Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left lower extremity pain following a traumatic injury. Mechanism of injury described as [mechanism]. Patient reports inability to bear weight, localized swelling, and deformity of the left mid-leg. No reported numbness, tingling, or loss of distal sensation.
Clinical Examination Findings
Left lower extremity: Significant swelling and ecchymosis noted at the mid-shaft of the tibia. Obvious bony deformity present. Skin is intact with no open wounds or tenting. Distal pulses (dorsalis pedis and posterior tibial) are palpable and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes. Motor function preserved in extensor hallucis longus and flexor hallucis longus.
Treatment Protocol
Patient placed in a long leg splint for immobilization. Pain managed with [medication/dosage]. Radiographs confirm closed oblique fracture of the left tibial shaft. Orthopedic surgery consultation requested for definitive management (IM nailing vs. ORIF). NPO status initiated. DVT prophylaxis ordered.