Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right lower extremity pain following a mechanical fall/trauma. Reports inability to bear weight, localized swelling, and visible deformity of the right tibial shaft. Denies distal paresthesia or numbness. No open wounds noted.
Clinical Examination Findings
Right lower extremity: Obvious deformity and tenderness to palpation over the mid-shaft of the tibia. Skin intact, no tenting or open wounds (Gustilo-Anderson Grade 0). Distal neurovascular status intact: dorsalis pedis and posterior tibial pulses palpable (2+), capillary refill <2 seconds, sensation intact to light touch in all dermatomes, and full toe flexion/extension.
Treatment Protocol
Immobilization with a long-leg splint/cast. Orthopedic consultation for definitive management (IM nailing vs. ORIF). Pain management with NSAIDs/analgesics. Strict non-weight bearing status on the right lower extremity. Elevation of the limb above heart level to reduce edema.