Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute pain, swelling, and deformity of the left lower extremity following a high-energy trauma. Patient reports inability to bear weight on the left leg. Neurovascular status intact distal to injury. No reported numbness or paresthesia.
Clinical Examination Findings
Left lower extremity examination reveals significant edema, ecchymosis, and palpable bony crepitus over the tibial shaft. Deformity noted with associated tenderness to palpation. Distal pulses (dorsalis pedis and posterior tibial) are 2+ and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in peroneal and tibial nerve distributions.
Treatment Protocol
Immediate immobilization with a long leg splint. Radiographic imaging (AP/Lateral) confirmed displaced tibial shaft fracture. Orthopedic consultation requested for surgical stabilization (IM nailing vs. ORIF). Pain management initiated with IV analgesics. NPO status maintained pending potential operative intervention.