in 11 yr old is overkill,nice one Rahul
    1 hora · Me gusta · 1
  • Srinivas Daravathu This fracture being metaphyseal ,it united well
    1 hora · Me gusta · 1
  • Srinivas Daravathu I told in the beginning only that bridging callus would form anyhow
    1 hora · Me gusta · 1
  • Srinivas Daravathu But thanks for a nice suspense thriller
    1 hora · Me gusta · 2
  • Rahul B Tanga Thanks srinivas. It's not about suspense .at times we need to be defensive than aggressive in revising cases in paediatric age group.
    1 hora · Me gusta · 1
  • Srinivas Daravathu True but it's hard to explain gaps in fractures to parents in postop X-rays ,they go for multiple opinions,most of our colleagues wud suggest plating wud have been done
    59 min · Me gusta · 1
  • Bansal Ajay We should be defensive after any surgery even done by otherone
    57 min · Me gusta · 3
  • Nitin Sanadhya This is the beauty of nature remodeling capacity in children , it could have united with cr and cast later remodelled, but when decided to operate we should try to achieve good reduction.
    54 min · Me gusta · 4
  • Vinit Yadav Nice one Dr Rahul B Tanga. My querry is if it unites well , was there really a need of surgery? This sort of reduction cud have been achieved by MR and pop application.
    Few days back thr was a post regarding remodelling in paediatric pt on conservative tt.
    Operation means perfect reduction for the attendants. Many a times it becomes v hard for us to convince attendants post surgery if X-ray is not gud looking.
    45 min · Me gusta · 2
  • Rahul B Tanga Thanks vinit.ya if it was isolated distal tibia then yes definitely I would had tried CR and cast.as it's been tibia and fibula same level with fibula being comminuted fracture with impaction and being highly unstable so opted for fixation of fibula and tibia and have couple of cases and got good results.but this case on table it appeared to be Ok but xray was big surprise for me.rightly said father kept on asking why lateral view looks weird and gave him detailed explanation and he got convinced. At the same time I told he may need revision of tibia in future. It's all about your instinct, experience , depth of knowledge and decision making makes the difference.
    37 min · Me gusta · 1
  • Rahul B Tanga Dr Ajay Bansal I agree with you
    37 min · Me gusta
  • Rahul B Tanga Dr nitin sandya agreed with you.
    36 min · Me gusta · 1
  • Narayan Bs Dr Rahul B Tanga once u fix fibula with plate and screws, don't you think it will become isolated tibia fracture?
    27 min · Me gusta · 1
  • Rahul B Tanga Similar case
    18 min · Me gusta
  • Rahul B Tanga Post op
    17 min · Me gusta
  • Rahul B Tanga Dr Narayan Bs after fixing fibula under anaesthesia I would never hesitate to operate tibia.why do less?
    14 min · Me gusta · 1
  • Nitin Sanadhya Sir Dr Rahul B Tanga agreed when we decide to operate do it as complete we can never in between or half hearted.
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