Author Question: Medical Complications for Badly Broken Leg 2/2

Today, we’re continuing with Mareike’s question dealing with a character who has several medical complications from a broken leg as a result of a physical assault. You can read Part I here.

wheelchair-1629490_1920Today, I’m hosting Tim B. (my own physical therapist!) If you’re south of Denver and need an excellent physical therapist I’d be happy to refer you.

Here are Tim’s thoughts on the rehab aspects of this character. He also gives great insight into the medical treatment of such a fracture.

Welcome, Tim!

If a person has a compound, open, major fracture of the leg (the part between the knee and ankle), then the most likely treatment would be an ORIF (open reduction, internal fixation), or plates and screws. People with ORIF are then not given a cast.
If the fracture was comminuted (bone is fragmented versus a straight fracture), the typical treatment might be ORIF or an external fixator (halo). You can view this link for photos.

That person would then be non-weight bearing for at least 6 weeks (or more, depending on radiographic evidence of healing), then transitioned into partial weight bearing. They would use crutches or a wheelchair during the non weight bearing phase. The weight bearing phase would progress according to radiographic healing, more than anything else. There is no protocol, per se.

If a person is casted all the way to the hip, then there most likely would have been a fracture extending into the knee joint line, such as a tibial plateau fracture—which could be one of several fractures, including a compound fracture let’s say in the mid-shaft of the tibia/fibula.

Sometimes, an external fixator is applied (in the case of badly damaged and very swollen surrounding soft tissues). After swelling decreases, another procedure could take place (removal of external fixator and placement of internal plates/screws). A cast to the hip would not be used for a fracture below the knee, most likely. So the knee must be involved somehow for the cast to need to go all the way to the hip. Most people are issued a knee immobilizer after these fixation procedures. Perhaps in regions/countries where immobilizers and braces are not commonly found a person could be casted.

Compartment syndrome could be a result of the initial mechanism of injury—lots of soft tissue damage along with bleeding from the fracture—causing compression of the nerves and blood vessels of the leg. Or compartment syndrome might result from a cast that is too tight. Or a bedridden person who doesn’t move at all (same mechanism as a person developing a DVT due to lack of movement).

If blood vessels and/or nerves are compromised in the initial injury or by permanent damage from compartment/compression, the first attempt would be microsurgery by vascular/neurosurgeons to try and repair. Also, a release of the compartment would most likely take place.

Compartment releases are left open and frequent dressing changes take place until swelling comes down. It leaves a wide and long scar in the long run. It takes a little time to realize if it was successful or not (nerve and vessel repair). Perhaps a week later it would really be evident if the correction was successful, or if the leg/foot was “dying” due to lack of blood supply. Those dead areas would not be able to bleed, would probably start turning color, would start to smell, and might be numb.

PT would vary greatly.  Typically, non weight bearing to partial with appropriate crutch use while working the regions of the body surrounding the leg, including even the upper body for strengthening. Progression depends upon radiographic evidence of bone healing for the most part. Range of motion of the knee, ankle, and hip would be emphasized (for most people who have immobilizer but not casts).

Hope this helped and best of luck with your story!

Fractures: General Guidelines

Fiction, particularly the thriller genres, generally require a character to sustain an injury. These can run the gamut from minor to life-threatening.

Today, I’m going to focus on a couple of general guidelines if you injure a character with some type of fracture.

Though it may be hard to break a bone, sometimes it seems the most minor accidents can cause a fracture. My mother once slipped off a small rock onto the side of her foot. Her foot was bruised and mildly swollen and in my nursing wisdom (I was only in nursing school at the time), I said, “There’s no way you broke it slipping sideways off a rock.” Needless to say I was wrong. Yes, broken foot.

Guideline #1
: The amount of swelling is not indicative of fracture. Ankle injuries are classic for this. Patients come in with a horribly swollen ankle, convinced they broke it. My guess in the pediatric realm (up to age 21), the ankle is 95% of the time sprained and not broken. Arms that have an obvious deformity and you can see the limb is broken before you get an x-ray, have little swelling in comparison.

Guideline #2: If something is broken, generally the joint above and below will need to be immobilized (or very close to the next joint). Someone asked me once if a person broke one bone in their lower leg, could they drive? There are two bones in the lower leg: the tibula and the fibula. Depending on how close the fracture is to the knee, the ankle and knee will have to be immobilized. I don’t know how many people can drive with a straight leg.

Guideline #3: Splints are placed first. It is rare to put a cast on in the emergency department. The reason splints are placed first is to allow for swelling to come and go. A splint is generally fiberglass sheets secured in place with an ace wrap. This allows for expansion during swelling. Then in 7-10 days, the patient is referred to an orthopedic doctor for cast placement.

Guideline #4: A good rule is that a cast will be in place for 6-8 weeks. Now, this is highly variable and if an author said the cast needed to stay in place for nine weeks, it probably wouldn’t drive me nuts enough to go check it out. However, a cast on for two weeks is unlikely. You should consider this guideline because it will effect your character for that length of time and inhibit their mobility. Maybe, this is something you want as the author.

Guideline #5: My observation: these bones/joints have a higher incidence of requiring surgery: ankle, elbow, and femur. Now, you can make any fracture bad enough to require surgery but these ones can be more common to require the OR.

What other guidelines would you like to see?