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Name
:B
Age
: 44 years old
Sex
: Male
Date of Admission :August 23rd, 2015 at
16.30
RM number
: 723290
HISTORY TAKING
Chief Complaint: Pain at right leg
Suffered since 22 hours before being admitted to
Wahidin General Hospital
Patient was riding a motorcycle when he fell down
due to loss of balance
Patients right leg first came into contact with the
ground.
Vomitting (-) nausea (-)
Prior treatment : Pangkep Hospital
PRIMARY SURVEY
Airway : Clear
Breathing: RR = 20x/min, regular, spontaneous,
thoracoabdominal type, symmetrical.
Circulation: BP = 120/70 mmHg,HR = 80 x/min regular,
strong.
Disability : GCS 15 (E4V5M6),isochoric pupil, : 2,5 mm,
light reflex +/+
Exposure : T = 36,70 C (axilla)
SECONDARY SURVEY
Localized status :
Right Leg region
Look:
CLINICAL FINDINGS
Left
ALL
86
87
TLL
82
83
LLD
1 cm
LABORATORY FINDINGS
WBC : 15.400/ ul
RBC : 5.000.000/ ul
HBG : 14.7 g/dl
HCT : 43 %
PLT
: 233.000/mm3
CT
: 730
BT
: 230
HBsAg
: Non reactive
AP View
Lateral View
DIAGNOSIS
Closed fracture 1/3 distal right tibia
Closed fracture 1/3 distal right fibula
MANAGEMENT
IVFD
RL
Analgesic
Report to Orthopaedic senior, advice:
Apply
Plan
RESUME
A Boy 44 years old came to the hospital with chief
complaint pain at the left leg, suffered since 22 hours
before admitted to Hospital.
At the anterolateral aspect, there is haematom and edema.The
region was tenderness on palpation, with unknown active and
passive motion of knee joint and ankle joint due to pain.
Sensibility is good and dorsalis pedis artery is palpable, CRT <2 .
laboratory findings are within normal limit,
From radiology finding (X-Ray cruris dextra AP/Lateral)
there is closed fracture 1/3 distal of right tibia and fibula.
Discussion
TIBIA AND
FIBULA
Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010.
TYPES OF FRACTURES
Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010.
Clinical features
Diagnosis
Anamnesis
Physical examination
Laboratory examination
Oedema
Hematoma
Grade I
Grade II
Grade III
TREATMENT
Conservative
Closed reduction
Apply long leg cast
Functional bracing with Early weight-bearing
Pain medication if needed
TREATMENT
Operative
Internal Fixation
External Fixation
DEFINITIVE TREATMENT
Open Reduction Internal Fixation
Indication of ORIF in this patient is :
ORIF Tibia
Acceptable fracture reduction is not indicated anymore in
this patient
ORIF Fibula
Theres fracture at 3 cm from syndesmosis at X-Ray
findings
Advantage
Adequate reduction
Early movement
Disadvantage
Increase risk of infection, skin problem
A high degree of surgical technique and facilities are
essential
COMPLICATIONS
Early complications
Late complication
Neurovascular injury
Compartment syndrome
Joint stiffness
infection