Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right lower extremity pain following high-energy trauma. Reports inability to bear weight, localized swelling, and visible deformity of the right tibial shaft. Denies numbness or paresthesia in the foot. Neurovascular status intact upon initial assessment.
Clinical Examination Findings
Right lower extremity: Obvious deformity and focal tenderness over the tibial diaphysis. Skin integrity intact (Gustilo-Anderson Grade 0). Distal pulses (dorsalis pedis and posterior tibial) 2+ and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes. No motor deficits in toe extension or flexion.
Treatment Protocol
Immobilization with long leg splint. Strict non-weight bearing on the right lower extremity. Pain management with analgesics. Orthopedic surgery consultation for definitive fixation (IM nailing vs. ORIF). Radiographic imaging (AP/Lateral) confirmed displaced tibial shaft fracture.