Closed Fracture of Left Distal Tibia & Closed Fracture Distal Third of Left Fibula

Name Sherla Wijoyo (C 111 07 095) Mentors dr. Teuku Nanta Aulia dr. Erick Gamaliel Amba Supervisor dr. Muhammad Sakti Sp.OT
Orthopedic and Traumatology Department Hasanuddin University 2012

Patient Identity
NAME AGE REGISTRATION ADMISSION DATE : R (boy) : 7 years old : 527616 : January 3th, 2012

History Taking

Chief Complaint:

Pain at the left leg

Suffered since 3 hours before admitted to the Wahidin Sudirohusodo general hospital due to traffic accident.

Mechanism of Trauma : The patient was playing beside the street and got hit by motorcycle from his left side. History of unconsciousness (-), vomiting (-), nausea (-). History of prior treatment at Faisal Hospital.

(At 3th January,

Primary Survey
A B C
Patent, airway obstruction (-). RR = 20 x/min, regular, symmetric, spontaneous, thoracoabdominal breathing type. BP = 110/70 mmHg, PR = 82 x/min, regular, adequate. GCS = 15 (E4M6V5), pupil isochors 2,5/2,5mm, Light reflex +/+. Temperature = 36.50 C (axillaries)

D
E

(At 3th January,

Secondary Survey
(Region: Left Leg)
INSPECTION Deformity (+), swelling (+), hematoma (+), wound (-). PALPATION Tenderness (+) RANGE OF MOVEMENT (ROM) Active and passive movement of knee and ankle joints are limited due to pain. NEUROVASCULAR DISTAL (NVD) Sensibility is good, pulse of dorsalis pedis artery is palpable, capillary refill < 2

(At 3th January,

Secondary Survey
(Region: Left Leg)
Front Aspect

Side Aspect

(At 3th January,

Secondary Survey
(Region: Left Foot)
INSPECTION Abrasion lesion (vulnus excoriation) at medial aspect size 3 x 2 cm, deformity (-), swelling (-), hematoma (-). PALPATION Tenderness (+) RANGE OF MOVEMENT (ROM) active and passive movement of ankle joint is limited due to pain.

NEUROVASCULAR DISTAL (NVD) Sensibility is good, pulse of dorsalis pedis artery is palpable, capillary refill < 2

(At 3th January,

Secondary Survey
(Region: Left Foot)

Above Aspect Below Aspect

Lateral Aspect Medial Aspect

(At 3th January,

Leg Length Discrepancy

RIGHT ALL TLL 68 cm 65 cm LEFT 67 cm 64 cm

LLD

1 cm

(At 3th January,

Laboratory Findings

WBC RBC HGB HCT PLT CT BT HbSAg 16,82 x 103 /uL 4,61 x 106 /uL 13,6 g/dL 38,9 % 354 x 103 /uL 900 300 (-)
(At 3th January,

Radiologic Findings
(Right Cruris) (Left Cruris)

AP view

Lateral view

Lateral view

AP view

Radiologic Findings
(Left Pedis)

AP view

Oblique view

Diagnose
Closed fracture of the Left distal tibia Closed fracture distal third of the Left fibula Vulnus excoriation of the Left foot

Management
IVFD

Antibiotic
Analgesic Apply long leg back slab ORIF

Applied Long Leg Back Slab

Front Aspect

Side Aspect

(At 3th January,

Left Leg X-Ray Applied Long Leg Back Slab

AP view

Lateral view

Resume
A boy, 7 years old, came to Wahidin Sudirohusodo Hospital
with chief complaint is pain at the left leg. It suffered since 3 hours before admitted to the hospital due to traffic accident. On the left leg region: Deformity (+), swelling (+), hematoma (+), Tenderness (+), active and passive movement of knee and ankle joints are limited due to pain. Radiography showed fracture line in distal of tibia and fibula. On the left foot region: Abrasion lesion (vulnus excoriation) at medial aspect size 3 x 2 cm, tenderness (+), active and passive movement of ankle joint is limited due to pain. Radiologic findings is within normal limit.

Discussion

Tibia & Fibula Shaft Fracture

PEDIATRIC CASE

Epidemiology
Fractures of tibia shaft are the third most common in children (after femur and forearm)
Tibia shaft fractures are associated with fibula fractures in 30 percent of cases.

Of pediatric tibia fractures, 39% occur in the middle third.

Usually due to traffic accident & sports injury

Tibia fracture is commonly in long bone fracture cases.

1. Koval, K., Zuckerman, J. Tibia Fibula Shaft in Handbook of Fractures T 2. Tachdjians Pediatric Orthopardics

Mechanism of Injury
Mechanism of injury Direct trauma High-energy injuries Motor vehicle accident children and adolescents Indirect trauma

Energy of injury

Low energy injuries

Torsional (Fall and twisting) younger child

Examples

Common Age

1. Heinrich SD, Rockwood and Wilkins' Fractures in Children, 4

Anatomy

Netters concise orthopaedic anatom

Netters concise orthopaedic anatomy, P. 316

Netters concise orthopaedic anatomy, P. 317

Netters concise orthopaedic anatomy, P. 318

Netters concise orthopaedic anatomy, P. 319

Classification of Fracture
Clinical types:

open fracture / close fracture Etiology : traumatic fracture/ stress fracture/ pathologic fracture Configuration classification:

Netters concise orthopaedic anatomy, P

Diagnosis
Anamnesis Physical examination X- ray, with AP and lateral view Laboratory examination

Clinical features
Oedema Hematoma Tenderness at the fracture site. Decreased range of motion at

the ankle or knee, depending on the location of the fracture If fracture is displaced, a deformity may be noted

Appleys . Sistem Of orthopaedis & fracture,8th edition.

Treatment
(Conservative)
Closed reduction followed by a long leg cast

application with ankle slightly plantar flexed and the knee is flexed. Indication:
Closed fracture, Undisplaced fracture, Low-energy trauma.

Treatment
Acceptable Fracture Reduction: In children, acceptable reduction includes 50% apposition of the fracture ends, <1 cm of shortening, <5- to 10-degree angulations in the sagittal and coronal planes.

(Operative)

Treatment

Open reduction followed by Intramedullary (IM) Nailing, Plate

and screw, External fixation. Indication: Open fracture. Fractures in which a stable reduction is unable to be achieved or maintained. Associated vascular injury. Fractures associated with compartment syndrome. Severely comminuted fractures. Associated femoral fracture (floating knee). Fractures in patients with spasticity syndromes (cerebral palsy, head injury). Patients with bleeding diatheses (hemophilia). Patients with multisystem injuries Associated plafond fracture

Complication
Early complications
Vascular injury Nerve injury Compartment syndrome

Late complications
Infection Delayed union, or non union Joint stiffness

Prognosis
For diaphyseal fractures, union can be expected in

over 95 per cent of cases. Time to healing varies according to patient age: Neonates: 2 to 3 weeks Children: 4 to 6 weeks Adolescents: 8 to 12 weeks

THANK YOU

Differential between bone in child and adult

1. 2. 3. 4. 5. 6. 7.

8.
9. 10.

Fracture more common in child Thicker and more active periosteum More rapid fracture healing Special problems of diagnosis Spontaneous correction of certain residual deformities Differences in complications Different emphasis on methods of treatment Torn ligaments and dislocations less common Less tolerance of major blood loss Still has epiphysial plate

Signs of high-energy mechanism Segmental fracture Bone loss Compartment syndrome Crush mechanism Extensive degloving of subcutaneous fat and skin Requires flap coverage (any size defect)

The muscles in the anterior and the lateral compartments of the lower leg produce a valgus deformity in complete ipsilateral tibia and fibula fractures.

CAS T

EXTERNAL FIXTATION

IM NAILING
KIRSCHNER WIRE

PLATE & SCREWS

Conservative Method
Application of a long leg cast with progressive weight bearing can be used for closed, low-energy fractures with minimal displacement and comminution

Cast with the knee in 0 to 5 degrees of flexion to allow for weight bearing with crutches as soon as tolerated by patient, with advancement to full weight bearing by the second to fourth week.
After 4 to 6 weeks, the long leg cast may be exchanged for a patella-bearing cast or fracture brace.

Union rates as high as 97% are reported, although with delayed weight bearing related to delayed union or nonunion.

Operative
Intramedullary (IM) Nailing Preservation of periosteal blood supply and limited soft tissue damage Able to control alignment, translation, and rotation Plates and Screws Reserved for fractures extending into the metaphysis or epiphysis. Reported success rates as high as 97%. Complications are infection, wound breakdown, and malunion or nonunion increase with higher-energy injury patterns. External Fixation Primarily used to treat severe open fractures, it can also be indicated in closed fractures complicated by compartment syndrome, infection, concomitant head injury, or burns. Union rates: Up to 90%, with an average of 3.6 months to union.

Koval, Kenneth J, Zuckerman, Joseph D. Handbook of fractures. 3rd