What is the best course of treatment for a patient with a recent fall and leg pain, who is currently using a moon boot and taking Tramadol (tramadol) for pain management, and has a history of a right tibia and fibula shaft fracture?

Management of Recent Fall and Leg Pain in Patient with Prior Tibia/Fibula Fracture

For a patient with a recent fall and leg pain who is recovering from a tibia/fibula shaft fracture, the most appropriate treatment is to continue the current moon boot with gradual weight bearing as directed by orthopedics, use tramadol judiciously for pain control, and implement ice, elevation, and gentle stretching exercises while monitoring for complications.

Assessment of Current Injury

The patient's presentation suggests a soft tissue injury rather than a new fracture:

• Lateral thigh tenderness without knee pain on palpation
• No swelling or redness at surgical sites
• Normal sensation in both feet
• Able to mobilize with moon boot
• Recent orthopedic review (02/09/2025) showed well-healed fracture

Immediate Management

1. Continue Moon Boot Use

   • Follow orthopedic recommendation to "wean from boot over next month to 6 weeks" 1
   • Maintain weight bearing as tolerated per orthopedic instructions
   • The controlled ankle motion (CAM) walker boot provides better stabilization during healing 2

2. Pain Management

   • Tramadol dosing: Continue tramadol for pain control but with caution
     • Recommended dosage: 50-100 mg every 4-6 hours as needed, not exceeding 400 mg/day 3
     • For patients >65 years: Consider lower doses (start at low end of dosing range) 3
     • For patients with renal impairment (CrCl <30 mL/min): Increase dosing interval to 12 hours with maximum 200 mg/day 3
   • Non-opioid options:
     • Regular paracetamol administration should continue throughout the recovery period 1
     • NSAIDs should be used with extreme caution, particularly in patients with renal dysfunction 1

3. Non-Pharmacological Measures

   • Ice application to reduce swelling (continue as patient has already found this helpful)
   • Elevation of the affected limb
   • Limited activity with gradual increase as tolerated
   • Avoid barefoot walking 1

Rehabilitation Approach

1. Physical Therapy

   • Continue ongoing physiotherapy
   • Focus on gentle range-of-motion exercises for knee and ankle
   • Gradually progress to muscle strengthening exercises 1
   • Include balance training to prevent future falls 1

2. Fall Prevention

   • Assess home environment for fall hazards
   • Consider vitamin D supplementation (800 IU/day) with adequate calcium intake, as this is associated with 15-20% reduction in falls 1
   • Implement multidimensional fall prevention strategies 1

Monitoring for Complications

1. Signs requiring urgent assessment:

   • Severe, worsening, or uncontrolled pain
   • Significant swelling or redness
   • Inability to bear weight
   • Numbness or tingling in the extremity
   • Signs of DVT (calf tenderness, swelling, warmth)

2. Follow-up recommendations:

   • Continue with scheduled orthopedic follow-up in 8 weeks
   • Return sooner if symptoms worsen or new symptoms develop
   • Consider imaging if pain persists beyond 2-3 weeks

Special Considerations

1. Multiple falls since surgery:

   • The patient's history of multiple falls warrants additional attention
   • Consider assessment for proximal tibiofibular joint instability, which can cause lateral knee pain and is often underrecognized 4
   • Evaluate for possible gait abnormalities that may have developed during recovery

2. Long-term recovery expectations:

   • Full recovery may take up to 1 year per orthopedic assessment
   • Patient education about realistic recovery timeline is important
   • Regular assessment of wound healing, radiographic union, and hardware-related pain is necessary 5

This approach prioritizes continued healing while providing adequate pain control and preventing complications, with the ultimate goal of returning the patient to their pre-injury functional status.