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Case Report

Closed Fracture of Right Tibial Plateau Schatzker VI


Nurul Nadiah Binti Ahmad Shaharuddin
C111 10 856
ADVISOR: dr. Padlan, dr. Qariah
SUPERVISOR:
dr. Muhammad Andry Usman, Ph.D, Sp.OT
Orthopaedic and Traumatology Department
Medical Faculty of Hasanuddin University

PATIENTS IDENTITY

Name
Register

: Mrs. M
no. :774350

Sex

: Female

Age

:47 years old

Date

of admission : October 4th 2016

HISTORY
TAKING

Chief complaint: Pain at the right leg and right


knee.

Suffered since + 15 hours before admitted to


Wahidin Hospital due to traffic accident.

Mechanism

of

injury:

patient

was

riding

motorcycle when a car from opposite site hit her.


She lost balance and fell on the ground on her right
side.

History of unconsciousness (-), vomiting (-)

History of going to bonesetter (+).But the pain does

PRIMARY
SURVEY
Airway

DEPARTEMENT OF ORTHOPAEDIC AND TRAUMATIC MEDICAL FACULTY OF HASANUDDIN UNIVERSITY

SECONDARY SURVEY
Right Knee Region

Description
LOOK

Deformity (+), Swelling (+), Haematoma


(+)

FEEL

Tenderness (+), Patellar Tap (+),


Ballotement (+)

MOVE

Active and passive movement of the knee


joint is limited due to pain.

NVD

Sensibility is good, Pulsation of dorsalis


pedis and tibialis posterior arteries are
palpable, Capillary Refill Time 2
seconds.Extend big toe (+).

SECONDARY SURVEY
Right leg Region

Description
LOOK

Deformity (+), Bulla (+) diameter 3cm,


Shiny Skin (+)

FEEL

Tenderness (+)

MOVE

Active and passive movement of the knee


joint is limited due to pain.

NVD

Sensibility is good, Pulsation of dorsalis


pedis and tibialis posterior arteries are
palpable, Capillary Refill Time 2
seconds.Extend big toe (+)

Leg Length Discrepancy

Right

Left

Appearance Leg
Length

99cm

99cm

True Leg Length

88cm

88cm

Leg Length
Discrepancy

Clinical Photo

Medial View

Anterior View

Lateral View

Radiological Finding
Right Genu X-Ray Ap/Lat

Comminutive

fracture 1/3
proximal right
tibia
Oblique
fracture right
head of fibula

Radiological Finding
Right Cruris X-Ray Ap/Lat

Comminutive

fracture 1/3
proximal right
tibia
Oblique
fracture right
head of fibula

LAB

Lab Finding

WBC

7.5 x 103/uL

4-10 x 103/uL

RBC

3.88 x 106/uL

3.8-5.8 x 106/uL

HB

11.8 gr/dl

12-16 gr/dl

PLT

191x 103/uL

150-400 x 103/uL

Resume

Female, 47 years old admitted to Wahidin General Hospital on 4th


of October 2016 with chief compaint of pain at the right leg and
right knee. Suffered since + 15 hours ago. Mechanism of injury:
patient was riding a motorcycle when a car from opposite site hit
her. She lost balance and fell on the ground on her right side.
History of going to bonesetter (+).But the pain does not fade away
, and she decided to hospital.

Based on the Primary survey of the patient: BP 100/70mmHg, HR


102x/min, RR 20x/min and T 36.6.

From the secondary surveyat the right knee region: Deformity (+),
Swelling (+), Haematoma (+). Tenderness (+), Patellar Tap (+),
Ballotement (+). Active and passive movement of the knee joint
is limited due to pain. NVD: Sensibility is good, Pulsation of
dorsalis pedis and tibialis posterior arteries are palpable,
Capillary Refill Time 2 seconds.Extend big toe (+).

Secondary survey at the right leg region: Deformity (+), Bulla (+)
diameter 3cm, Shiny Skin (+). Tenderness (+). Active and
passive movement of the knee joint is limited due to pain.
Sensibility is good, Pulsation of dorsalis pedis and tibialis
posterior arteries are palpable, Capillary Refill Time 2
seconds.Extend big toe (+)

From X-ray right cruris AP/Lateral and right genu AP/Lateral found
Comminutive fracture 1/3 proximal right tibia ,Oblique fracture
right head of fibula.

DIAGNOSIS

Closed Fracture of Right Tibial


Plateau Schatzker VI
Closed Fracture Head of Right Fibula
Hemarthrosis right knee

MANAGEMENT
Early treatment :
IVFD

crystaloid

Analgesic
Observe

NVD and sign of compartment


syndrome

Temporary Management
Apply

Long Leg Back Slab

Definitive treatment :
Internal

fixation (ORIF)

Discussion
Tibial Plateau Fractures

ANATOMY OF TIBIA & FIBULA

Netter, Frank H. Netters Concise Orthopaedic Anatomy 2 nd edition. Saunders Elseiver

Leg Compartment

Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010

Compartment of Leg (transverse


view)

Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010

Muscle :
Anterior
Compartment
Tibialis anterior
Extensor hallucis
longus
Extensor digitorum
longus
Peroneus tertius

Thompson JD. Netter's Concise Atlas of Orthopedic


Anatomy 2010

Muscle :
Lateral
Compartment

Peroneus longus
muscle and tendon
Peroneus brevis muscle
and tendon

Thompson JD. Netter's Concise Atlas of Orthopedic


Anatomy 2010

Muscle :
Superficial
Posterior
Compartment
Gastrocnemius
Soleus
Plantaris

Thompson JD. Netter's Concise Atlas of Orthopedic


Anatomy 2010

MUSCLES: DEEP
POSTERIOR
COMPARTMENT

Posterior tibialis
Flexor hallucis longus
Flexor digitorum longus
Popliteus

Thompson JD. Netter's Concise Atlas of Orthopedic


Anatomy 2010

Netter, Frank H. Netters Concise Orthopaedic Anatomy 2 nd edition. Saunders Elseiver

FRACTURE ?
Break in the structural
continuity of bone.

CLOSED

overlying skin
remains intact

OPEN

The skin or one of the


body cavities is
breached, liable to
contamination and
infection.

Solomon, Louis et al. 2010. Apleys System of Orthopaedics and Fractures, 9 th edition. New

TIBIAL PLATEAU
FRACTURES?

Intra-Articular
fractures of
proximal tibia

Knee Joint

Extends
higher
Convex
in both
sagittal
and
coronal
axes

Larger
Concave
in both
sagittal
and
coronal
axes

Netter, Frank H. Netters Concise Orthopaedic Anatomy 2 nd edition. Saunders Elseiver

EPIDEMIOLOGY
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

10%

to 25% isolated medial plateau fractures

10%

to 30% bicondylar lesions

From

1% to 3% of these fractures are open


injuries.

Fractures

of the lateral plateau are more

common.
Koval, Zuckerman. Handbook of fractures, 3rd edition

SCHATZKER CLASSIFICATION
TYPE

DESCRIPTION

Type 1

Vertical split of the


lateral condyle.

Type 2

Vertical split of the


lateral condyle combined
+
Depression of an
adjacent loadbearing
part of the condyle.

Type 3

Depression of the
articular surface with an
intact condylar rim.

Robert W, dkk. Rockwood and Greens Fractures in Adult 7th edition. Lippincott: 2010

TYPE

DESCRIPTION

Type 4

Fracture of the medial


tibial condyle.

Type 5

Fracture of both
condyles.

Type 6

Shaft dissociated from the


metaphysis.

Robert W, dkk. Rockwood and Greens Fractures in Adult 7th edition. Lippincott: 2010

Meniscus tear

Knee ligament
injury

Fracture of
patella

ASSOCIATE
D INJURY
Common
Peroneal nerve
injury
Moore D. Tibia Plateau Fracture. Orthobullets.

Fracture of
fibular head

CLINICAL FEATURES
Look

: swollen knee, Deformity (+),


Bruising (+);

Feel

: tissues feel doughy because of


haemarthrosis, medial or lateral
instability but often difficult to perform
given pain.

Move

: active and pasive movement


limited

NVD

: Examined for signs of vascular or


neurological injury.

Solomon, Louis et al. 2010. Apleys System of Orthopaedics and Fractures, 9 th edition. New
York : Arnold.

IMAGING
1.

Anteroposterior, lateral and


oblique x-rays

2.

Computer tomography (CT)


provides information on the:
1.

amount of comminution or
plateau depression

2.

location of the main fracture


lines

3.

site and size of the portion of


condyle that is depressed

position of major parts of


articular surface that have been
displaced.
Solomon, Louis et al. 2010. Apleys System of Orthopaedics and Fractures, 9 edition. New
4.

th

York : Arnold.

RADIOLOGICAL IMAGING

(a) X-rays provide information about the position of the main fracture
lines and areas of articular surface depression.
(b,c) CT reconstructions reveal the extent and direction of
displacements, vital information for planning the operation.

Solomon, Louis et al. 2010. Apleys System of Orthopaedics and Fractures, 9 th edition. New
York : Arnold.

TREATMENT
NON OPERATIVE
Hinged
Partial

knee brace
weight bearing for 8-12

weeks
Immediate

passive ROM

Indication: Minimally displaced split


or depressed fracture; low energy
fracture stable to varus/valgus
alignment; nonambulatory patient.
Moore D. Tibia Plateau Fracture. Orthobullets.

TREATMENT

Open

OPERATIVE

Reduction and Internal


Fixation
Indications: articular stepoff
>3mm; condylar widening
>5mm; varus/valgus
instability; all medial plateau
fractures; all bicondylar
fractures.

Moore D. Tibia Plateau Fracture. Orthobullets.

COMPLICATIONS
Without Treatment
Early
Compartment
syndrome

With Treatment

Late
Joint stiffness
Malunion
Nonunion

Early
Infection
Implant failure
Fat emboli
DVT

Late
Post traumatic
Osteoarthritis
Deformity
(valgus or
varusdeformity)

Post traumatic
Osteoarthritis
Deformity
(valgus or
varusdeformity)
Robert W, dkk. Rockwood and Greens Fractures in Adult 7th edition. Lippincott: 2010
Solomon, Louis et al. 2010. Apleys System of Orthopaedics and Fractures, 9 th edition. New
York : Arnold.
Koval, Zuckerman. Handbook of fractures, 3rd edition

THANK YOU

Classification of Closed Fracture


(Tscherne Classification)
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, K., Zuckerman, J. Tibia Fibula Shaft in Handbook of Fractures Third Edition. New York: Lippincott Williams &
Wilkins. 2006.

3 mechanism of tibial plateau


fracture
1)medial/lateral

based force
(Bumper fracture as car strikes
outside of persons leg and create a
valgus )

2)pure

axial / compression force

3)combination

of both :axial &


medial/lateral force

When & how to treat Non-Surgical

PRICE
(protection/rest/ice/compression/elevation)

Non-displaced fracture(Treated with period


of non-weight bearing with a hinged knee
brace)

Mechanical alignment & articular congruity

When & how to treat surgically

Open fractures / Displaced fractures /


Fractures that alter the mechanical
alignment of the limb

EXTERNAL FIXATION INDICATION


Open

fractures with severe soft-tissue injury.


External fixation can be applied with minimal
trauma, avoiding additional damage to soft
tissues and bone vascularity.
In closed fractures, external fixation is indicated
for temporary bridging in severe polytrauma and
severe
closed
soft-tissue
contusions
or
degloving.
Damage-control surgery in polytrauma.
Open or closed articular fracture with severe
soft-tissue compromise, when the external
fixator can be applied in a joint-bridging fashion.

Thomas, Richard. AO Principle of Fracture Management. Thieme: 2007