Tibial plateau case

Identitas pasien
Nama: Bp. S
Umur: 47 tahun
Pekerjaan: buruh
Tgl masuk: 22 oktober 2014

anamnesis

Keluhan utama
Nyeri pada kaki kanan

Riwayat penyakit sekarang:

HMRS, pasien jatuh dari motor, terpental dan kaki
kanan terbentur trotoar. Pasien tidak mengingat jelas
kejadian. Nyeri dirasakan dikaki kanan, nyeri terutama
dirasakan jika digerakkan dan berkurang saat istirahat,
bengkak (+).
Saat kejadian pasien sadar, pasien dibawa ke rumah
sakit. Mual dan muntah disangkal, pusing dan nyeri
kepala disangkal.

Status Generalis
KU : CM, sedang (E4V5E6)
Vital Sign :
TD : 130/80
N : 83 kpm
RR

: 20 kpm

T : 36 oc

Emergency care
AIRWAY : clear
BREATHING : normal, RR 20 kpm
CIRCULATION : dbn
Debridement
Immobilisasi
Medikamentosa :
- Inj. ATS IM 250 IU
- Inj. Ceftriaxone 1g
- Inj. Ketorolac 30mg
- Inj. Ranitidine 25mg

Pemeriksaan fisik
Status lokalis regio cruris dextra
Look: terdapat vulnus laceratum ukuran 7 cm, keadaan
kotor, deformitas (+), edema (+).
Feel: NT (+), akral hangat, WPK <2 detik, pulsasi arteri
dorsalis pedis dan tibialis posterior (+), fungsi sensoris
dbn
Movement: fungsi motoris dbn.

Pemeriksaan penunjang
CBC
X-ray (regio cruris dextra) AP dan lateral
Albumin

Interprasi x-ray
Tampak dikontinuitas tulang kominutif pada tibial plateau
dextra.

Manajemen
Debridement + ORIF dengan plat.

Pembahasan

Open Fracture

Definition
An open fracture refers to osseous disruption in which a
break in the skin and underlying soft tissue
communicates directly with the fracture and its
hematoma

 Soft tissue injuries in an open fracture may have three

important consequences:
Contamination of the wound and fracture
Crushing, stripping, and devascularization that results in soft
tissue compromise and increased susceptibility to infection.
Destruction or loss of the soft tissue envelope may affect the
method of fracture immobilization

Clinical evaluation Initial

Management Patients with open fractures may have multiple injuries,
a rapid general assessment is the first step and any life
threatening conditions are addressed
Primary survey involve ABCDE : Airway, Breathing,
Circulation, Disability and Exposure.

Clinical Evaluation
Patient assessment involves ABCDE: airway, breathing,
circulation, disability, and exposure.
Initiate resuscitation and address life-threatening injuries.
Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
Identify all injuries to the extremities. Assess the neurovascular
status of injured limb(s).
Assess skin and soft tissue damage
Identify skeletal injury; obtain necessary radiographs.

Classification -Gustilo and Anderson-

Grade I: Clean skin opening of <1 cm, usually from inside to outside; minimal
muscle contusion; simple transverse or short oblique fractures
Grade II: Laceration >1 cm long, with extensive soft tissue damage; minimal to moderate
crushing component; simple transverse or short oblique fractures with minimal
comminution
Grade
Extensive soft tissue damage, including muscles, skin, and neurovascular
III:
structures; often a high-energy injury with a severe crushing component
IIIA:
Extensive soft tissue laceration, adequate bone coverage; segmental fractures,
gunshot injuries, minimal periosteal stripping
IIIB:
Extensive soft tissue injury with periosteal stripping and bone exposure requiring
soft tissue flap closure; usually associated with massive contamination
IIIC:
Vascular injury requiring repair

Treatment
After initial trauma survey and resuscitation for life-threatening injuries
Perform a careful clinical and radiographic evaluation
Wound hemorrhage should be addressed with direct pressure rather than
limb tourniquets or blind clamping.
Initiate parenteral antibiosis
Assess skin and soft tissue damage; place a saline-soaked sterile
dressing on the wound.
Perform provisional reduction of fracture and place a splint.
Operative intervention: open fractures constitute orthopaedic
emergencies, because intervention less than 8 hours after injury has
been reported to result in a lower incidence of wound infection and
osteomyelitis.

Principle of Treatment

Antibiotic prophylaxis.
Urgent wound and fracture debridement.
Stabilization of the fracture.
Early definitive wound cover.

 Grade I, II: First-generation cephalosporin

Grade III: Add an aminoglycoside
Farm injuries: Add penicillin and an aminoglycoside

Tetanus Prophylaxis
Should also be given in the emergency room.
The current dose of toxoid is 0.5 mL regardless of age;
for immune globulin,

the dose is 75 U for patients <5 years of age,

125 U for those 5 to 10 years old, and
250 U for those >10 years old.
Both shots are administered intramuscularly, each from a
different syringe and into a different site

Operative Treatment
Adequate irrigation and debridement are the most
important steps in open fracture treatment:
- The wound should be extended proximally and
distally to examine the zone of injury.
- The clinical utility of intraoperative cultures has been
highly debated and remains controversial.
- Meticulous debridement should be performed,
starting with the skin and subcutaneous fat

Factors of muscle viability

Color

Normally beefy red; rarely, carbon monoxide

exposure can be deceiving

Consistency

Normally firm, not easily disrupted

Capacity to
bleed

Can be deceiving because arterioles in necrotic

muscle can bleed
Typically reliable

Contractility

Responsive to forceps pinch or low cautery setting

Typically reliable

Fracture Stabilization
External fixation
Periarticular fractures
Definitive
Distal radius
Elbow dislocation
Selected other sites

Temporizing

Knee
Ankle
Elbow
Wrist
Pelvis

Distraction osteogenesis
In combination with screw fixation for severe soft tissue injury
Severe contamination: any site

Fracture Stabilization
Internal fixation
Periarticular fractures
Distal/proximal tibia
Distal/proximal femur
Distal/proximal humerus
Proximal ulnar radius
Selected distal radius/ulna
Acetabulum/pelvis
Diaphyseal fractures
Femur
Tibia
Humerus
Radius/ulna

Soft Tissue Coverage and Bone

Grafting
Wound coverage is performed once there is no further
evidence of necrosis.
The type of coveragedelayed primary closure, splitthickness skin graft, rotational or free muscle flapsis
dependent on the severity and location of the soft tissue
injury.
Bone grafting can be performed when the wound is clean,
closed, and dry. The timing of bone grafting after free flap
coverage is controversial. Some advocate bone grafting at
the time of coverage; others wait until the flap has healed
(normally 6 weeks).

Limb Salvage
Immediate or early amputation may be indicated if:
The limb is nonviable: irreparable vascular injury, warm
ischemia time >8 hours, or severe crush with minimal
remaining viable tissue.
Even after revascularization the limb remains so severely
damaged that function will be less satisfactory than that
afforded by a prosthesis.
The severely damaged limb may constitute a threat to the
patients life, especially in patients with severe, debilitating,
chronic disease.

COMPLICATIONS
Infection: cellulitis or osteomyelitis, despite
aggressive, serial debridements, copious lavage,
appropriate antibiosis, and meticulous wound care.
Compartment syndrome: severe loss of function,
especially in tight fascial compartments including the
forearm and leg. It may be avoided by a high index of
suspicion with serial neurovascular examinations
accompanied by compartment pressure monitoring,
prompt recognition of impending compartment
syndrome, and fascial release at the time of surgery.

Tibial Plateu

Epidemiology
Tibial plateau fractures constitute 1% of all fractures and
8% of fractures in the elderly.
Isolated injuries to the lateral plateau account for 55%
to 70% of tibial plateau fractures, as compared with 10%
to 25% isolated medial plateau fractures and 10% to
30% bicondylar lesions.
There is a wide spectrum of fracture patterns that involve
the medial tibial plateau (10% to 23%), the lateral tibial
plateau (55% to 70%), or both (11% to 31%).
From 1% to 3% of these fractures are open injuries.

Anatomy

Mechanism of injury
Fractures of the tibial plateau occur in the setting of varus
or valgus forces coupled with axial loading. Motor vehicle
accidents account for the majority of these fractures in
younger individuals, but elderly patients with osteopenic
bone may experience these after a simple fall.
The direction and magnitude of the generated force, age of
the patient, bone quality, and amount of knee flexion at the
moment of impact determine fracture fragment size,
location, and displacement.
A bicondylar split fracture results from a severe axial force
exerted on a fully extended knee.

Clinical evaluation
Neurovascular examination
Hemarthrosis
Open injuries
Compartment syndrome (4P)
Assessment for ligament

Associated Injury
Soft tissue injury (90%).
Meniscal tears occur (50%)
Collateral or cruciate ligament rupture(30%).
Peroneal nerve injuries
Arterial injuries

Radiographic Evaluation
Anteroposterior and lateral views supplemented by 40-degree
internal (lateral plateau) and external rotation (medial plateau)
oblique projections
A 10- to 5-degree caudally tilted plateau view
Avulsion of the fibular head, the Segond sign (lateral capsular
avulsion) and PellegriniSteata lesion (calcification along the
insertion of the medial collateral ligament) > ligamentous
injury.
A physician-assisted traction view
Stress views, preferably with the patient under sedation or
anesthesia and with fluoroscopic image intensification.

Classification
Schatzker (Fig. 36.1)

Treatment

Nonoperative
Indicated for nondisplaced or minimally displaced fractures and in patients with advanced osteoporosis.
Protected weight bearing and early range of knee motion in a hinged fracture brace are recommended.
Isometric quadriceps exercises and progressive passive, active-assisted, and active range-of-knee motion
exercises are indicated.
Partial weight bearing (30 to 50 lb) for 8 to 12 weeks is allowed, with progression to full weight bearing.
Operative
Surgical indications
The reported range of articular depression that can be accepted varies from <2 mm to 1 cm.
Instability >10 degrees of the nearly extended knee compared to the contralateral side is an accepted
surgical indication. Split fractures are more likely to be unstable than pure depression fractures in which the
rim is intact. (Fig. 36.3)
Open fractures.
Associated compartment syndrome.
Associated vascular injury.

Complications
Arthrofibrosis: This is common, related to trauma from injury and surgical
dissection, extensor retinacular injury, scarring, and postoperative immobility. More
common in higher energy injuries.
Infection: This is often related to ill-timed incisions through compromised soft
tissues with extensive dissection for implant placement.
Compartment syndrome
Malunion or nonunion: This is most common in Schatzker VI fractures at the
metaphysealdiaphyseal junction, related to comminution, unstable fixation,
implant failure, or infection.
Posttraumatic osteoarthritis
Peroneal nerve injury.
Popliteal artery laceration (rare).
Avascular necrosis of small articular fragments: This may result in loose
bodies within the knee.