Fr.tibia Dan Fibula_irham

Irham KhairiC 111 10 820

Advisor:dr. M. Luthfi Muammar

dr. AndikaSupervisor:

dr. Muhammad Sakti, Sp.OT

Department of Orthopedic and TraumatologyFaculty of Medicine Hasanuddin University

Makassar 2015

CASE REPORT

OPEN COMMINUTIVE FRACTURE OF THE RIGHT TIBIA AND SEGMENTAL FRACTURE OF THE FIBULA

GRADE IIIA

Name : BAge / Sex : 50 years old/ male Address : Emmy Saelan MakassarAdmission : January 8th, 2015MR : 479019

PATIENT IDENTITY

Chief complain : Wound at the right leg Anamnesis : Suffered since 15 minutes before

admitted to the hospital due to traffic accident Mechanism of trauma : The patient was cross the

street then got hit by a motorcycle from the right side.

History of unconsciousness (-), nausea (-), vomited (-).

HISTORY TAKING

A : PatentB : RR = 20 x/min, spontan, thoracoabdominal type.C : BP = 120/80 mmHg, RR = 7 x/min, regular, strong palpable. D : GCS 15 (E4M6V5), pupil isochors, Ø : 2.5 mm /2.5 mm , light reflex +/+E : T = 36.5o C (axillar temp)

Primary Survey

Right Leg RegionI : Lacerated wound at middle side from anterior aspect

extend to medial aspect, sized 10 x 5 x 2 cm, deformity (+), swelling (+), hematoma (+), muscle exposed (+), bone exposed (+).

P : Tenderness (+)ROM : active and passive motion at knee and ankle joint are

limited due to painNVD : sensibility is good, the pulse of dorsalis pedis artery is

palpable, capillary refill time < 2”

Secondary Survey

WBC 14,72 x 103 /uL RBC 4,02 x 106 /uL HGB 12,4 gm/dL HCT 36,3 % PLT 223 x 103 /uL CT 7’ 00’’ BT 2’30’’

LABORATORY FINDINGS

CLINICAL PICTURES

Radiologic findings

Open comminutive fracture of the right tibia grade III A

Open segmental fracture of the right fibula grade III A

Diagnosis

IVFD RL Antibiotic Anti tetanus Analgesic Debridement Immobilize fracture with long leg back slab

Planning :1. Plan for ORIF

MANAGEMENT

Male 50 years old, admitted to the hospital with chief complain of wound at right leg region due to traffic accident.

On physical Examination lacerated wound sized 10cm x 5cm x 2 cm at at anterior aspect extend to medial aspect, deformity (+), swelling (+), hematoma (+), muscle exposed (+), bone exposed (+).

ROM of knee joint and ankle joint was limited due to pain.

NVD: within normal limited On radiologic examination, there are comminutive

fracture at the right tibia and segmental fracture at the right fibula

SUMMARY

DISCUSSION

FRACTURE OF TIBIA AND FIBULA

Open fracture means that bone penetrated skin resulting in open wound and exposed to external environment.

Tibia is the major weight bearing of the leg (85% of the whole load), while fibula responsible for 6% -17% of weight bearing load.

INTRODUCTION

Anatomy

COMPARTMENTS OF THE LOWER LEG

Anterior Compartement

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

Lateral Compartement


Superficial Posterior Compartement


Deep Posterior Compartement


innervation


Vascularitation


Muller’s Classification

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apley’s system of orthopaedic and fractures. 8th edition. New York: Oxford University

Press Inc; 2001.

PROXIMAL

DISTAL

MECHANISM OF INJURY

Indirect • Low energy• Spiral or long oblique• Bone fragment may pierce the

skin from within

Direct • High energy• Crushes or splits the skin• Usual open


Press Inc; 2001.

Gustilo and Anderson Classification for open fracture

Type Wound Level of contamination Soft tissue injury Bone injury

I < 1 cm long

Clean Minimal Simple, minimal comminution

II > 1 cm long

Moderate Moderate, some muscle damage

Moderate comminution

IIIA Usually > 10 cm

High Severe with crushing Usually comminuted; soft tissue coverage of bone possible

IIIB Usually > 10 cm

High Very severe loss of coverage; usually require soft tissue reconstruction surgery

Bone coverage poor; variable may be moderate to severe comminution

IIIC Usually > 10 cm

High Vascular injury requiring repair

Kenneth Koval, et al. Handbook of fractures third edition. 2006. Lippincott Williams and wilkins. USA

TYPES OF TIBIA AND FIBULA SHAFT FRACTURES

Thompson, Jon C. Netter Concise Orthopaedic Anatomy 2nd Ed. China : Saunders. 2010.

Clinical features Soft tissue damage :

bruise severe swelling crushing or tenting of skin open wound circulatory changes weak or absent pulses diminution or loss of sensation and ability to move the

toes Deformity Alert for impending compartment syndrome


Press Inc; 2001.

Diagnosis

History Taking : History of illness, Mechanism of trauma

Physical examination: LOOK, FEEL, MOVE (examine the good limb the

bad limb) X- ray, with rule of ‘2’:

2 view, 2 limb, 2 joint, 2 occasion, 2 injuries Laboratory examination

Goals of fracture management

• Fracture site, types of fractureRecognize

• For adequate apposition and normal alignment of boneReduction

• Immobilize promote soft tissue healingRetention

• As early as possible by active and passive exercise (restore function)

Rehabilitation

Management

Low energy fracture

Non operative: CastingSplint

Bracing

Operative : Intramedullary nailing

Plates fixation External fixation


Press Inc; 2001.

High energy fracture

- Transverse fracture : surgical- Comminuted & segmental fracture : surgical

stabilization- Open fracture : external fixation

- Closed fracture : external fixation & closed nailing

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apley’s system of orthopaedic and fractures. 8th edition. New York: Oxford University Press Inc; 2001.

Complication

Early complications Compartment syndrome Vascular injury Infection

Late complications Malunion Delayed union Non union Joint stiffness

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apley’s system of orthopaedic and fractures. 8th edition. New York: Oxford University Press Inc; 2001.

THANK YOU

Fr.tibia Dan Fibula_irham

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