CASE REPORT

Submitted To Fulfill The task And Complete One Of The requirements In Taking

The Professional Medical Education Program in the Department of Surgery

at RSUD Soewondo Kendal Hospital

Open Fracture 1/3 Distal Os Tibia And Fibula Sinistra

Arranged by :

Farizka Dwinda Hidayat

30101206623

Advisor :

dr. Wisnu Murti, Sp.OT

MEDICAL FACULTY OF

SULTAN AGUNG ISLAMIC UNIVERSITY

SEMARANG

2019

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 ATTESTATION PAGE

Name : Farizka Dwinda Hidayat

NIM : 30101206623

Faculty : Medical

University : Sultan Agung Islamic University (UNISSULA)

Level : Doctor Professional Education Program

Section : Surgery

Title : Open Fracture 1/3 Distal Os Tibia And Fibula Sinistra

Kendal, October 2019

Know and agree

Clinical Registrar Advisor

Department of Surgery Hospital Dr. H. Sooewondo Kendal

Advisor,

dr. Wisnu Murti, Sp.OT.

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 CHAPTER I

INTRODUCTION

Fractures on the shaft (stem) of the tibia and fibula are often called cruris
fractures which often occur compared to fractures in other long bones and are
often found in orthopedic cases. The tibia and fibula are two long calf bones.
These fractures often occur due to injuries related to sports or motor vehicle
accidents. Most tibia and fibula fractures heal without complications, and patients
can resume their normal activities.

Of these two bones, the tibia is the only bone that holds weight. Tibial
fractures are commonly associated with fibula fractures, because the force is
transmitted along the interosseous membrane to the fibula. The periosteum lining
the tibia is rather thin, especially the path of the front area which is covered only
by the skin so that the bone is easily broken and the fracture fragments usually
shift because it is directly under the skin so that most of the fractures in the lower
limbs open more frequently. Even in closed fractures, soft tissue can be disrupted.

Open fractures of the lower limbs are the main cause of morbidity due to
the high tendency for the development of osteomyelitis and inadequate bone
healing. Besides causing morbidity, lower limb fractures can cause compartment
syndrome.

Fractures are not just a matter of dissolving bone continuity and how to
solve it, but must be reviewed as a whole and must be dealt with simultaneously.
To see what happened as a whole, how, the types of causes, if there is damage to
the skin, blood vessels, nerves and to find out the location of the event, the time of
occurrence to take action can produce something optimal.

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 CHAPTER II

CONTENT REVIEW

I. ANATOMY
A. Tibia

The tibia (shin bone) is the medial bone of the leg and is larger than the
fibula, with which it is paired. The tibia is the main weight-bearing bone of the
lower leg and the second longest bone of the body, after the femur. The medial
side of the tibia is located immediately under the skin, allowing it to be easily
palpated down the entire length of the medial leg.

The proximal end of the tibia is greatly expanded. The two sides of this
expansion form the medial condyle of the tibia and the lateral condyle of the tibia.
The tibia does not have epicondyles. The top surface of each condyle is smooth
and attened. These areas articulate with the medial and lateral condyles of the
femur to form the knee joint. Between the articulating surfaces of the tibial
condyles is the intercondylar eminence, an irregular, elevated area that serves as
the inferior attachment point for two supporting ligaments of the knee.

The tibial tuberosity is an elevated area on the anterior side of the tibia,
near its proximal end. It is the final site of attachment for the muscle tendon
associated with the patella. More inferiorly, the shaft of the tibia becomes
triangular in shape. The anterior apex of this triangle forms the anterior border of
the tibia, which begins at the tibial tuberosity and runs inferiorly along the length
of the tibia. Both the anterior border and the medial side of the triangular shaft are
located immediately under the skin and can be easily palpated along the entire
length of the tibia. A small ridge running down the lateral side of the tibial shaft is
the interosseous border of the tibia. This is for the attachment of the interosseous
membrane of the leg, the sheet of dense connective tissue that unites the tibia and
fibula bones. Located on the posterior side of the tibia is the soleal line, a
diagonally running, roughened ridge that begins below the base of the lateral
condyle, and runs down and medially across the proximal third of the posterior
tibia. Muscles of the posterior leg attach to this line. The large expansion found on

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the medial side of the distal tibia is the medial malleolus. This forms the large
bony bump found on the medial side of the ankle region. Both the smooth surface
on the inside of the medial malleolus and the smooth area at the distal end of the
tibia articulate with the talus bone of the foot as part of the ankle joint. On the
lateral side of the distal tibia is a wide groove called the fibular notch.

This area articulates with the distal end of the fibula, forming the distal
tibiofibular joint.

B. Fibula

The fibula is the slender bone located on the lateral side of the leg. The
fibula does not bear weight. It serves primarily for muscle attachments and thus is
largely surrounded by muscles. Only the proximal and distal ends of the fibula can
be palpated. The head of the fibula is the small, knob-like, proximal end of the
fibula. It articulates with the inferior aspect of the lateral tibial condyle, forming
the proximal tibiofibular joint. The thin shaft of the fibula has the interosseous
border of the fibula, a narrow ridge running down its medial side for the
attachment of the interosseous membrane that spans the fibula and tibia. The distal

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 end of the fibula forms the lateral malleolus, which forms the easily palpated bony
bump on the lateral side of the ankle. The deep (medial) side of the lateral
malleolus articulates with the talus bone of the foot as part of the ankle joint. The
distal fibula also articulates with the fibular notch of the tibia.

The anteromedial aspect of the tibia is subcutaneous, without protecting th

e muscular. The vascularization of the tibia and fibula originates from the posterio
r tibial artery which enters the distal posterolateral cortex to the origo musculus so
leus in the oblique line of the tibia. After entering the intramedular canal this arter
y provides 3 ascending branches and 1 descending branch. These branches lead to
endosteal vascular anastomosis with periosteal veins from the anterior tibial artery
. The anterior tibial artery ruptures easily when a fracture occurs because it passes
through the interosseous membrane hiatus. The peroneal artery (fibularis artery) h
as an anterior communicating branch into the dorsalis pedis artery. Fibula is respo
nsible for supporting the body by 6% -17%. The peroneus communis nerve goes a
round the head of the fibula which is close to the subcutaneous area, so it is easily
affected when there is a blow or traction in this area.

II. FRACTURE
A. Definition
A fracture is an integrity breaks of bones, usually due to trauma. Fractures
were classified according to the type and direction of the fracture line.
B. Classification of fractures:
According to Hardiyani (1998), the fracture can be classified as follows:
1. Based on its location (fractures of the humerus, tibia, clavicula, and cruris etc.).
2. Based on the extension and the fracture line consists of:
 complete fractures (broken lines through the entire cross-section through
bothcortical bone or bone).
 Incomplete fractures (when the broken line is not through the entire line
of bone cross section)
3. Based on the shape and the number of broken lines:
 Comminuted fractures (broken line is more than one and interconnected).

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  Segmental fracture (fracture lines more than one but not related).
 Multiple fracture (fracture lines more than one but at different bone place,
forexample a fracture of the humerus, femur fractures and so on).
4. Based on the position of fragments:
 Undisplaced (not shifted) / complete fracture line but the second fragment
isnot shifted.
 Displaced (shift) / shift fracture fragments
5. Based on the relationship with the outside world:
 Closed
 Open (presence of skin injury).
6. Based on the shape of the fracture line and relations with the mechanism of
trauma:
 Transverse fracture lines.
 Oblique / slant.
 Spiral / encircling bone.
 Compression
 Avulsion / trauma pull or muscle insertion at insertion
7. Based on the position of the bones:
 Absence of dislocation.
 Presence of dislocation
 At axim : forming an angle.
 At lotus : distracted bone fragment
 At longitudinal : longitudinally distracted bone fragment.
 At lotus cum contractionum : distracted and shortened.

C. Classification Of Tibial And Fibular Fractures

Classification of tibial and fibular fractures based on The Orthopedic Trauma

Association (OTA)

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D. Open Fracture Classification

Open fracture classification according to Gustilo Anderson

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Gustilo Classification for Open Fractures
Grade I:
 Wound less than 1 cm with minimal soft tissue injury;
 Wound bed is clean;
 Bone injury is simple with minimal comminution;
 With intramedullary nailing, average time to union is 21–28 weeks
Grade II:
• Wound is greater than 1 cm with moderate soft tissue injury;
• Wound bed is moderately contaminated;
• Fracture contains moderate comminution;
• With intramedullary nailing, average time to union is 26–28 weeks
Grade III: The following fracture types automatically results in classification as
type III:
• Segmental fracture with displacement
• Fracture with diaphyseal segmental loss;
• Fracture with associated vascular injury requiring repair;
• Farmyard injuries or highly contaminated wounds;
• High velocity gun shot wound;
• Fracture caused by crushing force from fast moving vehicle;
Grade IIIA fracture:
• Wound less than 10 cm with crushed tissue and contamination;
• Soft tissue coverage of bone is usually possible;
• With intramedullary nailing, average time to union is 30–35 weeks;
Grade IIIB fracture:
• Wound greater than 10 cm with crushed tissue and contamination;
• Soft tissue is inadequate and requires regional or free flap;
• With intramedullary nailing, average time to union is 30–35 weeks;
Grade IIIC fracture:
• Fracture in which there is a major vascular injury requiring repair for limb
salvage;
• In some cases it will be necessary to consider BKA following tibial
fracture

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III. Bone Healing Proccess

There are three primary stages of bone healing:

1. the early inflammatory stage
2. the repair stage
3. the late remodelling stageThese stages are distinct, but there is overlap.

1. Inflammatory Stage
A hematoma (localized blood collection) forms within the fracture site
during the first few hours and days. Inflammatory cells infiltrate the bone, which
results in the formation of granulation tissue (which is important inhealing and
repair), vascular tissue (for blood delivery to the new bone), and immature tissue
(which will specialize to form a bridge of tough connective tissue). This stage can
last 2 – 4 weeks after a fracture, and it overlaps with the next stage 2.
2. Repair Stage
This is the stage where the fracture gets ‘healed’that is, the bone ends
become joined and stabilized. The cells of the body that are capable of changing
into bone cells are activated or fired up to do so, and they start laying down new
bone tissue. This tissue, called fracture callus, is weak; and has to be protected.
The hardening of the cartilage begins at each end of the fracture and sweeps
toward the center. During this stage, the new blood vessels for the new growth are
also developed. But it’s during this stage that nicotine from smoking can really

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 slow down this blood vessel growth, which will impact, in a negativeway, how the
bone heals. - this stage can last 1 – 2 months after a fracture.

3. Remodelling Stage
This is the stage where the body changes the weak bone material into
strong bone material. Because this new material is so strong, the bod ydoes not
need a lot of it, and it will remodel the fracture callus down to normalsized bone.
The bone should be restored to its original shape, structure, andmechanical
strength. Remodelling of the bone occurs slowly over months to yearsand is
helped along by mechanical stress (i.e. weight bearing) placed on the bone.

IV. Cause Of The Fracture

The cause of fracture is generally caused by a blow direct, sudden circular
movements, contractions extreme muscles. The tibia fibula fracture is most often
caused by tibial displacement of the lateral condilius caused by a blow which
bends the knee joint and tears the medial ligament these joints.
The causes of fracture are:
a. Direct trauma
Fractures caused by direct impact on bone tissue such as in traffic accidents,
falls from height, and collision of hard objects by direct force.
b. Indirect trauma (indirect)
Fractures that are not caused by direct impact, but rather caused by an
excessive burden on bone tissue or muscle, for example as in sportsman or
gymnast using only one hand to support the weight of his body.

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 c. Pathological trauma
Fractures caused by disease processes such as osteomyelitis, osteosarcoma,
osteomalacia, cushing syndrome, cortisone / ACTH complications,
osteogenesis imperfecta (congenital disorders that are affect the formation
of osteoblasts). Occur because of structure weak and easily broken bones.
 Osteoporosis occurs because the speed of bone reabsorption exceeds the
speed of bone formation, so the bone is consequently become porous and
brittle and can experience fractures.
 Osteomillitis is an infection of the bone and bone marrow caused by
pyogenic bacteria from which microorganisms originate from focusing
elsewhere and circulating through the blood circulation.
 Ostheoarthritis is caused by damaged or thinning of the bearing joints
and cartilage.
V. Mechanism Of Fracture
Direct trauma and indirect trauma and pathological conditions in the bone
can cause bone fractures. A fracture is a bone discontinuity or bone separation.
Separation of bone into several bone fragments causes changes in the tissue
around the fracture including laceration of the skin due to the injury of the bone
fragments, this injury to the skin tissue raises nursing problems in the form of
damage to skin integrity. Skin injury by bone fragments can cause venous and
arterial blood vessels in the area of fracture to break up, causing bleeding. Venous
and arterial bleeding that lasts for a period of time and is long enough to cause a
decrease in blood volume and fluid flowing in the blood vessels so that
complications will appear in the form of hypovolemic shock if the bleeding is not
immediately stopped.
Changes in the surrounding tissue due to bone fragments can cause
deformity in the fracture area due to the movement of the bone fragment itself.
Deformity in the extremity area or other body parts causes a person to have
limitations to move due to changes and malfunction in the area of the deformity so
that nursing problems arise in the form of physical mobility disorders. Shifting
bone fragments itself raises nursing problems in the form of pain.

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 Some time after the fracture occurs, the muscles in the fracture area will
perform a protective mechanism in the area of the fracture by doing muscle
spasm. Muscle spasm is a natural splint that prevents the shifting of bone
fragments to a more severe level. Muscle spasm causes an increase in capillary
blood pressure and stimulates the body to release histamine which can increase
the permeability of blood vessels so that intravascular fluid transfer to the
interstitial appears. The transfer of intravascular fluid to the interstitial also carries
the plasma protein. The transfer of intravascular fluid to the interstitial which lasts
for some time will cause edema in the surrounding or interstitial tissue due to the
accumulation of fluid causing compression or pressure on the surrounding blood
vessels and perfusion around the tissue decreases. Decreased tissue perfusion due
to edema raises nursing problems in the form of tissue perfusion disorders.
Problems with tissue perfusion can also be caused by damage to bone
fragments themselves. Bone discontinuity which is damage to bone fragments
increases bone system pressure that exceeds capillary pressure and the body
releases catecholamines as a stress compensation mechanism. Catecholamines
play a role in mobilizing fatty acids in blood vessels so that they combine with
platelets and form emboli in blood vessels so that they clog arteries and interfere
with tissue perfusion.
VI. Clinical Presentatition
1. History
A complete medical history is obtained, including prior fractures
ororthopedic surgery, medical conditions (especially any underlying bone
disease,neoplasia, arthritis), medications taken, allergies, and occupation. A
descriptionof the mechanism of injury, including the magnitude, location
and direction ofimpact, is helpful. The individual may report recent trauma,
such as a motorvehicle accident, a sports injury, or a severe fall. The
individual may also reportsevere pain, inability to bear weight on the leg,
and changes insensation. Walking may be possible if only the fibula is
fractured.
In the case of stress fractures, the individual may report recent
changes in physical activity level, athletic training intensity, or training

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 surfaces. Pain mayworsen with weight-bearing activity and decrease with
rest.
2. Physical
Visual examination
All clothing should be removed from the extremity.The overall
appearance of the extremity should be noted for open
wounds,alignment, contusions, swelling, and color. Wounds should be
assessed for size,location, degree of contamination, and severity of
tissue injury.
 Deformities
Often a significant deformity is present at the level of thefracture.
Contusions may indicate the point where a force was applied to theleg
to create the fracture, or they may be incidental. The location of
asignificant contusion is important because it can necessitate a change
in thetreatment plan to avoid incising through badly traumatized tissue.
 Comparison to the contralateral leg
Comparison of the injured leg to thecontralateral leg usually
reveals a large amount of swelling. This swelling progresses with time.
The amount of swelling present should serve as a preliminary index of
the severity of injury to the tissues.
 Color
The color of the extremity reveals essential information about a
limb’s perfusion. A pinkish color indicates oxygenated blood in the
capillaries of the skin but reveals little about th deep circulation. A gray
ordusky color, however, indicates circulatory compromise and a
potential for limb loss if proper treatment is not provided promptly.
 Movement
After visually inspecting the leg, the physician should observe what
the patient can do with the leg before the physician palpates or
manipulates it. Attention should be directed at flexion and extension of
the knee, ankle, and toes. Occasionally, the patient is too uncomfortable
to comply with this part of the examination.

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 Palpation
 Pulses
An effort should be made to feel for pulses of the popliteal,
dorsalis pedis, and posterior tibial arteries. If strong pulses are not
appreciated, Doppler ultrasound should be used to evaluate the
dorsalis pedis and posterior tibial arteries. If triphasic pulses are not
present on Dopplerultrasound and the leg is deformed, traction should
be applied to the extremity and the pulses reevaluated. If the pulses
remain abnormal,emergent arteriography and/or consultation with a
vascular surgeon should be obtained.

 Direct palpation
Occasionally, the injured leg appears fairly normal, andthe results
of the neurovascular exam are unremarkable. Direct palpation ofthe
fracture, however, elicits pain and possible crepitation, which are
indicative of a tibial shaft fracture.
Compartment syndrome
After ruling out vascular injury, the physician mustevaluate for
compartment syndrome. If the patient can actively flex and extendthe ankle and
toes without severe pain, compartment syndrome is not likely to be present at that
time. Compartment syndrome can, however, evolve with time; this serial
examination and attention to the patient’s symptoms are necessary.
Open fractures
It must be assumed that open wounds in the vicinity of a tibial shaft
fracture communicate with the fracture, and urgent irrigation and debridement
should be planned. Open wounds a distance away from the fracture may
communicate with the fracture. Probing or inspection of extremity wounds for
communication with the fracture should be performed in the operating room after
sterile preparation and draping of the extremity.

VII. Supporting Examination

Plain x-rays will usually establish the diagnosis of a tibia and/or fibula
fracture. X-rays of the knee or ankle may also be needed, depending on the

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 location of the fracture. CTscan and MRI are rarely needed, unless the fracture
extends into the knee joint. Because plain film radiographs usually do not show
stress fractures until 2 to 8 weeks after the fracture has occurred, a bone scan is
sometimes used to detect a stress fracture in the earliest stages. A triple phase
nuclear medicine bone scan is often used to confirm the diagnosis. An arteriogram
may be done if there is a problem with blood circulation (vascular compromise) is
suspected. A complete blood count (CBC), blood typing, coagulation profiles,
and electrocardiogram (ECG) are part of routine preparation for surgery. The
necessity of other laboratory studies depends on the extent of injury and comorbid
conditions.

VIII. Management
 Prehospital Care
 Address airway, breathing, and circulation.
 Check and document neurovascular status.
 Apply sterile dressing to open wounds.
 Apply gentle traction to reduce gross deformities; splint the extremity.
 Emergency Department
Care Parenteral analgesia should be administered when appropriate.
Although management of pain has improved, pain due to long bone fractures is
notably undertreated in the emergency department. Inpatient admission may be
advised to observe development of compartment syndrome. Continuous
compartment pressure monitoring in asymptomatic patients with
tibia fractures is not recommended. Open fractures must be diagnosed and treated
appropriately. Tetanus vaccination should be updated, and appropriate antibiotics
should be given in a timely manner. Some recommend antibiotics within 3 hours
of the accident. This should involve anti staphylococcal coverage and
consideration of an aminoglycoside for more severe wounds. Orthopedics should
be consulted for emergent debridement and wound care. Fractures with tissue at
risk for opening should be protected to prevent further morbidity. Open fractures
require debridement and irrigation in the operating room. According to one study,
delay of the first operative procedure beyond the day of admission appears to be
associated with a significantly increased probability of amputation in patients with

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open tibia fracture. In this study, data were analyzed from the Nationwide
Inpatient Sample, 2003 to 2009.
Definitive Treatments for Tibia and Fibula Shaft Fracture
The aims of the therapy of tibial shaft fractures are :
1. reach full weight bearing fast
2. reach solid bony union and avoid pseudarthrosis
3. regain full range of motion of the knee and ankle joint
4. avoiding infections and further soft tissue damage
Open fractures with precarious blood supply and weak soft tissue covering
are vulnerable to complications and remain a challenge for every treating surgeon.
Reconstruction of axis, length and rotation is essential for a good outcome.
In particular axial deviation should be avoided to prevent secondary
osteoarthritis of the knee and ankle. The choice of technique depends on fracture
localization, type of fracture, history of concomitant disorders and soft tissue
damage
 Conservative management
 Casting
Initially, all tibial shaft fractures should be stabilized with a long
posterior splint with the knee in 10-15° of flexion and the ankle flexed at
90°. Admission to the hospital may also be necessary to control pain and
to monitor closely for compartment syndrome.
Closed fractures with minimal displacement or stable reduction
may be treated non operatively with a long leg cast, but cast application
should be delayed or 3-5 days to allow early swelling to diminish. The cast
should extend from the mid thigh to the metatarsal heads, with the ankle at
90° of flexion and the knee extended. The cast increases tibial stability and
can decrease pain and swelling.
Early ambulation with weight-bearing as tolerated should be
encouraged. Tibial shaft fractures treated with casting must be monitored
closely with frequent radiographs to ensure that the fracture has
maintained adequate alignment. Adequate callus formation generally takes
6-8 weeks before cast therapy can be discontinued.

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 Despite proper casting techniques and adequate follow-up, not all
non operatively treated tibial shaft fractures heal successfully. In addition,
6 week swith out knee motion often results in a stiff joint. In fact, Kyro et
al found that 53%of patients reported a fair or poor result using long leg
casts to treat tibial shaft fractures. This and many other studies have shown
that simply putting a tibial fracture in a long leg cast may lead to increased
joint stiffness, some difficulty ambulating, and increased union times.
Another type of cast, the patellar tendon bearing cast, was
proposed by Sarmiento for use early in treatment of tibial shaft fractures in
place of the long leg cast, and good results were reported. In general,
however, better results are reported with internal fixation of displaced
tibial shaft fractures than with non operative treatment. Hooper et al found
that the results of treatment of displaced tibial shaft fractures were not as
satisfactory as those with intramedullary nailing.
 Bracing
Three years after describing the patellar tendon-bearing cast,
Sarmiento proposed another treatment, the functional brace.
This device has replaced the long leg cast in many circumstances because
it can be put on within 2-4 weeks of injury. It allows more movement of
the knee and ankle while still protecting the tibial fracture. Movement of
the knee and ankle may decrease the stiffness that patients encounter after
the fracture is healed. However, the long leg cast is still used for the first
few weeks until the fracture begins to stabilize. As with the patellar cast,
Sarmiento found very good results with the functional brace; however,
others subsequently discovered problems, including a40% nonunion rate
in one trial. Although no definitive non operative treatment has been
determined for tibial fractures, many authors have noted increased
nonunion and healing time with casts and braces as compared with
surgical fixation. Therefore, casts and braces have limited use, especially
with displaced fractures. The ideal candidate for non operative treatment is
a young patient with a non displaced fracture.
 Operative management

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 Intramedullary nailing
Biomechanical stability and minimally invasive approach with
distance to the fracture are the major advantages of intramedullary nailing.
Evidence supports the use of intramedullary nailing in diaphyseal tibial
fractures as the implant of choice. There is also strong evidence that
intramedullary nails offer a benefit over external fixation in open fractures
if wound closure is performed soon. Intramedullary nailing is indicated for
open and closed isolated tibia shaft fractures and even extraarticular distal
tibial fractures. This includes oblique, transverse fractures, segmental
fractures, torsion fractures and debris fractures of the tibial shaft as well as
open fractures even with bone loss. Immediately intramedullary nailing is
not indicated for severe soft tissue injuries, multiple trauma patients,
thoracic trauma, infection, non-union or children with joint growth.
Intramedullary nailing is well established as a standard treatment
for diaphyseal fractures of the long bone despite the negative effects such
as endosteal necrosis and systematic fat embolism. The resulting
biological osteosynthesis conserves the fracture hematoma. Angular stable
locking screws facilitate the control of rotation, length and axis and
expand the indication for intramedullary nailing. There is considerable
controversy concerning intramedullary nailing. One key area is whether
intramedullary nails should be inserted with reaming or unreamed.
Another issue is whether intramedullary nails should be locked with
locking screws or not. Intramedullary reaming deposits the debris formed
by reaming at the fracture site, acting like an autologous bone graft and
also improves cortical contact with improved stability. In vitro studies
have shown that intramedullary reaming in combination with an irrigation
and aspiration system(Reamer/Irrigator/Aspirator (RIA), Synthes, West
Chester, Pennsylvania) and replantation of reaming’s into the bone void
improve the volume stiffness and strength of callus during the early phase
of healin. Unreamed nailing preserves endostal blood supply with quicker
healing and lower incidence of infection. Blood supply and soft tissue
covering are the major problems in tibial shaft fractures while fat

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embolism is more relevant in femur fractures. Trauma to endosteal blood
supply has shown to be responsible for the negative effects of
intramedullary reaming. For this reason unreamed intramedullary nailing
has experienced widespread clinical application in open and closed tibial
shaft fractures. Court-Brown et al. pointed out that reamed nailing is
associated with a significantly lower time to union and a reduced
requirement for a further operation. They recommended not to use
unreamed nailing in the treatment of the common Tscherne C1 tibial
fracture with a spiral wedge. Coles et al. presented superior results
obtained by reaming with less delayed union, non-union, mal-union and
Distal tibial shaft fracture, Typ 43 A2.2 with primary intramedullary
nailing and 6 months postoperative of a 33-year-old male patient. screw
break agein a review of prospective literature on closed tibial shaft
fractures . Their finding swere supported by Forster et al. Lam et al. also
described a beneficial effect of reaming in closed tibial shaft fractures,
which was not reflected in open tibial shaft fractures. They concluded that
reaming on the one hand disrupts the blood flow to the cortex but on the
other hand induces a six fold increase in periosteal blood flow.
This reaction does not occur in open fractures with frequent
severe periosteal damage possibly contributing to the lack of benefit in
open fractures. A recent Cochrane review published by Duan X et al
outlined that there is no clear difference in the rate of major re-operations
and complications between reamed or unreamed nailing. Low quality
evidence could be found that reamed nailing reduces the incidence of
major reoperations related to non- union in closed fractures rather than in
open fractures. In conclusion reaming acts like an osteogenic debris
similar to an autologous bone graft. Improved union rates following
reaming have been described in closed tibial shaft fractures while
the benefit in open fractures has not yet been proven. Recently Fuchs et
al. published their first short term results using a gentamicin coated
intramedullary nail and demonstrated the possible use in open and closed
fractures as the gentamicin coated intramedullary nail was associated with

20
 the absence of deep wound infections, good-fracture healing and an
increasing weight bearing capacity after six months. Certainly further
studies monitoring longer terms of follow up and larger patient cohorts are
required.
 Plate osteosynthesis
Conventional plate osteosynthesis used to be the method of choice
for tibial shaft fractures without soft tissue injury until recently being
replaced by intramedullary nailing with locking screws. Former
developments in plate osteosynthesis led to a surgical technique that
attempted to adapt every fragment exactly to anatomy. Such traumatic
surgical techniques led to denudation of these fragments, whilst wide
exposure of the fracture zone caused delayed healing, nonunion and a
tendency towards infection. Subsequently the concept of bridging plate
and biological osteosynthesis where implemented with the use of angular
locking screws. These developments allowed careful surgical techniques
with the prevention of soft tissue damage. Nevertheless indication for
plate osteosynthesis in tibial shaft fractures is rare. In current literature
indication for plate osteosynthesis can be found in fractures close to
metaphysis, intraarticular components, segmental tibial fractures or growth
joint. Plate osteosynthesis is contraindicated in open fractures or patients
with former injuries to their lower limb or vessel diseases. If fractures
cannot be treated by intramedullary nailing there is evidence that internal
plate fixation is superior to external fixation.
 External fixator
Before implementation of intramedullary nailing with locking
screws, external fixation was the most common surgical treatment for open
fractures of the tibial shaft. A minimally invasive approach and
implantation with distance to the fracture side, as well as biological osteo -
synthesis and improvements in vacuum wound closure and plastic surgery,
extended the field to intramedullary nailing. Even type IIIb open fractures
can nowadays be treated by primarily intramedullary nailing. External
fixation is indicated as primary stabilization for multiple trauma patients,

21
 severe soft tissue injury close to the joints or generally inoperable patients.
There are no contraindications for external fixation in tibial shaft fractures.
For the treatment of multiple trauma patients following the damage control
principle, the initial external fixation is the method of choice. Further
patients at risk are those suffering thoracic trauma, craniocervical injury,
hypothermia or coagulopathy. If procedural change can be performed
within 5– 10days there is no increase in the rate of infection. Primary
external fixation is also often useful in severe soft tissue injuries without
any fractures and provides immobilization. External fixators are still used
for the definitive treatment of juvenile tibia shaft fractures.
 Postoperative Care
After the surgical procedure, the patient should be monitored in the post
anesthesia care unit until stable. Depending on the extent of the other injuries, the
patient may be transferred to the surgical intensive care unit or to a regular ward
bed. Initially, the patient's vital signs should be monitored repeatedly, with careful
attention paid to any abnormalities. If a complication occurs, early discovery
almost always improves the prognosis.
On the postoperative day 1, the patient should be examined by the surgical
team, and a complete blood count should be obtained. Once the patient has
recovered from surgery and is considered safe to leave the hospital, he or she
should be discharged home or to a suitable rehabilitation facility.
 Medication
As with all fractures, pain management should be a primary concern.
Often, acetaminophen or an NSAID is prescribed for the acute pain of a fracture.
However, additional pain relief may be necessary if the patient does not have
relief with acetaminophen or NSAIDs alone. In this case, an opiate may be
required, particularly for breakthrough pain. Adjustment of pain
medications may be necessary, especially in the acute phase.
 Analgesics
Pain control is essential to quality patient care. Analgesics ensure
patient comfort, promote pulmonary toilet, and have sedating properties,
which are beneficial for patients who have sustained injuries.

22
 Acetaminophen (Tylenol, Feverall, Tempera, Aspirin-Free Anacin,
Tylenol-3) Indicated for mild to moderate pain. DOC for pain in patients
with documented hypersensitivity to aspirin or NSAIDs, with upper GI
disease, or who are taking oral anticoagulants.
 Ibuprofen (Motrin, Ibuprin) DOC for patients with mild to
moderate pain. Inhibits inflammatory reactions and pain by
decreasing prostaglandin synthesis.
 Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR,
Tylox, Roxiprin) Analgesic with multiple actions similar to those
of morphine; may produce less constipation, smooth muscle spasm,
and depression of cough reflex than similar analgesic doses of
morphine
 Antibiotics
Various antimicrobial substances have been shown to be effective
in perioperative prophylaxis. The drug should be active against the most
common infecting agents in volvedin implant-associated infection. This
spectrum of germs is well known; however, the susceptibility of these
microorganisms may differ in various hospitals. Therefore, each hospital
needs its up-to-date analysis of the resistance pattern of surgical site
isolates. Another prerequisite for the use of a drug in antimicrobial
prophylaxis is that its risk of causing toxic or allergic reactions is minimal.
Antimicrobial substances with a high potency to produce resistant strains
should be avoided, for example, strong β-lactamase inducers like cefoxitin
or ceftazidime. If two drugs have similar efficacy, cost should also be
considered in the choice of prophylaxis. In fracture surgery, first-
generation or second-generation cephalosporins suchas cefazolin,
cefamandole, or cefuroxime, are a rational choice. If the patient is allergic
to cephalosporins, or in settings with high prevalence of methicillin-
resistant Staphylococcus aureus (MRSA), vancomycin or teicoplanin are
alternative options.

23
 CHAPTER III

PATIENT STATUS

I. IDENTITY
 Name : Miss. Dwi Herawati
 Age : 14 years old
 Gender : Female
 Religion : Moslem
 Come to Hospital : September 15, 2019
 Room : Kenanga 3
 No CM : 587470
 Address : Turunrejo
II. ANAMNESIS
Autoanamnesis with the patient held on September 17 , 2017 in Kenanga room
and also supported by medical records.

Primary Survey :
 Airway: patent, clear
 Breathing: Adequate breathing (respiration rate: 24x/minutes)
 Circulation: Adequate circulation (HR: 110x/minutes)
 Dissability: Alert, GCS 15, pupil refleks +/+ isokor
 Exposure: Wound and deformity on left lower extremity

Main complaints :
Pain in the lower left leg

Present Status :
Patients come to the emergency room of RSUD dr. H. Soewondo Kendal on
Monday, September 15, 2019 at 17.19 WIB with complaints of pain in the left
leg after falling from a motorcycle on that day.

24
 Medical condition history:
a. History of drug allergy: denied
b. History of asthma: denied
c. History of Heart Disease: denied
d. History of injuries : denied
e. History of Operation : denied

Family Medical History

a. History of injuries: denied
b. History of drug allergy: denied
c. History of asthma: denied
d. History of Heart Disease: denied
e. History of Operation : denied

Socioeconomic status:
NON BPJS Patients

III. Physical Examination

a. General Condition : Fussy
b. Awareness: Composmentis
c. GCS E4V5M6 (15)
d. Vital Signs :
 Heart rate : 110 x / minute, regular
 Temperature : 36oC
 Breathing : 24 x / minute

IV. Physical Assessment

a. Head : mesochepal, wound (+)
b. Eyes : anemic conjunctiva (- / -), jaundice sclera (- / -), isochoric pupils
Ø
2 mm / 2 mm, light reflexes (+ / +)
c. Ear : normal form, tragus tenderness (- / -), auricular pull pain (- / -),
otorhea (- / -)
d. Nose : normal form, deviation of septum (-), deformity (-), Rhinorea (-)
e. Mouth : cyanosis (-), laceration (-),cyanosis (-)

25
f. Neck : symmetrical, pain (-),enlarged lymph nodes clear (-), anenlarged
thyroid gland (-)
g. Chest :
EXAMINATION RESULTS

Inspection normochest, symmetrical, retraction (-), injury (-),

RR: 22x / minute, ictus cordis (-)
Palpation pain (-), mass (-), symmetrical vocal vermitus (+),
crepitation (-), palpable ictus cordis (+)
Percussion Sonor (+)
Auscultation vesicular (+), Whezzing (-), Ronchi (-), regular I-II
heart sounds, gallops (-), murmurs (-)
Interpretation Normal

h. Abdomen :

EXAMINATION RESULTS

Inspection flat (+), symmetrical (+), matrix (-), striae (-), mass
(-), injury (-)
Auscultation bowel sounds (+) normal
Percussion timpani (+)
Palpation Supple (+), tenderness (-), loose pain (-), mass (-),
defance muscular (-)
Interpretation Normal

i. Extremities :

Superior Inferior
Oedema -/- -/+
Cold Extremity -/- -/-
Sianosis -/- -/-
CRT <2” <2”

26
 Distal Pulsation Radialis : + /+ Dorsalis pedis : + /+

ROM +/+ +/-

V. Localized Status
Lower left leg :
Look :
 Skin color : normal
 Edema : (+)
 Pale and wrinkled : (-)
 Wound : (+)
 Deformity : (+)
 Swelling : (+)
Feel :
 Skin temperature : normal
 Sensibility : (+)
 Crepitation : (+)
 Dorsalis pedis artery pulsation : (+)
Movement :
Dissability of ROM and pain of movement

VI. Laboratory Results

Examines Result Normal
Hb 11 .6 gr/dl 11.5-16.5 gr/dl
Leukocyte 18.700 cell/mm3 4.000-10.000
cell/mm3
Trombocyte 356.000 cell/mm3 150.000-400.000
cell/mm3
Hematokrit 33,6 % 35.0-49.0 %
PT 16.5 second 11.3-14.7 second
APTT 30.5 second 27.4 – 39.3 second

27
VII. Radiology
X- Ray Cruris sinistra (AP/Lateral)
 PRE ORIF

 POST ORIF

VIII. Diagnosis
Open Fracture 1/3 Distal Os Tibia And Fibula Sinistra

28
IX. Plans Of Therapy
Medical :
IGD
 Infus RL 20 tpm
 Inj. Cefazolin 2x1 gr
 Inj. Ceftriaxon 650 mg / 24 jam
 Inj. Ketorolac 1 amp / 8 jam
 Inj. Ranitidin 1 amp / 12 jam
 Inj. Tranexamate acid 500 mg
 Inj. ATS 1 amp
 Hecting Situation

Post Operative
 Infus RL 20 tpm
 Inj. Cefazolin 2x1 gr
 Inj. Hypobac 2x100 (1 day)
 Inj. Dexketoprofen 2x50 mg
 Inj. Ranitidine 3x50 mg
 Inj. Carbazokrom 2x25 mg
 PO : Levofloxacine 2x500 mg
 Meloxicam 2x15 mg
 Kalk 1x1
Non-Medical :
Conservative :
 Vital Sign evaluation
Operative :
 Consult to orthopedic
 Open Reduction and Internal Fixation
Post Operative :
 Treat injury (day 2)
 ROM Exercise

29
 CHAPTER IV

DISCUSSION

The diagnosis is open fracture os tibia et fibula sinistra 1/3 distal in the
patient is made from the history that the patient complains of pain in the left leg
after falling off the motorcycle.

From the results of physical examination, we found abnormalities in the

left leg. Examination of local status in the lower left leg includes injuries (+),
edema (+), bleeding (+), deformity (+). Palpitations have pain (+), crepitation (+),
pulsation (+), sensibility (+). Movement ROM is limited.

The definitive diagnosis is open fracture os tibia et fibula sinistra 1/3

distal made based on the results of the x-ray cruris sinistra (AP-lateral). The
medical management of this case are Infusion of RL 20 tpm, Inj. Cefazolin 2x1 gr,
Inj. Ceftriaxon 650 mg / 24 hours, Inj. Ketorolac 1 amp / 8 hours, Inj. Ranitidine 1
amp / 12 hours.

Non-medical therapy consists of conservative therapy immobilizing as

first aid with spalk. Evaluate neurovascular disease to monitor for complications
of pain and fracture as well as vital signs. And operative therapy, can do internal
reduction in open fixation (ORIF).

30
 CHAPTER V

CONCLUSION

Lower limb fractures include tibia and fibula fractures. Of these two
bones, the tibia is the only bone that holds the weight. Tibial fractures are
commonly associated with fibula fractures, because they are forced along the
interosseous membrane into the fibula. Causes include direct forces such as those
used by falls and MVA (Motor Vehicle Accident) and indirect forces such as
rotations.

The National Center for Health Statistics (NCHS) reports an annual

incidence of 492,000 tibial and fibular fractures per year in the United States.
Patients with tibial fractures remain in hospital for a total of 569,000 days in the
hospital and experience 825,000 doctor visits per year in the United States.

The diagnosis of tibial shaft fractures is obtained by history taking,

physical examination, and radiographic examination. As with all fractures, pain
management must be a major concern.

Correct management of tibial fractures is an important thing that can

seriously affect the healing process. Because it is caused by a traumatic accident,
management includes management during prehospital, emergency department,
and definitive care itself. Routine follow-up is needed to prevent complications.

31
 CHAPTER VI
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