CASE REPORT

Open fracture 1/3 distal right tibia grade IIIB

Open fracture 1/3 distal right fibula grade IIIB

By;
Mikael Sri Pabilang
C 111 07 126

Advisor:
Dr. Risal
Dr. Evan

Supervisor:
Dr. Supriyadi, Sp.OT

Orhtopedic dan Traumatology

Faculty of Medicine Universitas Hasanuddin
Makassar
2011
Identity
Name : An. TH
Age : 12 years old
Admission : 19th December 2011
Address : Takalar
Occupation: Student
Registration : 52 51 03
HISTORY TAKING
Chief complaint : wound at right leg
Anamnesis: suffered since 1 week before
admitted to the hospital due to traffic
vehicle accident.
Mechanism of trauma : patient was riding
a motorcycle and suddenly got hit by
another motorcycle from right side. He
felt and the motorcycle hit his right leg.
History of unconscious (-), nausea (+),
vomit (-)
History of first medical treatment in
RSUD Takalar
General status
Good nourish / conscious

Blood pressure = 110/70 mmHg

Pulse Rate = 90x/min
Respiratory Rate = 22 x/min
Temperature = 36,90 C (axillar)
LOCAL STATUS
Right leg region
I : - Lacerated wound at distal medial aspect
sized 10cm x 5cm, at distal lateral aspect
10cm x 10 cm, bone exposed (+), tendon
exposed (+), muscle exposed(+) ,deformity
(+), edema (+), hematoma (+)
P : Tenderness (+)
ROM : Active and passive movement of the knee
joint and ankle joint are limited due to
pain.
NVD : Sensibility is good, pulse of dorsalis
pedis artery is not palpable and tibialis
psterior artery is palpable, capillary refill
time < 2 sec
LABORATORY FINDINGS
WBC 13,41 x 103 /uL
RBC 3,29 x 106 /uL
HGB 8,9 g/dL
HCT 26,7 %
PLT 196 x 103 /uL
MCV 81,2 Fl
MCH 27,1 pg
MCHC 33,3 g/dl
CT 700
BT 200
RADIOLOGy FINDINGS
MANAGEMENT
IVFD RL
Analgetic
Antibiotic and anti tetanus serum
Immobilize fracture with leg back slab
Debridement + External fixation
Stabilization using external fixation
Diagnosis
Post Debridement + External Fixation
due to :
Open fracture 1/3 distal right tibia
grade IIIB
Open fracture 1/3 distal right fibula
grade IIIB
SUMMARY
A Boy, 12 years old, admitted to the hospial with chief
complaint of wound at right lower leg region suffered
4 hours before admitted to the hospital due to traffic
vehicle accident.
On physical examination, we found Lacerated wound
at distal medial aspect sized 10cm x 5cm, distal lateral
aspect sized 10cm x 10 cmbone exposed (+), tendon
exposed (+), muscle exposed(+) deformity (+), edema
(+), hematoma (+)
ROM of knee joint and ankle joint was limited due to
pain.
NVD: sensibility is good, tibialis posterior artery on
right leg is palpable, CRT < 2.
On radiologic examination, there are fracture
communitif 1/3 distal of right tibia and 1/3 distal of
right fibula
 DISCUSSION

FRACTURE OF TIBIA AND FIBULA

Introduction
Open fracture means that skin around the fracture site has
been punctured and exposed to external environment, it
increases the risk for bacterial infection.
Tibia is the major weight bearing of the leg (85% of the
whole load), while fibula responsible for 6% -17% of
weight bearing load. Fractures of the tibia and fibula shaft
are the most common long bone fractures.
Men are more commonly affected than women.
Usually due to traffic accident & sports injury.
Gustilo & Anderson classification of open fracture
Grad Woun Contami Soft tissue Bone injury
e d size nation
I <1cm Clean Minimal -Simple (transverse,
short oblique)
-minimal comminution
II >1cm Moderat Moderate -moderate comminution
e (transverse, short
oblique)
III A >1 cm High -extensive soft -minimal periosteal
tissue laceration stripping
- Adequate soft -soft tissue coverage of
tissue coverage bone is possible
III B >1 cm Massive -Extensive soft -moderate to severe
tissue injury comminution
- Need soft tissue -poor bone coverage
reconstruction
III C >1 cm Massive -severe loss of soft -poor bone coverage
tissue -moderate to severe
-need NV comminution
reconstruction
Anatomy
The tibia and fibula are long bone.
It has a subcutaneous anteromedial border
and is bounded by four tight fascial
compartments
anterior, lateral, superficial posterior, and deep
posterior
The compartmental anatomy can become
extremely important during a traumatic
situation in which internal bleeding in the leg
can lead to a compartment syndrome.
COMPARTMENTS OF THE LEG

Superficial
Posterior
compartment

Deep
Posterior
compartme
nt

Lateral
compartme
nt
Anterior
compartme
nt
Diagnosis

Anamnesis
Physical examination
X- ray, with anteriorposterior 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
management
- Objectives:
1.To limit soft tissue damage and preserve skin
coverage.
2.To prevent, or at least recognize compartment
swelling.
3.To obtain and hold fracture alignment
4.To start early weight-bearing
5.To start join movement as soon as possible.

- Conservative and Operative

Treatment
Conservative Operative

Antibiotic Plan for ORIF

Anti tetanus Using intramedullary

nailing
Debridement Using plates and
screw
Stabilization with
leg back slab
Conservative
A leg cast with progressive weight bearing can be used for
isolated, 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 leg cast may be exchanged for a patella-

bearing cast or fracture brace.

Union rates as high as 97%, although with delayed weight

bearing related to delayed union or non-union.
 Operative
Indications for operative management include:
Open fracture.
Fractures in which a stable reduction is unable
to be achieved or maintained.
Associated neurovascular injury.
Fractures associated with compartment
syndrome.
Severely comminuted fractures.
Associated femoral fracture (floating knee).
Unstable fracture
Intramedullary (IM) Nailing
Advantage: Preservation of periosteal blood supply and
limited soft tissue damage.
Operative treatment is desirable due to
1) Shorten length of hospitalization
2) Allow partial weight bearing soon after operation and full
weight bearing sooner
3) Suitable for young active people
4) Recommended for most fracture patterns.
Plates and Screws
Plating is best for metaphyseal fracture that unsuitable for
nailing.
The disadvantages are:
1) Increase risk of infection, wound breakdown, mal-union,
non-union
2) Need to expose the fracture site
3) Stripping of the soft tissue around the fracture
4) Less secure fixation and delay weight bearing (usually after
6 week)
Factors that influence
healing
Promote healing
Early age
Early weight bearing or
exercise
Nutrient (vitamin C, vitamin D,
retinoid acid)
Electric stimulation of the bone Poor oxygenation, anemia
Normal absorption of nutrients
Growth hormone, thyroid
hormone, and pancreas
hormone
Delay healing
Advanced age
Disease of the bone like
osteoporosis
Deficiency of vitamin D
Excessive bone gap, infection
to the bone, neoplasm,
intraarticular fracture
Deficiency of sex hormone,
and insulin like in diabetes
mellitus
Complications
Early complications Late complication

Vascular injury Malunion, delayed

union, non- union

Compartment Joint stiffness

syndrome
Infection osteoporosis
THANK YOU