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BAGIAN ORTOPEDI DAN TRAUMATOLOGI CASE PRESENTATIONFAKULTAS KEDOKTERAN FEBRUARY 2014

UNIVERSITAS HASANUDDIN

CLOSED FRACTURE 1/3 MIDDLE OF THE LEFT TIBIA AND FIBULA

CLOSED FRACTURE OF THE LEFT MEDIAL MALLEOLUS

OLEH:

M. A. AIRLANGGA

C111 09 258

PEMBIMBING:

dr. Mervin O. O. Jakarimilena

dr. Michael Horeb

SUPERVISOR:

Dr. Muhammad Sakti, Sp.OT

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN ORTOPEDI DAN TRAUMATOLOGI

FAKULTAS KEDOKTERAN

UNIVERSITAS HASANUDDIN

MAKASSAR

2014


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Patient Identity

Name : Mrs. N MR : 652670 Sex : Female Age : 45 years old Date of admission : February 26th2014

Anamnesis

Chief complain: Pain at the left leg History of illness:

Suffered since 5 days before admitted to Dr Wahidin SudirohusodoHospital due to traffic accident. Pain increases when she try to move her

left leg. History of treatment in RS Ibnu Sina with long leg back slab on the

left leg. History of unconscious (-), nausea (-), vomit (-)

Mechanism of trauma: Patient was crossing the street and was hit by a motorcycle from the left

and she fell to the ground.

Physical Examination

General Status: Conscious/ Well-nourished Vital sign:

Blood Pressure : 120/70 mmHg Heart rate : 80 bpm, regular. Respiratory rate : 18 tpm Temperature : 36,7 C (axilla)

Localized status

(Left Leg Region)

Inspection Deformity (-), swelling (+), hematoma (+), wound (-) Palpation Tenderness (+) ROM Active & passive movement of the knee and ankle joints cannot be

evaluated due to pain


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NVD : Sensory : Sensibilitas is goodMotoric : extend big toe

Vascular : dorsalis pedis artery is palpable, capillary refill time is

less than 2 seconds

CLINICAL PICTURES


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LABORATORIUM FINDING

WBC : 6.3 x103/mm3 RBC : 4.51 x 106/mm3 HB : 11.6 g/dL PLT : 177 x 103/mm3 GDS : 110mg/dl Ur/Cr : 17 / 0.60 mg/dL SGOT/SGPT : 37 / 29 u/L CT/BT : 6.30 / 2.00 minutes

RADIOLOGY FINDING

X-Ray position AP/lateral (Left Leg)

DIAGNOSIS

Closed Fracture 1/3 middle of the left tibia Closed Fracture 1/3 middle of the left fibula Closed Fracture 1/3 middle of the left medial maleolus


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MANAGEMENT

Analgetic Apply long leg back slab Plan for ORIF

RESUME

A 45 years old woman came to the hospital with pain at the left leg suffered since 5

days ago due to traffic accident and prior treatment long leg back slab at RS Ibnu Sina.

From the physical examination on the left lower extremity : Oedem (+) hematom (+)

deformity (-), palpation: Tenderness (+) and movement cannot be evaluated due to pain.

NVD: normal. From radiologic finding: fracture at 1/3 middle left tibia and fibula, fracture

at left medial maleolus. Laboratory finding: normal.


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DISCUSSION:

FRACTURE OF TIBIA DAN FIBULA

1. IntroductionA fracture is a break in the structural continuity of bone. It may be no more

than a crack, a crumpling or a splintering of the cortex; more often the break is

complete and the bone fragments are displaced. If the overlying skin remains intact

it is a closed (orsimple) fracture; if the skin or one of the body cavities is breached

it is an open (or compound)fracture, liable to contamination and infection.(1)

Fractur divides into fractur because of trauma, stress, and pathological

fracture. Trauma fracture divides into direct trauma and indirec trauma. Stress

fracture usually happens to athletic people with repetitive movement on the same

place. Pathological fracture happens may occur even with normal stresses if the

bone has been weakened by a change in its structure example in osteoporosis.(1)

2. EpidemiologyTibial and fibular fractures are the third most common pediatric long bone

injuries (15%) after femoral and radial/ulnar fractures (1,2). The prevalence oftibial fractures in both boys and girls has increased since 1950 (3). The average age

of occurrence is 8 years, and the frequency of occurrence does not change

significantly with age (4). Seventy percent of pediatric tibial fractures are isolated

injuries; ipsilateral fibular fractures occur with 30% of tibial fractures (2,5,6). Fifty

to 70% of tibial fractures occur in the distal third, and 19% to 39% in the middle

third. The least commonly affected portion of the tibia is the proximal third, yet

these may be most problematic. Thirty-five percent of pediatric tibial fractures areoblique, 32% comminuted, 20% transverse, and 13% spiral. Tibial fractures in

children under 4 years of age usually are isolated spiral or sharp oblique fractures

in the distal and the middle one third of the bone. Most tibial fractures in older

children and adolescents are at the ankle. Rotational forces produce an oblique or a

spiral fracture and are responsible for approximately 81% of all tibial fractures

without fibular fractures. Bicycle spoke injuries occur in children 1 to 4 years of

age, whereas most tibial fractures in children 4 to 14 years of age occur in sporting

or traffic accidents. Over 50% of ipsilateral tibial and fibular fractures result from


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vehicular trauma. Most isolated fibular fractures result from a direct blow (1,4).

The tibia is the second most commonly fractured bone in abused children.

Approximately 16% to 26% of all abused children with a fracture have an injured

tibia.(2)

3. Etiology Direct

o High-energy: motor vehicle accident Transverse, comminuted, displaced fractures commonly occur. The incidence of soft tissue injury is high.

o Penetrating: gunshot The injury pattern is variable. Low-velocity missiles (handguns) do not pose the problems from

bone or soft tissue damage that high-energy (motor vehicle

accident) or high-velocity (shotguns, assault weapons) mechanisms

cause.

o Bending: three- or four-point (ski boot injuries) Short oblique or transverse fractures occur, with a possible butterfly

fragment.

Crush injury occurs. Highly comminuted or segmental patterns are associated with

extensive soft tissue compromise.

Must rule out compartment syndrome and open fractures.o Fibula shaft fractures: These typically result from direct trauma to the

lateral aspect of the leg.

Indirecto Torsional mechanisms

Twisting with the foot fixed and falls from low heights are causes. These spiral, nondisplaced fractures have minimal comminution

associated with little soft tissue damage.

o Stress fractures


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In military recruits, these injuries most commonly occur at themetaphyseal/diaphyseal junction, with sclerosis being most marked

at the posteromedial cortex.

In ballet dancers, these fractures most commonly occur in themiddle third; they are insidious in onset and are overuse injuries.

Radiographic findings may be delayed several weeks.(handbook offracture).(3)

4. Anatomy of Tibia and FibulaThe tibia is a long tubular bone with a triangular cross section. It has a

subcutaneous anteromedial border and is bounded by four tight fascial

compartments (anterior, lateral, posterior, and deep posterior)

Blood supply

The nutrient artery arises from the posterior tibial artery, entering theposterolateral cortex distal to the origination of the soleus muscle. Once the

vessel enters the intramedullary (IM) canal, it gives off three ascending

branches and one descending branch. These give rise to the endosteal

vascular tree, which anastomose with periosteal vessels arising from the

anterior tibial artery. The anterior tibial artery is particularly vulnerable to injury as it passes

through a hiatus in the interosseus membrane.

The peroneal artery has an anterior communicating branch to the dorsalispedis artery. It may therefore be occluded despite an intact dorsalis pedis

pulse.

The distal third is supplied by periosteal anastomoses around the ankle withbranches entering the tibia through ligamentous attachments.

There may be a watershed area at the junction of the middle and distalthirds (controversial).

If the nutrient artery is disrupted, there is reversal of flow through thecortex, and the periosteal blood supply becomes more important. This

emphasizes the importance of preserving periosteal attachments during

fixation.


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The fibula is responsible for 6% to 17% of a weight-bearing load. The

common peroneal nerve courses around the neck of the fibula, which is nearly

subcutaneous in this region; it is therefore especially vulnerable to direct blows or

traction injuries at this level.(3)

Picture 1 - Tibia and Fibula(4)

Picture 2Compartment of the leg(4)


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Picture 3The Anterior Compartment(4)

Picture 4Lateral Anterior(4)

Anterior tibialis

Extensor hallucis longusExtensor digitorum longus

Fibularis eroneus lon us


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Picture 5Superficial Posterior Compartment(4)

Picture 6Deep Posterior Compartment(4)

Soleus musclePlantaris muscle

Tibialis posterior

Flexor hallucis longus muscle

Flexor digitorum longus

Polpiteal muscle


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Picture 7Fibrosseus Compartment of the Leg(2)

5. Fracture Type of Tibia and Fibula

Picture 8Fracture Type of Tibia and Fibula(4)


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Tscherne Classification for Closed Fracture

This classifies soft tissue injury in closed fractures and takes into account indirectversus direct injury mechanisms

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

Picture 9 - The Tscherne classification of closed fractures


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6. Clinical FeaturesThe signs and symptoms associated with tibial and fibular diaphyseal

fractures vary with the severity of the injury and the mechanism by which it was

produced. Pain is the most common symptom. An isolated fibular fracture

normally produces mild pain, whereas tibial fractures produce more severe pain.

Children with stress fractures of the tibia or fibula complain of pain on

weightbearing, but rarely have pain at rest.

Children with fractures of the tibia or fibula have swelling at the fracture

site, and the area is tender to palpation. Young children with nondisplaced

fractures may refuse to walk. If there is significant injury to the periosteum, a bony

defect or prominence may be palpable in patients with a complete fracture.

Neurologic impairment is rare except with fibular neck fractures caused by direct

trauma.(2)

7. Radiographic EvaluationRadiographic evaluation must include the entire tibia (anteroposterior [AP]

and lateral views) with visualization of the ankle and knee joints. Oblique views

may be helpful to further characterize the fracture pattern. Postreduction

radiographs should include the knee and ankle for alignment and preoperative

planning. A surgeon should look for the following features on the AP and lateral

radiographs:

o The location and morphology of the fracture should be determined.o The presence of secondary fracture lines: These may displace during

operative treatment.

oThe presence of comminution: This signifies a higher-energy injury.

o The distance that bone fragments have traveled from their normal location:Widely displaced fragments suggest that the soft tissue attachments have

been damaged and the fragments may be avascular.

o Osseous defects: These may suggest missing bone.o Fracture lines may extend proximally to the knee or distally to the ankle.o The state of the bone: Is there evidence of osteopenia, metastases, or a

previous fracture?


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o Osteoarthritis or the presence of a knee arthroplasty: Either may change thetreatment method selected by the surgeon.

o Gas in the tissues: These are usually secondary to open fracture but mayalso signify the presence of gas gangrene, necrotizing fasciitis, or other

anaerobic infections.

X-ray examination is mandatory. Remember the rule of twos:

Two viewsA fracture or a dislocation may not be seen on a single x-ray film, and at

least two views (anteroposterior and lateral) must be taken.

Two joints In the forearm or leg, one bone may be fractured and angulated.

Angulation, however, is impossible unless the other bone is also broken, or a joint

dislocated. The joints above and below the fracture must both be included on the x-ray

films.

Two limbs In children, the appearance of immature epiphyses may confuse the

diagnosis of a fracture; x-rays of the uninjured limb are needed for comparison.

Two injuriesSevere force often causes injuries at more than one level. Thus, with

fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine.

Two occasionsSome fractures are notoriously difficult to detect soon after injury,

but another x-ray examination a week or two later may show the lesion. Commonexamples are undisplaced fractures of the distal end of the clavicle, scaphoid, femoral

neck and lateral malleolus, and also stress fractures and physeal injuries wherever they

occur.(1)

Computed tomography and magnetic resonance imaging (MRI) usually are

not necessary. Technetium bone scanning and MRI scanning may be useful in

diagnosing stress fractures before these injuries become obvious on plain

radiographs. Angiography is indicated if an arterial injury is suspected.(3)

8. TreatmentNon-operative

Fracture reduction followed by application of a long leg cast with

progressive weight bearing can be used for isolated, closed, low-energy fractures

with minimal displacement and comminution.


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Cast with the knee in 0 to 5 degrees of flexion to allow for weight bearingwith 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 long leg cast may be exchanged for a patella-bearingcast or fracture brace.

Union rates as high as 97% are reported, although with delayed weightbearing related to delayed union or nonunion.

Acceptable Fracture Reduction

Less than 5 degrees of varus/valgus angulation is recommended.

Less than 10 degrees of anterior/posterior angulation is recommended (20 weeks.

Nonunion: This occurs when clinical and radiographic signs demonstrate thatthe potential for union is lost, including sclerotic ends at the fracture site and

a persistent gap unchanged for several weeks. Nonunion has also been

defined as lack of healing 9 months after fracture.

Tibia Stress Fracture

Treatment consists of cessation of the offending activity. A short leg cast may be necessary, with partial-weight-bearing ambulation.


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Fibula Shaft Fracture

Treatment consists of weight bearing as tolerated. Although not required for healing, a short period of immobilization may be

used to minimize pain.

Nonunion is uncommon because of the extensive muscular attachments.(3)

Operative Treatment

Intramedullary (IM) Nailing

IM nailing carries the advantages of preservation of periosteal blood supplyand limited soft tissue damage. In addition, it carries the biomechanical

advantages of being able to control alignment, translation, and rotation. It is

therefore recommended for most fracture patterns.

Locked versus unlocked nailo Locked nail: This provides rotational control; it is effective in preventing

shortening in comminuted fractures and those with significant bone loss.

Interlocking screws can be removed at a later time to dynamize the

fracture site, if needed, for healing.

o Nonlocked nail: This allows impaction at the fracture site with weightbearing, but it is difficult to control rotation. Nonlocked nails are rarely

used.

Reamed versus unreamed nailo Reamed nail: This is indicated for most closed and open fractures. It

allows excellent IM splinting of the fracture and use of a larger-diameter,

stronger nail

o Unreamed nail: This is designed to preserve the IM blood supply in openfractures where the periosteal supply has been destroyed. It is currently

reserved for higher-grade open fractures; its disadvantage is that it is

significantly weaker than the larger reamed nail and has a higher risk of

implant fatigue failure.

Flexible Nails (Enders, Rush Rods)


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With IM nailing, fibula plating or use of blocking screws may help to preventmalalignment.

Use of a percutaneously inserted plate has had recent popularity.

Tibia Fracture with an Intact Fibula

If the tibia fracture is nondisplaced, treatment consists of long leg castingwith early weight bearing. Close observation is indicated to recognize any

varus tendency.

Some authors recommend IM nailing even if tibia fracture is nondisplaced. A potential risk of varus malunion exists, particularly in patients >20 years.

Fasciotomy

Evidence of compartment syndrome is an indication for emergent fasciotomyof all four muscle compartments of the leg (anterior, lateral, superficial, and

deep posterior) through one or multiple incision techniques. Following

operative fracture fixation, the fascial openings should not be

reapproximated.(3)

9. Complicationo Malunion: This includes any deformity outside the acceptable range.oNonunion: This associated with high-velocity injuries, open fractures

(especially Gustilo grade III), infection, intact fibula, inadequate fixation,

and initial fracture displacement.

o Infection may occur.o Stiffness at the knee and/or ankle may occur.o Knee pain: This is the most common complication associated with IM tibial

nailing.

o Hardware breakage: Nail and locking screw breakage rates depend on thesize of the nail used and the type of metal from which it is made. Larger

reamed nails have larger cross screws; the incidence of nail and screw

breakage is greater with unreamed nails that utilize smaller-diameter

locking screws.


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o Thermal necrosis of the tibial diaphysis following reaming is an unusual,but serious, complication. Risk is increased with use of dull reamers and

reaming under tourniquet control.

o Reflex sympathetic dystrophy: This is most common in patients unable tobear weight early and with prolonged cast immobilization. It is

characterized by initial pain and swelling followed by atrophy of limb.

Radiographic signs are spotty demineralization of foot and distal tibia and

equinovarus ankle. It is treated by elastic compression stockings, weight

bearing, sympathetic blocks, and foot orthoses, accompanied by aggressive

physical therapy.

o Compartment syndrome: Involvement of the anterior compartment is mostcommon. Highest pressures occur at the time of open or closed reduction. It

may require fasciotomy. Muscle death occurs after 6 to 8 hours. Deep

posterior compartment syndrome may be missed because of uninvolved

overlying superficial compartment, and results in claw toes.

oNeurovascular injury: Vascular compromise is uncommon except withhigh-velocity, markedly displaced, often open fractures. It most commonly

occurs as the anterior tibial artery traverses the interosseous membrane of

the proximal leg. It may require saphenous vein interposition graft. The

common peroneal nerve is vulnerable to direct injuries to the proximal

fibula as well as fractures with significant varus angulation. Overzealous

traction can result in distraction injuries to the nerve, and inadequate cast

molding/padding may result in neurapraxia.

o Fat embolism may occur.o Claw toe deformity: This is associated with scarring of extensor tendons or

ischemia of posterior compartment muscles.(3)


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DAFTAR PUSTAKA

1. Nalyagam S. Principles of Fractures. In: Solomon L. ApleysSystem of Orthopaedicsand Fractures. Ninth edition. UK: 2010. p. 687-693

2. Bucholz, Robert W.; Heckman, James D. Fractures of The Tibia and Fibula. In: Court-Brown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. UK:

Lippincott Williams & Wilkins. 2006. p. 2080-2143.

3. Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition. USA:Lippincott Williams & Wilkins. 2006.p. 340-352

4. Thompson, John C. Leg and Knee in: Netter's Concise Orthopaedic Anatomy. SecondEdition.Philadelphia: Saunders Elsevier. 2010.p. 294, 315-322

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