Stack the deck in your favor, wear your gear, ride conservatively and be hyper aware and suspicious of EVERYONE. As my instructor beat into our head; "Have an exit strategy."
FYI it’s a running joke in this sub. As a radiologist however I will never include the word “broken” in an official report. “Fractured” is formal, “broken” is informal.
Lord. I can still remember a patient's drunk group of friends fighting over broke vs fractured.when I took the pt back to the room. I burst their little bubble.
Curious: what was the hardest movement to get back? What movement wasn’t necessarily the hardest but surprised you at how hard it was? What about PT was most challenging? How did your PT most help you?
Thanks! Proud of your hard work
They initially applied an ex-fix to see if there would be enough healing eventually to salvage the leg. However, that wasn’t the case and this patient unfortunately ended up getting an amputation.
Ex-fix. Remove all nonviable bone fragments. Wash out. Wash out. Debride. Debride some more. Fix with nail/plate/combo. Cement spacer to bridge the defect temporarily. Return in a month or two and take out the spacer. Pack the defect with bone graft. Pray it heals.
Or just amputate.
Same. The outcome of this injury isn't surprising at all. Sucks but motorcycles and trucks aren't exactly friends who bump chests in joy when they see each other.
You get to teach the residents a lot of different techniques on cases like this.
If the pt refuses immed amp, I'll ex-fix and wait for their roommate to complain of the smell. That's always enough time for them to realize it's the right choice.
Usually this much comminution results in significant soft tissue loss which is the usually immediate determining factor that will result in amputation. Since the majority of comminution is occuring right at Hunters canal, where the femoral artery is tethered right next to the bone, I'll guess that vascular and soft tissue injuries will produce an amp.
Someone posted a nice sequence of steps, alluding to the Masqulet technique, where bone cement is used to make a vascularized bed for bone graft to make up for missing bone. Usually 8cm is about the average, although reports up to 20 cm have been done.
Been involved in a few around 16cm-20cm or so using TRuSS grafts with masquelet. Other option is obviously bone transport with a nail which would work well here provided articulate block reconstructs appropriately.
I knew I forgot one option. The bone transports are much less exciting now that we have nails instead of ex fixes. I did have one patient that got confused at which direction to turn the screws on his X fix and then delengthened his bone transport. Luckily I caught it before he docked it at the wrong site and he had to relengthen in it again
I had a similar accident (but not as bad) I posted my pictures here
https://www.reddit.com/r/Radiology/comments/u318qo/motorcycle_accident_illivarov_fitment_leg/?utm_source=share&utm_medium=ios_app&utm_name=iossmf
more proof of why i’ll never touch a motorcycle. i understand the thrill aspect, but it’s just not worth it. i’m nervous enough about getting in an accident in my vehicle with a giant steel body surrounding me. on a bike, you’re completely exposed and even the most minor of accidents can kill you. absolute no for me!
Pretty much what my dad taught me: you can be the best rider in the world, but all it takes is one idiot not paying attention and your life can be ruined forever. Or in my dad's case, break your leg and meet your future wife.
My dude. We are all here because we are looking at some motorcycle driver's mangled leg that probably had to be amputated and you think the reason they don't think motorcycles are worth it is because they're scared of driving a car??
i’m not scared of driving my car lmao, i’m scared at the thought of a car *accident* and how much worse it’d be on a motorcycle. i have seen so many patients involved in relatively minor accidents but they were mangled due to the fact that they were on a bike. it’s just common sense that motorcycles are insanely dangerous, no need to undermine that with your ignorance.
On top of that, the amount of people I see riding motorcycles (riding aggressively at that) with no protective gear is insane and makes me internally cringe every time.
It’s so close to the knee joint I have a hard time imagining how a surgeon might go about fixing the distal femur to the proximal femur. Amputation honestly might be the easiest option
I was thinking more in terms of this person’s quality of life. Whatever they could manage to reconstruct would be very painful and questionably functional.
Ive seen one injury similar, but the fractures were slightly more proximal than this one. Patient had a intramedullary rod and the fragments kind of just places around it hoping they would unify again. Some of the larger pieces has screws in them.
Not sure if a IM rod can be placed with a fracture that distal, never worked around ortho
Partly mentioned above. Debride non viable fragments, fix the articular block. Once soft tissues appropriate I’d stick a nail up retrograde through the knee spanning the defect and fill residual with antibiotic cement spacer.
Options then when the articular block has healed would be masquelet based technique (suspect the defect would be too large for primary masquelet so would do this around a custom 3D printed cage with bone graft - TRUSS graft) or other option is bone transport based technique over a lengthening nail. Either is a reasonable option but will require multiple trips to theatre.
Tibia just gets a plate.
My anatomy professor who was a clinical pathologist told our class that the reason he hated motorcycles was after one of his first cases involved a motorcycle crash and a severed foot in a boot.
The trauma team where I was a med student received a pt whose legs had been run over by a train. He arrived with a shoe on his chest which looked like there was a sock in it. It was his foot and the degloved skin of his lower leg. The other leg was almost as bad. He ended up with a BKA on one side and an AKA on the other, but died on POD 2 or 3.
The bone injury is not the issue here, its the soft tissue injury associated with this bone injury that’s almost always the issue,as well as patient factors (other medical issues, other injuries, and compliance with what would be many many trips to theatre over many years to reconstruct and heal). Bone can be transported and reconstructed and in reality if the soft tissues were appropriate it would be entirely possible to salvage this leg. I suspect however that the soft tissue injury was what resulted in this patient proceeding to amputation.
oof. We call them donorcycles for a reason. Not that this particular one donated anything in the end. Thankfully. I hope they make/made a solid recovery with good QoL and minimal residual pain.
We had a patient who looked like this after a similar accident. They refused amputation, so they come in every few months to revise all the hardware in the leg because of pain and infection. I can’t imagine how dealing with all that is better than an amputation.
This was done in the ER department portably and the ortho decided that the AP provided more than enough info. I would have loved to see what the lateral would have looked like!
From what I heard, they were travelling opposite directions. The truck driver was drunk and drifted lanes and hit the motorcyclist on the left hand side.
Oh shit I will never buy a bike
You can ride a bike just don't smash it into a truck
Damn. There go my plans for the weekend.
Often, it's the truck smashing into the bike....
Don't tell me what to do
Or a deer.
Well shit, I just got my learners motorcycle license…
Stack the deck in your favor, wear your gear, ride conservatively and be hyper aware and suspicious of EVERYONE. As my instructor beat into our head; "Have an exit strategy."
I think it's broke
Not an expert but I think it’s fractured.
Idk, it might just be a hairline fracture, I'm *sure* it can't cost that much to fix.
Idk I think we'll need an MR to rule that out completely, first the pt should do 4-6 weeks of PT and if it doesn't improve well get one.
Correlate clinically. Recommend follow up CT and MRI.
Does that mean it’s also broken? 😟
It’s either broken or fractured. Correlate clinically.
So you are saying there is a chance it’s not even broken. Jesus works in mysterious ways 🥹
Nah it’s just cracked
Fyi, it’s both: https://www.midatlanticorthonj.com/blog/the-difference-between-a-break-and-fracture#:~:text=The%20terms%20are%20actually%20interchangeable,be%20correct%20but%20more%20colloquial.
FYI it’s a running joke in this sub. As a radiologist however I will never include the word “broken” in an official report. “Fractured” is formal, “broken” is informal.
Ah, new to this sub so I didn’t get the running joke at first. Thanks for letting me know!
Lord. I can still remember a patient's drunk group of friends fighting over broke vs fractured.when I took the pt back to the room. I burst their little bubble.
That’s what patients say. “It’s not broken it’s just a hairline fracture”. It’s the same thing.
A hairline fracture is a type of bone breakage correct?
Correct.
I’m sorry I can’t say
The motorcycle isn't even in the picture, it might not be broken.
Calm down y’all I’m a doctor. I think it’s a green stick fracture.
A little worse than mine, but 9 surgeries and 2.9 years later I’m pretty much back to 100. A couple more months of hard PT. Let’s go!
Curious: what was the hardest movement to get back? What movement wasn’t necessarily the hardest but surprised you at how hard it was? What about PT was most challenging? How did your PT most help you? Thanks! Proud of your hard work
username checks out
His femur is MIA. Anybody care to chime in if this is recoverable? And treatment modalities used to fix this?
They initially applied an ex-fix to see if there would be enough healing eventually to salvage the leg. However, that wasn’t the case and this patient unfortunately ended up getting an amputation.
Ex-fix. Remove all nonviable bone fragments. Wash out. Wash out. Debride. Debride some more. Fix with nail/plate/combo. Cement spacer to bridge the defect temporarily. Return in a month or two and take out the spacer. Pack the defect with bone graft. Pray it heals. Or just amputate.
As a vet, all I can see is amputation. How were the blood vessels?
Surprisingly their vasculature was completely intact.
That's incredible.
Same. The outcome of this injury isn't surprising at all. Sucks but motorcycles and trucks aren't exactly friends who bump chests in joy when they see each other.
You get to teach the residents a lot of different techniques on cases like this. If the pt refuses immed amp, I'll ex-fix and wait for their roommate to complain of the smell. That's always enough time for them to realize it's the right choice.
Usually this much comminution results in significant soft tissue loss which is the usually immediate determining factor that will result in amputation. Since the majority of comminution is occuring right at Hunters canal, where the femoral artery is tethered right next to the bone, I'll guess that vascular and soft tissue injuries will produce an amp. Someone posted a nice sequence of steps, alluding to the Masqulet technique, where bone cement is used to make a vascularized bed for bone graft to make up for missing bone. Usually 8cm is about the average, although reports up to 20 cm have been done.
Been involved in a few around 16cm-20cm or so using TRuSS grafts with masquelet. Other option is obviously bone transport with a nail which would work well here provided articulate block reconstructs appropriately.
I knew I forgot one option. The bone transports are much less exciting now that we have nails instead of ex fixes. I did have one patient that got confused at which direction to turn the screws on his X fix and then delengthened his bone transport. Luckily I caught it before he docked it at the wrong site and he had to relengthen in it again
I had a similar accident (but not as bad) I posted my pictures here https://www.reddit.com/r/Radiology/comments/u318qo/motorcycle_accident_illivarov_fitment_leg/?utm_source=share&utm_medium=ios_app&utm_name=iossmf
Yours was a pretty routine Fx. This is much, much, much worse than yours.
I don't think you looked through the album. I believe they were referring to their Tib/Fib fracture as comparison
The tub/fib Fxs were pretty common. Needing a gastric rotation flap is a little unusual.
[удалено]
Genius
*Request for weight bearing images
ED PA's/NP's be like that.
more proof of why i’ll never touch a motorcycle. i understand the thrill aspect, but it’s just not worth it. i’m nervous enough about getting in an accident in my vehicle with a giant steel body surrounding me. on a bike, you’re completely exposed and even the most minor of accidents can kill you. absolute no for me!
Yup, and doesn't matter how good of a rider you are.
Pretty much what my dad taught me: you can be the best rider in the world, but all it takes is one idiot not paying attention and your life can be ruined forever. Or in my dad's case, break your leg and meet your future wife.
That’s why you don’t think it’s worth it, your scared to even drive a car. People die riding bicycles.
My dude. We are all here because we are looking at some motorcycle driver's mangled leg that probably had to be amputated and you think the reason they don't think motorcycles are worth it is because they're scared of driving a car??
Meh, I don’t let my work scare me from life. I also mountain bike, rock climb, fish, boat, drink. All things I’ve seen people die doing
You saw someone die fishing?
Yes
i’m not scared of driving my car lmao, i’m scared at the thought of a car *accident* and how much worse it’d be on a motorcycle. i have seen so many patients involved in relatively minor accidents but they were mangled due to the fact that they were on a bike. it’s just common sense that motorcycles are insanely dangerous, no need to undermine that with your ignorance.
On top of that, the amount of people I see riding motorcycles (riding aggressively at that) with no protective gear is insane and makes me internally cringe every time.
Pt ambulatory on scene
Wow. I’ve been in a lot of surgeries but never have seen one that bad. How would a surgeon even go about fixing that??
It’s so close to the knee joint I have a hard time imagining how a surgeon might go about fixing the distal femur to the proximal femur. Amputation honestly might be the easiest option
Amputation is almost always the easiest option.
I was thinking more in terms of this person’s quality of life. Whatever they could manage to reconstruct would be very painful and questionably functional.
Ive seen one injury similar, but the fractures were slightly more proximal than this one. Patient had a intramedullary rod and the fragments kind of just places around it hoping they would unify again. Some of the larger pieces has screws in them. Not sure if a IM rod can be placed with a fracture that distal, never worked around ortho
I was just thinking this! Is it even possible?
U/wangdoodle had a nice summary of the steps involved, just a few posts up.
Not an ortho…but I can’t think of any way to fix that other than amputation. That’s pretty much pulverized.
The bony injury is definitely reconstructable, the associated soft tissue injury possibly not. All depends on the soft tissues here.
I’d be interested to know how to reconstruct that. Cause in my head, I have visions of gluing a broken vase together.
Partly mentioned above. Debride non viable fragments, fix the articular block. Once soft tissues appropriate I’d stick a nail up retrograde through the knee spanning the defect and fill residual with antibiotic cement spacer. Options then when the articular block has healed would be masquelet based technique (suspect the defect would be too large for primary masquelet so would do this around a custom 3D printed cage with bone graft - TRUSS graft) or other option is bone transport based technique over a lengthening nail. Either is a reasonable option but will require multiple trips to theatre. Tibia just gets a plate.
Learn something new everyday. Thanks!
Yea I’m gonna need the sunrise view 🤣
My anatomy professor who was a clinical pathologist told our class that the reason he hated motorcycles was after one of his first cases involved a motorcycle crash and a severed foot in a boot.
The trauma team where I was a med student received a pt whose legs had been run over by a train. He arrived with a shoe on his chest which looked like there was a sock in it. It was his foot and the degloved skin of his lower leg. The other leg was almost as bad. He ended up with a BKA on one side and an AKA on the other, but died on POD 2 or 3.
Ow poor guy.
Joint spaces are grossly maintained
He is very kneedy now
The bone injury is not the issue here, its the soft tissue injury associated with this bone injury that’s almost always the issue,as well as patient factors (other medical issues, other injuries, and compliance with what would be many many trips to theatre over many years to reconstruct and heal). Bone can be transported and reconstructed and in reality if the soft tissues were appropriate it would be entirely possible to salvage this leg. I suspect however that the soft tissue injury was what resulted in this patient proceeding to amputation.
Woooowwwwwie
Fibulas intact, Id call that a win.
oof. We call them donorcycles for a reason. Not that this particular one donated anything in the end. Thankfully. I hope they make/made a solid recovery with good QoL and minimal residual pain.
By a car folks. Motorbikes are for organ donors.
Jesus Christ :O
Truck 1, Femur 0
Tis’ but a scratch
Sweet tunnel
You think that's bad, but you should see the truck drivers femur.
Man I think I’d opt out of the many surgeries required to even try with this one.
Altamante cominutiva
tibia rotational fracture?
Looks like the dude i posted a while back. Motorcycles don't mess around.
I’d hate to think what the skin looks like if that’s what the bone looks like. Ouch.
I’m in actual pain looking at this.
We had a patient who looked like this after a similar accident. They refused amputation, so they come in every few months to revise all the hardware in the leg because of pain and infection. I can’t imagine how dealing with all that is better than an amputation.
Just pour some Tussin on it.
WBAT?
Looks like thanos snapped his fingers😬😬😬
Unintentional tunnel view lol
Correction: femur and tibia versus truck. Ouch! Thanks for the image!
Bonesaw is READY!
I think the truck won
Just put a metal one in, no biggie
Oww
Looks more like LE vs truck.
What, no lateral? Smh 😜
Surprisingly decent AP given the circumstances though.
Oh for sure!
This was done in the ER department portably and the ortho decided that the AP provided more than enough info. I would have loved to see what the lateral would have looked like!
Totally on board with orthopods who make smart decisions. But for sure, I think a lateral would look crazy!
Dang. That truck driver really got roughed up.
Poor truck, I hope it doesn’t get totaled
Ouch. Not the kind of jigsaw puzzle I wanna play
And that was the trucker 👀
I think the femur needs amputation☹️
I’m not a doctor but I think that will require surgery.
Looks like I’m going to find so knee armor that rides a bit higher. Do you know if MOI was hit from the side or over the top hitting handlebars?
From what I heard, they were travelling opposite directions. The truck driver was drunk and drifted lanes and hit the motorcyclist on the left hand side.
Thank you. Id say that rider got off easy if still alive. That must not be the only injury.
‘Early degenerative spiking of the tibial eminences’
Is there a way other than amputation?
My espresso group would advise the trucker to "grind finer"
I have a Craftsman they can borrow. Too soon?
RIP femur
luque wire and dermabond should fix it
A mere flesh wound