ORTHOPEDICS Year 4, MBBS 08/09

CASE WRITE-UP 2 Comminuted Fracture of Tibia

Name: Harith Abdul Malek

Matric. No.: 0808-0875

Group: 03

Supervisor: Dr. Alla

2

TABLE OF CONTENTS

No. Component Page

1 Abstract 3

2 Patient’s Profile 4

3 Patient’s History 4

4 Summary 5

5 Physical Examination 6

6 List of Problems 7

7 Clinical diagnosis 7

8 Investigations 7

9 Definitive diagnosis 10

10 Treatment 10

11 Patient’s Progress 10

12 Discussion 11

13 References 14

3

ABSTRACT

This is a case of tibial shaft fracture in a 23 year-old soldier, Corporal MF. The

fracture was acquired from a high-energy trauma and was presented as deformity at

the casualty department. The fracture was a closed one. Further investigation

revealed moderate comminution of the fracture and varus angulation. He was

acutely treated with a back-slab cast to the above-knee level before a definitive

surgical treatment—internal fixation—was decided. The discussion will focus on the

nature, epidemiology, and classifications of tibial shaft fracture, options for

treatment and the importance of rehabilitation for fracture patients.

4

PATIENT’S PROFILE

Patient’s initials: Corporal MF

Age: 23 years old

Sex: Male

Race: Malay

Status: Single

Occupation: Soldier (Malaysian Army)

Address: Terendak Camp

Date of admission: 11th April, 2012

PATIENT’S HISTORY

Chief complaint

Corporal MF came to the emergency department with a deformed right leg

and pain over the left thigh for 30 minutes following an alleged motor vehicle

accident.

History of presenting illness

The corporal was standing on the side of a road waiting for his food ordered

from a nearby night stall. While he was waiting, a motorcycle came fast towards him

and hit him directly on the lateral side of his right leg. The motorcycle was of 110 cc

engine and the speed it was going with during the accident was approximated at 80

km per hour. The patient fell on the grass on his left thigh. He was still conscious

following the accident and found his right leg to be severely bended outward. The

bend was at the mid-shin level. He could not get up by himself and could not walk.

He was carried by his friends and brought to the hospital by a car. Upon reaching the

hospital, he noticed his right leg was swollen. He only complained of aching pain

over the ‘broken’ leg and a minor abrasion wound over the anterior aspect of the

leg.

The left limb of Corporal MF was relatively normal in comparison to the right

one. Beside the localized aching and throbbing pain over the left thigh, no other

complaints were made with regard to the limb. The limb could still be mobilized

without any problem.

5

The patient was conscious all the time. He did not complain of muscle

weakness, neck or back pain, headache and dizziness. He had no dyspnea, chest

pain, and abdominal pain. The corporal denied any tingling sensation or numbness

felt over both lower limbs. No foot drop was noted on the affected limb and no

urinary or bowel symptoms were reported.

Past medical, surgical, and drug history

Corporal MF was previously healthy and suffered from no chronic illness. He

had no significant surgical history. No allergy to food or medications was reported

by the patient.

Family history

The patient is not known to have any inherited bleeding disorder or any

other familial disease. Other than the fact that his father is a diabetic, no other

significant family history was obtained.

Social history

Corporal MF is a single Malay gentleman. He registered into the army when

he was 20 years old and is currently staying at the Terendak Army Camp. He smokes

5-10 cigarettes per day but does not drink. He will complete his recovery process at

his parents’ house in Penang. The house is a single-story house and his mother will

be at home all the time to look after him.

SUMMARY

Corporal MF, a 23 year-old gentleman, came in to the emergency department

complaining of a deformed right leg and pain over the left thigh for 30 minutes

following an alleged motor vehicle accident. The deformed leg was also swollen and

in pain. He had only minor abrasion wound over the affected leg. He suffered from

no head or spinal injury or difficulty in breathing.

6

PHYSICAL EXAMINATION

General inspection

From general inspection, Corporal MF was lying supine on the bed, propped

up at 30 degrees. The patient was alert, conscious, and oriented to time, place, and

person. He was breathing comfortably. The right leg was put on back-slab cast and

elevated by pillows.

Corporal MF hands were moist. The pulse rate was 84 beats per minute with

regular rhythm and good volume. The brachial blood pressure was 130 / 64 mmHg.

He was afebrile with a temperature of 37.0 degree Celcius. The respiratory rate was

12 breaths per min. His BMI was 22.1. He was not pale and his tongue was mildly

coated. There were two minor abrasion wounds over the ulnar side of his right hand

and the right elbow.

Regional examination

Both legs were in normal attitude. The right leg was somewhat swollen and a

minor abrasion wound with a size of 3x4 cm was noted on the anterior aspect of the

leg. The wound was inspected and it was not deep enough to provide contact for the

both with the external environment. The color of the skin was normal (when

compared to the other leg). On palpation, the leg was warm and slightly tender. The

swelling was maximal at the mid-shin level and extended to below the tibial

tuberosity on one side and just above the ankle joint on the other side. The

movement of ankle joint was restricted to limited dorsiflexion and plantarflexion.

The movement of all the toes was however in normal range. The sensation over the

leg and the foot was still spared.

The examination of the other (left) lower limb revealed no abnormality

except for the mild tenderness over the lateral aspect of the thigh. Full range of

movement was elicited in all the joints of the limb and no sensory deficit was noted

from the examination.

Other systemic examinations

The examination of the eyes was uneventful. Both heart sounds were heard

with no additional sound. The respiratory examinations revealed a full chest

expansion with vesicular breath sound. No abnormality was elicited from the

abdominal examination.

7

LIST of PROBLEMS

1. Possible closed fracture of the right tibia

2. Possible closed fracture of the right fibula

3. Minor soft tissue trauma on the left thigh

4. Chronic smoking

CLINICAL DIAGNOSIS

Closed fracture of the right tibia following a direct high-energy trauma

INVESTIGATIONS

Full blood count:

No. Component Value Normal value Remarks

1 Hemoglobin (Hb) 14.9 g/dL 11.0 – 16.9

g/dL

Normal level, no

anemia

2 Total White Count

(TWC)

13.1 x 10^9/L 4.0 – 11.0 x

10^9/L

Elevated with

dominance of

lymphocytes (20 %)

3 Platelets 380 x 10^9/L 150 – 400 x

10^9/L

Approaching the

high limit, possibly

reactive

thrombocytosis

Comment: the full blood count revealed no emerging issue if Corporal MF was ever

considered for a surgical procedure.

8

Imaging investigations

X-ray of right tibia (anterior-posterior view)

Comment: The above is Corporal MF’s plain radiograph of right tibia revealing

comminuted spiral wedge fracture of the tibial shaft and transverse fracture of the

fibular shaft.

9

X-ray of left femur (anterior-posterior and lateral view)

Comment: there is no fracture or abnormal feature seen in the left femur.

10

DEFINITE DIAGNOSIS

Closed comminuted fracture of the right tibial and fibular shaft

TREATMENT

Definitive treatment: Corporal MF was planned to have an open reduction (for both

tibia and fibula) and internal fixation (with intermedullary nail for the tibia).

Other treatments: While waiting for the procedure, Corporal MF’s right leg was

immobilized with back-slab cast until the above knee level. Intra-muscular Voltaren

(50 mg) was administered for pain relief. The minor abrasion wound of the right

leg, hand and elbow was cleaned and dressed with normal saline. Intravascular

injection of Rocephin (1 g BD) was also administered as a pre-caution against

infection.

PATIENT’S PROGRESS

The patient was on day-3 post-operation and was generally well. Corporal

MF did not spike any fever. The blood pressure of the patient was 120 / 78 mmHg

and the pulse rate was 64 / minute. He complained of pain only when producing

considerable movement. He could still move his right ankle and all of the right toes

without any restriction, even though the strength was still 3/5. The surgical wound

looked to be healing well. It was still slightly swollen and erythematous; but no

discharge was noted to be coming out of the wound. The patient was planned to be

discharged on the following day. He would continue the rehabilitation process in a

health facility in his hometown.

11

DISCUSSION

Tibial shaft fracture

The tibia is a long tubular bone and it has triangular cross-section. Its antero-

medial border is enveloped by subcutaneous tissue and the other aspects are

covered by four tight fascial compartments (anterior, lateral, posterior, deep

posterior). The fibula is located laterally to the tibia and the common peroneal nerve

is located subcutaneously, traveling around the fibular neck, making it particularly

vulnerable to direct blows or traction injuries at this level.

Tibia is currently leading the rank of fractured bones in the body. Mechanism

of injury is variable—ranging from low-energy trauma resulting in twisting and

rotation associated fracture to high-energy trauma, most commonly associated with

motor vehicle accident (MVA), resulting in fracture of both tibia and fibula. One

study in 1992 has reported an annual incidence of 2 tibial fractures per 1000

individuals (Alho et. al, 1992). The average age of patients suffering from this

fracture is 37 years old and teenage males make up the largest portion (Court-

Brown, McBirnie, 1995). This possibly correlates to the fact that high-speed trauma

is the highly associated with this fracture.

Fracture of the tibia can be classified in several ways. When the fracture is an

open one, Gustillo-Anderson classification can be employed. However, Corporal MF

suffered from a closed fracture of the tibia. The Orthopedic Trauma Associaton has

offered a system of classification which relies on the radiographic findings. The

classification has 3 main categories (A, B, and C) and the case of Corporal MF falls in

category C—spiral wedge fractures. Category C has several sub-classifications

depending of the number of fragments visible from the radiograph images. Because

there were 3 fragments seen in the radiograph, this fracture can be specifically

classified as C1.2.

Physiological of bone healing

A normal fractured bone will heal and be replaced by bone tissues. Bone

tissue is the only solid tissue in the body that can do this—as other tissues will be

replaced by fibrous tissue and form scars. Bone healing is generally staged into 5

phases—hematoma formation, inflammatory phase, callus formation, consolidation,

and remodeling. Currently, Corporal MF is undergoing the first two stages of

healing—hematoma and inflammatory phase. The direct trauma disrupted

endosteal and periosteal blood supply and maintaining adequate blood supply to

12

the fracture site is essential for healing. Disrupted local vascular supply at the

injured site creates a hematoma and prompts the migration of inflammatory cells,

which stimulate angiogenesis and cell proliferation. Then, the inflammation stage

will take place.

Options of treatment for tibial shaft fracture

Closed tibia fractures can often be treated conservatively. However, potential

fracture instability may necessitate open reduction and internal fixation. Operative

fixation is required when fractures are unstable. Instability is defined as greater

than 1.5 cm of apparent shortening, more than 5 degrees of varus or valgus

angulation, 10 degrees of anterior or posterior angulation, and/or less than 50%

translation while the leg is already in a cast. From the right leg radiograph, there is

approximately 20 degrees of varus angulation. Factors that have been identified to

cause instability include the degree of comminution, the presence of ipsilateral

fibular fractures, and the location of the fracture along the tibia. Corporal MF

suffered from a moderately comminuted tibial fracture with ipsilateral fibular

fracture; these increase the risk of fracture instability in him.

Fractures with significant displacement or comminution that requires

operative intervention can be treated acutely with a posterior long-leg splint or

external fixation if significant shortening or severe wound is present. Corporal MF’s

fracture did not involve significant shortening or severe contaminated wound;

hence, he was only treated with a long-leg back-slab cast when he arrived at the

casualty department.

Several options can be considered when surgical treatment is definitive:

intramedullary nailing, plates and screws. In the Corporal MF’s case, intramedullary

nailing with interlocking screws, which by far the most popular technique for tibial

shaft fracture, had been chosen. This technique preserves the periosteal blood

supply, which is extremely important considering the fact that tibia is quite distal

from the central blood supply. And this will optimize the condition for fracture

healing. Compartment syndrome should be treated emergently with 4-compartment

fasciotomies. However, the patient did not display any sign or symptom of

compartment syndrome during the 24-hour monitoring period. Concomitant

fractures of the fibula do not require surgical treatment once the tibia has been

stabilized.

13

Importance of rehabilitation

Corporal MF is still a young soldier and has many years ahead of his career.

This incident should not hinder his ambition to advance his career in the army. With

the availability of physiotherapy and understanding of function restoring process,

the patient can achieve his pre-morbid function as a whole. The post-trauma /

operative activities that will help in re-gaining the function include reduction of

edema, preservation of joint movement, restoration of muscle power, and guiding

the patient back to normal life.

Elevation of the affected site can prevent edema and this will in turn prevent

joint stiffness. Edema is especially expected in patients who have undergone

internal fixation procedure like Corporal MF. Hence, it is important for him to

maintain elevation of his leg for a few days post-surgery and start active exercise as

soon as he can tolerate it. Active exercise will not only help in preventing joint

stiffness, but it will also pump away the edema by improving circulation.

Physiotherapy will offer the necessary assisted movement in restoring muscle

power and guiding the patient to achieve his pre-morbid functional capacity.

14

REFERENCES

1) Solomon, Louis. Warwick, David. Nayagam, Selvaduria. Apley’s System of

Orthopedics and Fractures. Chapter 23: Principles of fractures by

Selvadurai Nayagam. Hodder Education (2010)

2) Dandy & Edwards: Essential Orthopedics and Trauma. 5th Edition.

Chapter 4: Basic Science in Orthopedics – Tissue Healing

3) Srinivasan R.C., Tolhurst S., Vanderhave K.L. (2010). Chapter 40. Orthopedic

Surgery. In G.M. Doherty (Ed), CURRENT Diagnosis & Treatment: Surgery,

13e.

Retrieved on April 27, 2012 from

<http://www.accesssurgery.com/content.aspx?aID=5314010>

4) Ronald Lakatos. General Principles of Internal Fixation. Last update:

February 7, 2012.

<http://emedicine.medscape.com/article/1269987-overview#aw2aab6b2>

5) Brian K. Konowalchuk. Tibial Shaft Fracture. Last update: February 10,

2012. <http://emedicine.medscape.com/article/1249984-overview>