Photo Credit: Russell Stitzlein
“Hey man, just giving you a heads up…I think we have an ankle fracture down here in the trauma bay.”
“Um…ok, you think you have an ankle fracture?”
“Yeah, the ankle is pretty deformed. We don’t have Xrays yet. The patient is in the CT scanner. We’ll get Xrays when she gets back here.”
There was a time when getting a consult for a presumed fracture would have infuriated me – it’s like consulting cardiology without an EKG. At this point, however, I’ve come to accept it as a common (albeit annoying) occurrence and it’s not something I’m going to Iet bother me. If we were to get consulted every time the ED thinks an ankle is broken we’d probably see three or four patients for every one real fracture. With a few exceptions (especially true for ankle fractures), if a bone is broken it’s going to show up on Xrays. Unless a limb is critically at risk due to vascular injury, there’s really no excuse for Xrays not to be performed prior to involving orthopaedic surgery.
As I introduced myself to the patient, she looked back at me through her bruised an swollen eyes and told me that the entire right side of her body hurt. She’d been involved in a car accident where she was the restrained driver and had been hit by another driver (she couldn’t remember the direction of the impact). On exam, her ankle was tender, swollen and deformed (so likely the trauma team got it right this time and the Xrays would reveal an ankle fracture). Additionally, her pelvis was tender, her right knee was tender and swollen, her right hand and foot were also tender.
I took a look at the AP pelvis and CT pelvis which revealed multiple right-sided pelvic fractures for which she would need surgery to stabilize her pelvis. I asked for additional Xrays of her entire right side given her clinical exam. After reviewing the Xrays, I noticed a distal femur fracture and the right ankle was fractured and dislocated. I was also suspicious that she had at least one fracture to the bones in her foot.
I proceeded to place a proximal tibial skeletal traction pin to help stabilize her pelvic fractures as well as her distal femur fracture and then I reduced and splinted her right ankle. It was definitely one of the worst ankle fractures I’ve reduced and I just couldn’t get it perfect because it was in so many pieces. After setting up the skeletal traction and attaching the weights via a pulley system, looking at the patient, you would have thought we had placed her in some sort of medieval torture device.
After all of our preliminary work was done, we got a CT of her entire right lower extremity to assess the extent of her injuries and better delineate the patterns of the fractures we did know about. After reviewing the CT it became clear that she’d broken every bone from her pelvis through the middle of her foot.
I then put together a PowerPoint slideshow with demonstrative images and emailed my attending to update him about the patient. Of all the patient’s I’ve seen and staffed with attending, the email I sent for this patient was the most complicated (and almost comical for the sheer magnitude of injuries sustained without any of them being life-threatening). Below is a portion of that email that is my quick breakdown of all of her injuries:
51yo female polytrauma status post MVC
Ortho injuries include:
- R iliac wing fracture (intra-articular to SI joint)
- R SI joint widening
- R acetabular fracture (ant column)
- R inferior ramus fracture
- R distal femur fracture (Hoffa fracture with vertical split that extends proximally)
- R tibial plateau fracture (Schatzker II – almost a pure depression but there is a split I think)
- R ankle trimalleolar fracture-dislocation (pilon type) with a history of previous R ankle ORIF s/p ROH (painful hardware)
- R talus fracture
- R calcaneus fracture
- R navicular fracture
- R cuboid fracture
Also has:
- R Rolondo fx w/ MCP subluxation (managed by Plastics)
- Multiple R rib fracture
- Multiple R sided facial/orbital fractures
Right now we have her in tibial traction with RLE Seattle splint with plan for OR later today.
The response I got from my attending was short and sweet (and priceless), “Seriously?”
“Yeah,” I responded.
“I thought you were kidding,” he returned. His incredulity stemmed from a conversation we’d had the night before about how in my three months on the trauma service every pelvis fracture case I’d seen ended up getting staffed with one of the other trauma attendings based on the call schedule and I’d joked that my goal was never to staff a pelvis case with him.
Ultimately, the patient would require five separate trips to the OR to fix her fractures (three with ortho, one with plastics and one with ENT). At last check, she had been discharged to a skilled nursing facility where she will continue her rehabilitation. We’ll bring her back to clinic to see us at regular intervals to make sure she’s healing and to make decisions on progressing her activity level and weight-bearing status.