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How can a fractured left fibula and tibia be treated?

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Orthopaedic Surgeon
Practicing since : 2011
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Question
Good day Dr

XXXX (43) was involved in a motorcycle accident on 29 Nov, 2017 while overseas on vacation. The left fibula and tibia was broken as closed fractures.

Attached a photo from the screen from an x-ray taken earlier today. Dr Danai advised the picture on the right was taken after the accident on the 29th, and the picture on the left was taken earlier today 24 Dec, 2017. The request for original is pending an email response.

The leg was initially In a stint for ~1 week, then adjusted with force and a cast was applied from foot to above the knee as it is currently set. Pain has subsided. There can be slight discomfort depending on orientation. Medication was stopped ~5 days ago. The majority of time spent following the accident is lying down with limited activity and movement.

What is your evaluation based on the screen capture picture provided?
There was originally a slight click noted when the leg was raised / lowered while in the cast. The click appears to have subsided. What is the likelyhood of a "natural" healing process and timelines?
If the leg is able to heal, what are the implications of the current alignment on future strength and mechanics and form?
In your opinion, What are the possible pros / cons of an operative procedure and how would this best be achieved?
Please share your thoughts on what you may believe to be of value / pertinent or to consider in your assessment?
How long does one have to decide on the operation route?

XXXX
Thu, 24 May 2018 in Back Pain
 
 
Answered by Dr. Aashish Raghu 28 minutes later
Brief Answer:
Needs surgery and bone graft

Detailed Answer:
Hi XXXX

I have read your query and viewed the attached xrays.

The xray after applying the cast (latest Xray) doesn't look too good and will need surgery to heal in my opinion.

The likelihood of natural healing process is slim because the fracture is widely displaced and no signs of healing till now.

If it does heal on its own without any surgical intervention it will take a couple or more years to achieve near normal strength as before.

Advantages of the surgery will be early mobilisation and physiotherapy do that you can bear weight as soon as possible (few days to weeks) and avoiding Medical problems of prolonged immobilisation and knee and ankle stiffness. Surgical risks include anaesthetic complications and also chance of delayed or non-union of the fracture, wound infection, bone infection.

It would be advisable to get operated with either of the two options. Intramedullary nailing or plating. Bone graft will also be needed to be introduced at the fracture site to stimulate healing.

It would be best to get operated.

Usually we wait for signs of healing for 2-3 months. If no signs of healing we go ahead with surgery. But in this case the cast didn't do much good in bringing the fracture fragments together so it needs surgery immediately.

I hope I have answered your query.

I will be available to answer your follow up queries.
Regards,

Dr.Aashish Raghu
Above answer was peer-reviewed by
 
Follow-up: How can a fractured left fibula and tibia be treated? 17 hours later
Good day Dr. Aashish,

If I get you correctly surgery sooner than later is recommended going forward.

I have a low annuity income that would enable me to extend the stay to recover, however I'm not able to afford the operation, at least not, at any private hospitals at this time.

The intention is to look at possible public options and costs as alternatives if surgery is the preferred option for recovery. Even this option may only be possible in the next 3-4 weeks.

Attached, please see updated x-rays from 24 Dec, 2017.

I am fortunate enough to be able to rest for another 1-2 months and looking at the updated images, what is the likelihood of natural / cast recovery on strength, form and function? I generally lead a healthy and nutritious lifestyle.

The local Dr suggested switching to a below the knee cast in the next 2 weeks. Is this the best next step on the "natural" path?

What are the implications of a delayed surgery to mid-Jan which may be 6-8 weeks after the actual injury occurred 29 Nov, 2017?


It's now


...what are your thoughts on the abstract from this medical article: https://www.XXXX.gov/XXXXmed/0000?


An further x-ray has been uploaded from an accident 1-year ago where the left fibula was broken, to give an indication on healing.


XXXX
 
 
Answered by Dr. Aashish Raghu 56 minutes later
Brief Answer:
Answers

Detailed Answer:
I am unable to see any evident signs of healing yet even in the latest Xray.

I still wouldn't advise changing to a below knee cast so soon because there aren't any evident signs of healing. Though if you do not change to a below knee cast, you have the risk of knee stiffness but also a risk of further fracture displacement if you change to short cast.

There won't be a problem to do the surgery in January.

I am unable to copy the PubMed link to view it. Please consult the Healthcare Magic team and request for this facility.

The fibula is the bone that heals nearly the fastest. Inspite of the fracture displacement if the fibula it heals quickly. Unfortunately the tibia is notorious in this regard and can take 8-12 months to heal compared top just a couple of months or so for the fibula.
Above answer was peer-reviewed by
 
Follow-up: How can a fractured left fibula and tibia be treated? 32 hours later
The PubMed medical article has been uploaded.


Good day Dr Aashish

Thank you for the quick response.

If I get you correctly, surgery would speed up recovery time, reduce downtime, muscle wastage, stiffness, etc, less the potential drawbacks. There is an awareness of relatives that ended up with bent, bowed or crooked results from fixation.

And there is uncertainty as to how successful the "natural" healing route would be, and how long it might take to regain function, and at what level.

This would be taken into consideration in weeks to come when the surgery option becomes possible, given the current constraints and situation, and load bearing capability then.

XXXX
 
 
Answered by Dr. Aashish Raghu 12 minutes later
Brief Answer:
Your fibula is already united. Expect delayed union

Detailed Answer:
Thank you for sharing the paper.

As you can see, your fabulous already united. This means you can expect delayed union from the get-go.

If you are prepared to wait 30 weeks as in the PubMed paper you can take that chance. I would still suggest surgery.



Brief Answer:
Go for surgery

Detailed Answer:
Yes, Surgery will definitely do more good as long as you are healthy and legally fit for surgery.

Natural healing in your case is very much doubtful because the fractured bone is not aligned, neither are the fragments in contact with each other. To top it off, the united fibula will cause a hindrance to healing.
Above answer was peer-reviewed by
 
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