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0MODERN TREATMENT AND CLINICAL STRUCTURE OF OPEN FRACTURES OF THE TIBIAL BONE SHAFT IN POLYTRAUMA Davlatov B.N.1, Abdukhalimov O.O.2, Khamidov S.M.3
1Davlatov Bakhodir Nabiyevich - Doctor of medical sciences, Associate Professor, 2Abdukhalimov Obidjon Odiljon ugli - Master, 3Khamidov Sultonbek Maksudbek ugli - Master, ANDIJAN STATE MEDICAL INSTITUTE ANDIJAN, REPUBLIC OF UZBEKISTAN
Abstract: the decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures.
Keywords: tibia fractures, Cast treatment, anatomical reduction of medial and lateral malleoli, successful.
Fractures without displacement: It is usually sufficient to protect the ankle in a below-knee plaster for 3-6 weeks. Good, ready-made braces can be used in place of rather uncomfortable plaster cast.
Fractures with displacement: Aim of treatment is to ensure anatomical reduction of the ankle-mortise. This means, ensuring anatomical reduction of medial and lateral malleoli, and reduction of the talus acurately within the mortise.
Internal fixation: In general, operative reduction and internal fixation may be used in cases where closed reduction has not been successful, or the reduction has slipped during the course of conservative treatment.
The following techniques of internal fixation are used depending upon the type of fracture.
Medial Malleolus Fracture
• Transverse fracture - compression screw, tension-band wiring;
• Oblique fracture - compression screws;
• Avulsion fracture - tension-band wiring; Lateral Malleolus Fracture
• Transverse fracture - tension-band wiring
• Spiral fracture - compression screws
• Comminuted fracture - buttress* plating
• Fracture of the lower third of fibula - 4-hole plate Posterior Malleolus
• Involving less than one-third of the articulating surface of the tibia - no additional treatment;
• Involving more than one-third of the articulating surface of the tibia -internal fixation with compression screws;
• Tibiofibular syndesmosis disruption - needs to be stabilised by inserting a long screw from the fibula into the tibia.
All major ligament injuries e.g., that of deltoid ligament, lateral ligament should be repaired.
Conservative methods: It is often possible to achieve a good reduction by manipulation under general anaesthesia. The essential feature of the reduction is to concentrate on restoring the alignment of the foot to the leg. By doing so the fragments automatically fall into place. Once reduced, a below-knee plaster cast is applied. If the check X-ray shows a satisfactory position, the plaster cast is continued for 8-10 weeks. The patient is not allowed to bear any weight on the leg during this period. Check X-rays are taken frequently to make sure the fracture does not get displaced. If everything goes well, the plaster is removed after 8-10 weeks and the patient taught physiotherapy to regain movement at the ankle. External fixation: This may be required in cases where closed methods cannot be used e.g., open fractures with bad crushing of the muscles and tendons, with skin loss around the ankle.
Simple types of ankle injuries are almost free of complications. More serious fracture-dislocation may be complicated because of improper treatment. Sometimes, the nature of injury is such that perfect functions cannot be restored. The following complications may occur:
1. Stiffness of the ankle: Following immobilisation in plaster, stiffness occurs. In ankle injuries, recovery takes a long time because of the tendency for gravitational oedema which may hinder mobilisation exercises. It is most common in elderly persons. With persistent treatment, using limb elevation, crepe bandage and active toe movements, oedema subsides. It may be necessary to continue ankle exercises for a long period (6-8 months).
It is the term used for ligament injuries of the ankle. Commonly, it is an inversion injury, and the lateral collateral ligament is sprained. Sometimes, an eversion force may result in a sprain of the medial collateral ligament of the ankle. Diagnosis: The patient gives history of a twisting injury to the ankle followed by pain and swelling over the injured ligament. Weight bearing gives rise to excruciating pain. In cases with complete tears, patient gives a history of feeling of 'something tearing' at the time of the injury.
There may be swelling and tenderness localised to the site of the torn ligament. If a torn ligament is subjected to stress by the following manoeuvres, the patient experiences severe pain:
• Inversion of a plantar-flexed foot for anterior talo-fibular ligament sprain.
• Inversion in neutral position for complete lateral collateral ligament sprain.
• Eversion in neutral position for medial collateral ligament sprain.
Treatment: It depends upon the grade of sprain:
• Grade I: Below-knee plaster cast for 2 weeks followed by mobilisation.
• Grade II: Below-knee cast for 4 weeks followed by mobilisation.
• Grade III: Below-knee cast for 6 weeks followed by mobilisation. Current trend is to treat ligament injuries, in general, by 'functional' method i.e., without immobilisation. Treatment consists of rest, ice packs, compression, and elevation (RICE) for the first 2-3 days. The patient begins early protected range of motion exercises. Methods are devised by which during mobilisation, stress is avoided on 'healing' ligaments, and the muscles around the joint are built up. For this approach, a welldeveloped physiotherapy unit is required. For grade III ligament
injury to the ankle, especially in young athletic individuals, operative repair is preferred by some surgeons.
References
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