Di Tommaso, Mariarosaria

Fambrini, Massimiliano

Giovanni, Sisti

Sorbi, Flavia

English

Florence Research

Traumatic Tibia and Fibula Fracture in a 36 Weeks’Pregnant Patient: A Case ReportFlavia Sorbi, MD, Giovanni Sisti, MD, Mariarosaria Di Tommaso, MD, PhD,Massimiliano Fambrini, MDDepartment of Science for Woman and Child Health, University of Florence, Florence, ItalyABSTRACTBackground: Bone fracture management in third-trimesterpregnant patients is rare and poorly discussed in the literature.In the case of fractures that require orthopedic surgery in near-term pregnant women, clinicians should decide betweenoperating before or after the delivery, carefully evaluating thehealth of the mother and fetus.Case Report: A pregnant 41-year-old woman at 36 weeks’gestation had a traumatic midshaft displaced tibia and fibulafracture. A multispecialty team approach resulted in nonoper-ative treatment until delivery. The sudden spontaneouspremature rupture of membranes led to a preterm cesareansection. Five days after cesarean section, the patientunderwent surgery for open reduction and internal fixationwith pins and plates. The patient recovered well and wasdischarged with her baby.Conclusion: The clinical and surgical management of bonefractures in pregnant women should be determined by amultispecialty team, and a tailored intervention should bechosen for each patient.INTRODUCTIONFracture of the tibia is the most common long-bone fracture and is generally associated with fibulafracture. Management depends not only on thefracture pattern but also on the patient’s systemiccondition. Typically, treatment of lower extremityfractures is operative, focused on the tibia fixation,and the associated fibula fracture is managed withoutfixation. Closed options are reduction and immobili-zation in a long-leg cast.Trauma, affecting 7% of all pregnancies, is theleading cause of nonobstetric death in pregnantwomen, with an overall maternal mortality of 6% to7%.1,2 Fetal mortality has been shown to range from55% to 65% in major trauma cases.1,3 Trauma affectsthe obstetric outcome when it is associated withmaternal death or direct uterine or placental injury.4We report a case of a pregnant woman in the 36thgestation week who sustained a traumatic tibia andfibula fracture. We found only 1 published case in theliterature that describes accelerated tibial fractureunion in the third trimester of pregnancy.5CASE REPORTA 41-year-old woman gravid 2, para 1, at 36weeks’gestation presented to the emergency depart-ment with severe left-sided lower extremity pain andlimping. The injury was associated with a low-energyfall. Her obstetric history revealed a previous vaginaldelivery at the 40th week of an uneventful gestation.She had no history of any medical disorder. She wasa nonsmoker and did not drink alcohol duringpregnancy. Her present pregnancy had been un-eventful. The patient underwent all routine laboratoryand ultrasound tests, and the fetus had developednormally.She was initially evaluated by an emergency roomorthopedist, followed by consultation with an obstetri-cian. Apart from generalized pain and limitation ofmotion in the patient’s lower left extremity, the generalphysical examination was unremarkable. There was noevidence of compartment syndrome or neurovasculardeficit. The skin was intact. Plain radiography showeda displaced midshaft fracture of the left tibia and fibulaAddress correspondence toGiovanni Sisti, MDViale Morgagni 8550134FirenzeDipartimento di Scienze per la Salute della Donna e del BambinoSezione di Ginecologia e OstetriciaAzienda Ospedaliero-Universitaria CareggiUniversita` degli Studi di Firenze, ItaliaTel: þ39-3387119678Fax: þ39-0554598900Email: giovanni83@email.itKeywords: Cesarean section, fibula, fractures—bone, pregnancy,tibiaThe authors have no financial or proprietary interest in the subjectmatter of this article.Volume 13, Number 4, Winter 2013 547The Ochsner Journal 13:547–549, 2013 Academic Division of Ochsner Clinic Foundation(Figure). Abdominal ultrasound revealed no patholog-ical findings. Fetal cardiotocography showed beat-to-beat heart rate variation with normal fetal heart rate.Because of the nature of the injury and thegestational age, nonoperative treatment until afterthe baby was delivered was considered the bestoption, with a low risk of causing the patient residualpain, long-term disability, and obstetric complications.After consulting with an orthopedist and an obstetri-cian, the patient decided to undergo conservativemanagement until elective cesarean section at term.Cesarean section was chosen to avoid the laborstress in a patient with an immobilized fractured limb.After application of a below-knee cast, the patient wastransferred to the obstetrics/gynecology departmentfor continued antepartum care. Because the patientwas not permitted to bear weight on the fractured leg,her risk of developing deep vein thrombosis (DVT)was increased. Therefore, she was administered4,000 UI of subcutaneous enoxaparin every 12 hoursfor thromboprophylaxis.Two days later, while the patient was lying in bed,she had a spontaneous premature rupture of mem-branes, leading to a cesarean section before theelective period initially planned. The infant’s birthweight was 2940 g, and Apgar scores were 9 and 9 at1 and 5 minutes, respectively. The umbilical arterialpH was 7.28 and the venous pH was 7.30.Lower limb color Doppler examination performed2 days after the cesarean section showed noabnormalities. Five days after the cesarean section,the patient underwent surgery for open reduction andinternal fixation with pins and plates and had anuneventful recovery. The patient continued subcuta-neous heparin for DVT prophylaxis and toleratedpostoperative rehabilitation without difficulty.Another lower limb color Doppler examinationperformed 9 days after cesarean section showed noabnormalities. After 15 days without weight-bearingactivity, a 30-day period of total left leg unload usingantebrachial crutches was prescribed. DVT prophy-laxis was continued until the patient was able toambulate on her own.DISCUSSIONTrauma is the main cause of nonobstetric death inthe gravid mother in the United States.2 With trauma,fetal mortality can rise to 65% as the result of placentalabruption, direct fetal injury, and other causes.3Because relatively minor injuries may be life threat-ening for both mother and fetus, it is important toassess the need for intensive medical care. If theinjury is completely away from the pregnant uterus,the prognosis for the pregnancy is good.Primary care varies little in pregnancy comparedwith the nonpregnant patient. The priority goes to themother. Once maternal assessment has been doneand care is set, noninvasive diagnostics, such asabdominal ultrasonography and cardiotocographicmonitoring, should be used as soon as possible.In reviewing English language publications inMEDLINE and Embase, we found only a few reportsof limb fracture during pregnancy6,7 and only 1 knowncase of tibia fracture.5We believe there are 2 main issues concerning themanagement of fractures in pregnancy. The first iswhether to treat the pregnant patient conservatively orsurgically. Tibia and fibula fractures are usuallytreated with tibia fixation, while the associated fibulafracture is managed without fixation. Very little isknown about the risks and complications of surgeryand anesthesia for fractures treated in pregnantwomen. No currently used anesthetics are known tobe teratogenic but when possible, regional techniqueis preferred.8 Our patient had no indications forimmediate surgery of the fractured limb and no signof DVT. Therefore we preferred the conservativeapproach with immobilization of the leg in a below-knee cast. We were concerned about her increasedrisk of developing DVT as a result of prolongedimmobilization, so the patient was started on subcu-taneous heparin for DVT prophylaxis. We have foundFigure. Initial radiograph showing the patient’s midshaftdisplaced tibia and fibula fracture.Bone Fracture During Pregnancy548 The Ochsner Journalno case reports in the literature describing DVT inpregnant women with isolated lower-limb fractures.The second issue to consider when managing afracture in pregnancy is the role and timing of acesarean section. The approach should be multidis-ciplinary involving a gynecologist, an orthopedist, anda neonatologist. A cesarean section may be indicateddepending on gestational age. Because our patientdid not have monitoring or ultrasound abnormalities,we planned an elective cesarean section at 38 weeks.The literature has some reports of preterm cesareandelivery performed prior to orthopedic surgery.9,10 Inthose cases, the patients had femoral or hip fractures.We did not find any case reports of preterm cesareansections for tibia fracture. Ahmad et al reported a caseof accelerated tibia fracture union in the third trimesterof pregnancy.5 The authors delayed operative treat-ment to the postpartum period. The pregnancyproceeded quietly with no complications. Fractureunion occurred spontaneously and did not needsurgery.CONCLUSIONOur case of traumatic midshaft displaced tibia andfibula fracture at the 36th week of pregnancy suggeststhat these injuries can be managed successfully inproperly selected patients with an initial nonoperativeintervention followed by open surgery postpartum.The efficacy and safety of this approach have yet tobe determined, and further clinical research isneeded.REFERENCES1. Barraco RD, Chiu WC, Clancy TV, et al; EAST PracticeManagement Guidelines Work Group. Practice managementguidelines for the diagnosis and management of injury in thepregnant patient: the EAST Practice Management Guidelines WorkGroup. J Trauma. 2010 Jul;69(1):211-214.2. Fildes J, Reed L, Jones N, et al. Trauma: the leading cause ofmaternal death. J Trauma. 1992 May;32(5):643-645.3. Ali J, Yeo A, Gana TJ, et al. Predictors of fetal mortality inpregnant trauma patients. J Trauma. 1997 May;42(5):782-785.4. Rothenberger D, Quattlebaum FW, Perry JF Jr, et al. Bluntmaternal trauma: a review of 103 cases. J Trauma. 1978 Mar;18(3):173-179.5. Ahmad MA, Kuhanendran D, Kamande IW, et al. Accelerated tibialfracture union in the third trimester of pregnancy: a case report. JMed Case Rep. 2008 Feb 9;2:44.6. El Kady D, Gilbert WM, Xing G, Smith LH. Association of maternalfractures with adverse perinatal outcomes. Am J Obstet Gynecol.2006 Sep;195(3):711-716.7. Bharathan R, Duckett J, Jain S. An unusual indication forcaesarean section: lower limb fracture. J Obstet Gynaecol. 2008Aug;28(6):648-649.8. Reitman E, Flood P. Anaesthetic considerations for non-obstetricsurgery during pregnancy. Br J Anaesth. 2011 Dec;107(Suppl 1):i72-i78.9. Csotye J, Sisak K, Bardocz L, et al. Bilateral spontaneousdisplaced femoral neck fractures during pregnancy. J Trauma.2010 May;68(5):E115-E116.10. Chalouhi GE, Harb C, Atallah D, et al. Total hip replacement atthirty years. Case report of crippling complications of a transientosteoporosis of the hip during pregnancy. Eur J Obstet GynecolReprod Biol. 2010 Apr;149(2):226-227. Epub 2009 Dec 16.This article meets the Accreditation Council for Graduate Medical Education and the American Board ofMedical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.Sorbi, FVolume 13, Number 4, Winter 2013 549

Traumatic tibia and fibula fracture in a 36 weeks&apos; pregnant patient: a case report.

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Traumatic tibia and fibula fracture in a 36 weeks' pregnant patient: a case report.

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Traumatic tibia and fibula fracture in a 36 weeks&apos; pregnant patient: a case report.

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Traumatic tibia and fibula fracture in a 36 weeks' pregnant patient: a case report.