CASE REPORT

CLOSED FRACTURE
1/3 MIDDLE LEFT
TIBIA et FIBULA
Presented by:
Nur Wahida bt Mohd Zulkifli
C11109852
Advisor:
dr. Ira Nong
dr. Nia Irayati
Supervisor:
dr. Zulfan Oktasatria Siregar ,Sp. OT
Department of Orthopaedic and Traumatology
Medical Faculty of Hasanuddin University
Makassar, 2014

PATIENT IDENTITY
Name
: Miss S
Age
: 35 years old
Admission date : June 19th, 2014
MR no.
: 668617

HISTORY TAKING
Chief Complain : Pain at the left lower
-extremity
Anamnesis : suffered since about 3 hours before admitted
to the Emergency Room of Wahidin General Hospital due
to traffic vehicle accident.
- Mechanism of trauma : The patient was crossing the road
and accidentally crashed into a motorcycle from the left
side.
- No history of unconscious, No history of nausea and vomit.

PRIMARY SURVEY
A : Patent
B
C
D
E

RR = 18 x/min (spontaneous, regular,

symmetrical, thoracoabdominal type)
: BP = 120/80 mmHg, HR= 92 x/min
(regular,
strong)
: GCS 15 (E4V5M6); pupil isochors,
2,5mm/2,5mm; light reflex +/+
: T = 37,1oC (axillar)

SECONDARY SURVEY
Left Leg Region
Look Deformity (+), edema (+), hematoma
:
(+)
Feel : Tenderness (+).
NVD: Sensibility & motoric of deep
peroneal nerve & superficial peroneal
nerve is good, pulsation of the dorsalis
pedis artery & posterior tibialis artery is
palpable. CRT <2 second.
ROM : Active and passive movement of knee
and ankle joint cannot be evaluated
due to pain

LEG LENGTH DISCREPANCY

ALL
TLL
LLD

R
86cm
75cm

L
86cm
75cm
0cm

CLINICAL PHOTO

X-RAY PHOTO

Left
Left Leg
Leg AP/Lateral
AP/Lateral View
View

LABORATORY FINDINGS
(24/06/14)

WBC : 13.1 x 103/mm3

RBC
: 3.87 x 106/mm3
HGB : 11.6 g/dL
HCT
: 33.8 %
PLT
: 259 x 103/mm3
BT
: 30
CT
: 8 0

RESUME
A female, 35 years old admitted to the Wahidin hospital with
chief complain pain at the left cruris suffered since 3 hours
before admission due to traffic vehicle accident. The patient
was crossing the road and

accidentally crashed into a

motorcycle from the left side.

On

physical

examination

of

the

left

cruris

was

found

deformity (+), edema (+). Tenderness (+), normal NVD .

Active and passive motions of knee and ankle joints are
limited due to pain. Radiology of cruris sinistra AP/Lat. shows
comminutive fracture 1/3 medial tibia et fibula sinistra.

DIAGNOSIS

Closed comminutive fracture 1/3

middle left tibia
Closed comminutive fracture 1/3
middle right fibula

MANAGEMENT
IVFD RL
Analgesic
Apply long leg back slab left leg
Plan for Elective ORIF

DISCUSSION
CLOSED FRACTURE 1/3
MIDDLE Left TIBIA
FIBULA

BASE OF DIAGNOSIS

High energy
injury /
Direct
trauma
usually
communitiv
e fracture &
involve both
tibia and
fibula
Anamnesis

Physical
examinatio
n:
There is
deformity (+)
Tenderness (+),
swelling (+),

Fracture
communitiv
e 1/3 middle
right os tibia
and fibula
configurativ
e of wedge
type may
due to
combination
of axial load
& bending
Radiograph

Koval KJ, Zuckerman JD. Tibia Fibula Shaft. Handbook of Fracture. 4th ed. New York: William & Wilkins; 2006. p. 387-97.
.

NVD examination
NERVES
SENSORIC
Superficial Peroneal

MOTORIC
Deep Peroneal

Tibialis

Superficial Peroneal

Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed. Saunders Elsevier. p. 316-22.

NVD examination
Artery
Dorsalis pedis
Tibialis Posterior

Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed. Saunders Elsevier. p. 316-22.

Classification
Amount and type of soft tissue damage: Closed
fractures are best described using Tschernes
method.For open injuries, Gustilos grading is
more useful
Grade

Explaination

Simple fracture with little / no soft tissue injury

Fracture with superficial abrasion/bruising of skin and

subcutaneous

Severe Fracture with deep soft tissue contussion &

swelling

Severe injury with marked soft tissue damage and

threatened compartment syndrome

 Severity of injury: High energy fracture (by

direct trauma, tend to open, Gustilo III a-c,
transverse or communited), low energy fracture
(typically closed, Gustilo I or II, spiral)
Stability: comminuted fracture are the least
stable of all

Muller AO Classification of shaft

TIBIA fracture

Muller AO Classificaion of Fractures Long Bones, p4-10

Other Possible
Injury
Compartment
Syndrome
P > 30 mmHg
immediate open
fasciotomy
Pain
Parlor
Pulseless
Paresthesi
a
Paralysis

If
If suspected,
suspected,
The
The affected
affected limb
limb is
is place
place at
at the
the level
level of
of
the
the heart
Release
Release the
the bandages
bandages and
and casts
casts
Immobilize
Immobilize the lower
lower leg
leg with
with the
the ankle in
in
slight
slight plantar
plantar flexion
flexion

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

Management
Conservative

Operative

Immobilization
- Long leg circular
Cast

Open Reduction
Internal Fixation
- Plate and screw
- Intramedullary
nailing

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

Management
Conservative (Non-operative)
- Closed reduction under general anaesthesia and a
long leg circular casting

Indication:
Minimal displaced with acceptable

< 5 varus-valgus
angulation
<10 AP/Post
angulation
<1cm shortening

alignment
Closed fractures
Low energy trauma
Minimal soft tissue damage
Cortical apposition greater than 50%
Stable fracture pattern

Miller DM, Thompson SR, Hart JA. Reviews of Orthopaedics. 6 th edition. 2012. Elsevier Saunders. P.761

Management
Management of Choice : Operation
Open Reduction Internal Fixation

Indications
Open fracture.
Unstable fractures, comminuted fracture, and
associated with varying degrees of soft-tissue trauma
Associated vascular injury.
Fractures associated with compartment syndrome.
Associated femoral fracture (floating knee)
Criteria for non-operative management not met or
failed non-operative management

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

Management Guidelines of
Conservative Treatment
Initial
Treatment :
Long-leg
posterior splint
with position
knee in 10-15
flexion, ankle at
90
Admission
for
for 24-48pain
hours
elevation,
control and
neurovascular
monitoring

Long-leg cast when

swelling stabilized
Position: Knee at 0 to 5
degrees of flexion; ankle
at 90 degrees
For 4-6 weeks
Repeat radiography
interval: Weekly for 3 to 4
weeks to ensure alignment.
Then every 2 to 4 weeks

Refer to Orthopeadic if the

fracture is not in
acceptable alignment:
< 5 varus-valgus
angulation
<10 AP/Post angulation
<1cm shortening

Eiff MP. et al. Fracture Management for Primary Care. 3rd Edition. Elsevier. 2012.p 247

Complications
Early

Late

Neurovascular
injury
Compartment
syndrome

Malunion, delayed
union, non-union
Muscle contracture
Joint stiffness

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

THANK YOU