Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left lower extremity pain following a low-energy/high-energy mechanism of injury. Patient reports inability to bear weight on the left leg. No history of open wounds, neurovascular compromise, or prior surgical intervention to the affected limb. Pain is localized to the mid-shaft tibia, exacerbated by movement.
Clinical Examination Findings
Left lower extremity examination reveals localized tenderness, swelling, and palpable deformity at the mid-shaft tibial region. Skin is intact with no evidence of tenting or open fracture. Neurovascular status: Distal pulses (dorsalis pedis and posterior tibial) are 2+ and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes. Motor function: No deficits in toe flexion/extension or ankle dorsiflexion/plantarflexion.
Treatment Protocol
Immobilization with a long leg splint applied. Patient instructed on strict non-weight bearing status for the left lower extremity. Pain managed with analgesics. Orthopedic consultation requested for definitive management (IM nailing vs. ORIF). Radiographic imaging confirms closed mid-shaft tibial fracture (S82.202A).