Module 38, THE ALFRED I. DUPONT INSTITUTE

Module 38, General Orthopaedist Level

A 14 year old Hispanic male presented to the emergency room after sustaining a hyperextension injury to his right knee during a soccer collision. He had the immediate onset of pain and noted swelling of the knee during the first hour after injury. He was unable to bear weight; flexion and extension of the knee exacerbated the pain. He had no previous history of injury to his right lower extremity. Examination of the right lower extremity was remarkable for a knee effusion with soft tissue swelling and diffuse tenderness at the proximal tibia. The patient was unable to dorsiflex or evert his foot. Sensation along the lateral calf and foot was diminished. The dorsalis pedis and tibialis anterior pulses were palpable and there was good distal capillary refill. AP and lateral views of the right lower extremity revealed a Salter Harris III proximal tibial fracture with intraarticular extension into the medial and lateral tibial plateaus. The epiphysis was anteriorly displaced on the metaphysis. The patient underwent closed reduction and application of a long leg splint on the night of injury. A palpable dorsalis pedis pulse was present after reduction. The numbness was less than when he presented.

Question 38A

The patient is discharged home with Tylenol with codeine and instructed to come to the office for an examination in 24 hours.

Question 38B

This patient should have an arteriogram to rule out arterial injury.

Question 38C

Closed reduction with internal fixation would be better than cast or splint immobilization.

Question 38D

The nerve injury will probably be a permanent part of the disability.

Question 38E

The day after the injury the child complains of increasing pain, increasing numbness in the foot, and you notice that the foot feels cool. You would completely remove the splint and all dressings to fully examine the limb.

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