CLOSED FRACTURE 1/3 DISTAL LEFT TIBIA

CLOSED FRACTURE 1/3 DISTAL LEFT FIBULA

Presented By:
HELDA
c1110727
Advisors:
Dr. Hendra Hermanto
Dr. Aries Freddy Hutabarat
Supervisor:
Dr. M. Ruksal Saleh, PhD, SpOT(K)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2014

PATIENT IDENTITY
Name

: Mr.B

Age

: 23 years old / Male

Admission

: June 1st, 2014 at 10.00

Registration

: 665944

AUTOANAMNESIS
Chief Complain : pain at the left leg

Suffered since 2 weeks before admitted to Wahidin

General Hospital due to traffic accident.
Patient was crossing, the street and suddenly get hit
by a high-velocity motorcycle.
History of unconscious (+), vomit (-), nausea (-)
History of prior treatment at Kaimana Hospital, west
Papua.
No histrory of going to bonesetter (-)

GENERAL STATE

General Appearance :
Conscious/ Well Nourished
Vital sign
VAS

: 2/10

Blood pressure
Heart rate
Respiratory rate

: 120/80 mmHg
: 80x/min regular, strong
: 18x/min, spontaneous,
thoracoabdominal
: 36o C (axilla)

Temperature

LOCAL STATE
Left Leg Region
I : Excoriated wound at lateral left distal aspect
size 2x1cm. Deformity (+), minimal swelling
(+), hematoma (+)
P : Tenderness (+)
RoM :
Active and passive motion on knee and ankle joints

cannot be evaluated due to pain

NVD : Sensibility is good, pulsation of

dorsalis pedis artery was palpable, CRT < 2

Leg Length Discrepencies

Right

Left

ALL

97 cm

96 cm

TLL

88 cm

87 cm

LLD

1 cm

CLINICAL FINDING

LABORATORY FINDING

WBC 10.9 103/mm3

RBC 6.27 106/mm3
HGB 13.9 g/dL
HCT 42.7 %
PLT 253 103/mm3
HbsAg Reactive
BT 3
CT 8

RADIOLOGY FINDING

RESUME
Male,

23 years old came to Wahidin Hospital with

pain on the left leg suffered 2 weeks before admitted
due to traffic accident.
There is deformity (+) on the left leg with
excoriated wound at lateral distal aspect. Tenderness
(+). NVD is good. ROM cant be evaluated. The
LLD shows 1 cm.
Radiologic shows comminuted fracture 1/3 distal
of the left tibia and fibula.

DIAGNOSIS

Closed fracture 1/3 distal left tibia

Closed fracture 1/3 distal left fibula

MANAGEMENT

IVFD
Analgesic
Apply long leg back slab of the left lower limb
Plan for Operative treatment (Open reduction
internal fixation)

DISCUSSION

Anamnesis
Hit by a high-velocity motorcycle high
energy trauma
2 weeks already

Soft callus formation

Compartment syndrome risk

No history of bone setter treatment more

soft tissue damage

Physical Examination
Excoriated wound mild soft tissue injury
(Tscherne grade I)
Deformity

Anterior angulation
Shortening (LLD=1cm)

Tschernes Classification of skin

lesion in closed fractures
Grade 0

Injury from indirect forces with negligible soft tissue damage

Grade I

Closed fracture caused by low-moderate energy mechanisms, with

superficial abrasions or contusions of soft tissues overlying the
fracture

Grade II

Closed fracture with significant muscle contusion, with possible

deep, contaminated skin abrasions associated with moderate to
severe energy mechanisms and skeletal injury; high risk for
compartment syndrome

Grade III

Extensive crushing of soft tissues, with subcutaneous degloving or

avulsion, with arterial disruption or established compartment
syndrome

Koval, Kenneth J, Zuckerman, Joseph D. Tibia fibula shaft. In: Handbook of fractures. 3rd Edition. USA:
Lippincott Williams & Wilkins; 2006. p.470

Radiologic finding

Fracture pattern
Comminuted type unstable
Fibular fracture as level as tibial fracture high-energy trauma associated injury?

Lateral view
AP view
Cortical contact

: Anterior angulation = 5
: Lateral/valgus angulation = 3
: 0-25%

Management
Nonoperative
Acceptable Fracture Reduction
5 varus/valgus angulation
10 anterior/posterior angulation
10 degrees of rotational deformity
More than 50% cortical contact

Koval, Kenneth J, Zuckerman, Joseph D. Tibia fibula shaft. In: Handbook of fractures. 3rd Edition. USA:
Lippincott Williams & Wilkins; 2006.p.471

Management

Operative

Unstable fracture
Associated intra-articular and shaft fractures
Open fractures
Major bone loss
Neurovascular injury
Compartment syndrome

Management
Conservative

Operative

1cm LLD

Unstable
fracture

5
angulation
deformity

Active pts

Management

Conservative

Immobilization
( full-length cast)

Operative
ORIF
( Plate and screw,
Intramedullary
nailling)

Complications
Early complications
Neurovascular injury

Compartment
syndrome

Late complication
Malunion, delayed
union, non- union
Joint stiffness
Infection

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures
9th Edition. UK: Arnold. 2010.