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Tibia and Fibula Shaft Fractures

Violita Iwamony C111 13 110


Muhammad Izzat bin Roziken C111 13 845
Nurul Ain binti Rojmi C111 13 849
Siti Nurjannah binti Fadzid C111 13 813

Asisted by:

dr. Randy Presly Octavianus


dr. Iswahyudi

Specialist:
dr. Ira Nong, M. Kes, Sp. OT
Introduction
• Fracture is a break in the structural continuity of bone.
• Causes Of Fractures :

Fractures due to sudden trauma Direct or Indirect

Stress or Fatigue fractures due to repetitive stress

bone has been weakened by change in its structure


Pathological fractures or through a lytic lesion

Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics and Fractures Ninth Edition. London: Hodder. Education. 2010. P916-923
Epidemiology
• Fractures of the tibia and fibula shaft are the most common long bone fractures. There are about
26 per 100,000 population per year.
o Males have the highest incidence of 21.5/100,000/year  the highest frequency between
the age of 10 and 20
o Women have a frequency of 12.3/100,000/year  the highest frequency between the age
of 30 and 40

Larsen P., Elsoe R., Hansen S.H., Graven-Nielsen T., Laessoe U., Rasmussen S. Incidence and epidemiology of tibial shaft fractures. Injury. 2015;46(4):746–750.
Koval, Kenneth J., and Joseph D. Zuckerman. Handbook of Fractures, Fifth Edition. Lippincott Williams & Wilkins, 2015. P421-423.
aNATOMY

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENTS OF LEG

Bulcholz RW, Heckman JD, Court-Brown CM. Rockwood & Green's Fractures in. Adults, 8th Edition. USA: Maryland Composition. 2015.
ANTERIOR COMPARTMENT

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


LATERAL COMPARTMENT

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


POSTERIOR SUPERFICIAL COMPARTMENT

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


POSTERIOR DEEP COMPARTMENT

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENTS OF LEG

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


MECHANISM OF INJURY

• High energy bending (ex: motor vehicle injury)


Direct • Penetrating gunshot
• Open fracture

• Low energy bending

Indirect • Torsional mechanism (ex: ballet)


• Oblique or Spiral fracture, nondisplaced

Handbook ok Fracture, Chapter 37: Lower Extremity Fracture and Dislocations


Types of Fracture
Complete Fractures
 Transverse
 Spiral
 Oblique
 Impacted
 Comminuted

 Incomplete Fractures
 Greenstick fracture
 Buckle/torus

Apley’s System of Orthopaedics and fracture, Chapter 23: Principle of fracture


Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010
Apley’s System of Orthopaedics and fracture, Chapter 23: Principle of fracture
Classic feature of Evaluate
History of injury to the fracture Neurovascular Status
leg - pain, swelling, - Diminished pulse
deformity, tenting skin -Loss sensation

Monitor
Compartment Assess soft tissue or
syndrome ligament injury
- 5P

Clinical Evaluation
Handbook ok Fracture, Chapter 37: Lower Extremity Fracture and Dislocations
Radiographic Evaluation
• Radiographic evaluation must include:
• - entire tibia, ankle, knee joints
• Recommended views:
• Full length AP and lateral view of affected tibia
• Oblique view, helpful to further characterize the fracture pattern
• CT scan and MRI are not necessary
• Ix: Intraarticular fracture extension
• Diminished pulse/arterial injury(ABIs)=> Angiography

Handbook ok Fracture, Chapter 37: Lower Extremity Fracture and Dislocations


Tibial Shaft Fracture Orthobullets
Fracture upper third shaft of tibia Open Fracture Tibia Fibula
FRACTURE CLASSIFICATION

Bulcholz RW, Heckman JD, Court-Brown CM. Rockwood & Green's Fractures in. Adults, 8th Edition. USA: Maryland Composition. 2015. P2420-2425.
Abdul Rahman. Ortho Bullet Trauma Volume 1, 2017 page 8 and 361-366
Nayaman S. Principles of Fractures. Dalam: Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics and Fractures Ninth Edition. London: Hodder. Education. 2010. P916-923.
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
CLASSIFICATION OF AO/OTA
OPEN FRACTURE
“The Oestern and Tscherne “
CLOSED FRACTURE
“Oestern and Tscherne”
SHAFT TIBIA FRACTURE
TREATMENT
Bulcholz RW, Heckman JD, Court-Brown CM. Rockwood & Green's Fractures in. Adults, 8th Edition. USA: Maryland Composition. 2015. P2420-2425.
Abdul Rahman. Ortho Bullet Trauma Volume 1, 2017 page 8 and 361-366
Nayaman S. Principles of Fractures. Dalam: Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics and Fractures Ninth Edition. London: Hodder. Education. 2010. P916-923.
CLOSED FRACTURE
ACCEPTABLE CRITERIA
< 5° varus-valgus angulation
< 10° degrees anterior/posterior angulation
> 50% cortical apposition
No
Yes < 1 cm shortening
< 10° rotation malalignment

Non operative Operative

Cast
External fixation Internal fixation
Elevated 24-48 hrs
IM Nailing
Home on 3rd day
Fixation plate
Follow up after 2 weeks

improved Not improved

Open cast below knee;


weight bearing Malalignment

12th week Cast free Swollen Remove cast


OPEN FRACTURE

Cephalosporin pada 24 - 48 hrs > grade I,II dan IIIA open fxs.
ANTIBIOTIC Aminoglycoside > group IIIB

Remove all foreign particles and dead cells to


DEBRIDEMENT promote wound healing and prevent infection

Internal/external fixation
STABILIZATION

AMPUTATION Warm ischemic > 6hrs


COMPLICATION
• Compartment syndrome
• Knee pain
• Symptomatic hardware
• Malunion
• Nonunion
• Deep infection

Bulcholz RW, Heckman JD, Court-Brown CM. Rockwood & Green's Fractures in. Adults, 8th Edition. USA:
CONCLUSION
• Tibia and fibula fractures are the most common long bone fractures that can be caused by direct or indirect
trauma. (men>>, 10-20 years old)
• Due to the thinner periosteum on the anterior tibia, susceptible to fractures
• Fractures line related to mechanism of trauma; transverse, oblique, spiral and avulsion fractures.
• A thorough history and examination should be carried out in patients with fractures (evaluate neurovascular
status and compartment syndrome) & radiological examination; AP and lateral.
• The fracture classification according to The Oestern and Tscherne is divided into 2; open and closed.
• The classification of diaphysis tibia fracture can be determined based on Gustilo-Anderson, which depends
on the size of the wound, contamination, soft tissue and bone injury.
• The general classification for tibia and fibula fractures; AO / OTA classification system is not too practical.
• General treatment; ATLS must be prioritized first in dealing with these cases.
• Management of closed tibial fractures for non-operative indication patients who meet the criteria is by
applying cast & for operative indication, internal fixation can be done; (Intramedullary nailing and plate
fixation) and external fixation.
• Management of open tibial fractures by giving antibiotics, debridement, stabilization, amputation.

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