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BAGIAN ORTOPEDI &TRAUMATOLOGI

UNIVERSITAS HASANUDDIN

CASE REPORT
MEI 2014

OPEN FRACTURE 1/3 MIDDLE RIGHT TIBIA GRADE III A


OPEN FRACTURE 1/3 MIDDLE RIGHT FIBULA GRADE III A

Dibawakan oleh:
Muhammad Fadzhil Bin Amran

C 111 09 841

Pembimbing:
dr. Hendra Hermanto
dr. Abdul Rizan Hermawan
Supervisor:
dr W. Supriyadi, SpOT
Dibawakan dalam rangka Kepanikteraan klinik
di Bagian Ortopedi dan Traumatologi
Fakultas Kedokteran Universitas Hasanuddin
Makassar
2014

Case Report
I.

II.

PATIENTS IDENTITY
NAME

: Mrs. I

AGE

: 66 years old

GENDER

: Female

DATE OF ADMISSION

: 26th April 2014

MEDICAL RECORD

: 660847

HISTORY TAKING
CHIEF COMPLAINT: Wound at the right leg.
Suffered since 6 hours ago before admitted to the hospital due to traffic accident.
MOT: The patient was riding her motorcycle and was hit by another motorcycle at
her right side from the opposite direction which later caused the wound on her leg.
History of loss of conciousness (-), nausea (-), vomitting (-), headache (-).

III.

PHYSICAL EXAMINATION
A. PRIMARY SURVEY
Airway
Breathing

: Patent
:Respiratory

rate

18x/minutes,

symmetric,

spontaneous,

thoracoabdominal type
Circulation
Disability

: Blood pressure 120/80 mmHg, Pulse 80x/minutes, regular, strong


: GCS 15 (E4M6V5), light reflex +/+, pupil isochors 2,5cm/
2,5cm

Exposure

: Temperature 36,8C (axillary)

B. SECONDARY SURVEY
LEFT LEG REGION :
Look :
Stitched wound at distal aspect of cruris with circular pattern by the length
of 20cm.
Deformity (+), hematoma (+), edema(+), bone exposed (-), muscle exposed
(+)
Feel :
Tenderness (+), Sensibility are hypothesia at personal nerve distribution,
tibialis posterior artery is not palpable , CRT < 2 seconds.
Move :
Active and passive movement of the knee and ankle joints are not examined
due to pain.
IV.

CLINICAL PICTURE

Anterior view

Lateral view
Leg Length Discrepencies:

Apparent leg length


True leg length
Leg Length discrepancy

Right
71 cm
61 cm

Left
70 cm
60 cm
1 cm

V.

LABORATORY FINDINGS:

Date: 21/3/2014
WBC
RBC
HGB
HCT
PLT

VI.

13.5 x 10/uL
2.27 x 10/uL
6.5 g/dL
19.8 %
127 x 10/uL

BT
CT
HbsAg

3
7
Non reactive

RADIOLOGICAL FINDINGS
Left cruris film AP and lateral

Result : Fracture of 1/3 distal of tibia and 1/3 distal fracture of fibula of the cruris.

VII.

RESUME
Woman, 66 years old came to the hospital with wound at the right cruris
since 6 hours before admitted that was caused by traffic accident.
From physical examination of the left cruris, there are lacerated wound at
the anteromedial aspect of 1/3 distal of right cruris, horizontally with the size of 20
cm x 4 cm. There are hematoma , edema and pain. The active and passive ROM
are not evaluated due to pain. The sensibilities are good. Dorsalis pedis artery and
tibialis posterior artery are palpable and CRT is < 2 seconds.
Radiological findings shows features of fracture of 1/3 distal tibia of right
and 1/3 distal fracture of fibula.

VIII.

DIAGNOSIS

Open fracture 1/3 middle right tibia grade III A


Open fracture 1/3 middle right fibula grade III A

IX.

THERAPY
Initial treatment
IVFD
Analgesic
Immobilization
Antibiotic
Antitetanus
Planning
-

External Fixation

Debridement

FRACTURE OF TIBIA AND FIBULA

I.

INTRODUCTION
An open fracture refers to osseous disruption in which a break in the skin and
underlying soft tissue communicates directly with the fracture and its hematoma.
Any wound occurring on the same limb segment as a fracture must be suspected to
be a consequence of an open fracture until proven otherwise. Soft tissue injuries in
an open fracture may have three important consequences:
o

Contamination of the wound and fracture by exposure to the external


environment.

Crushing, stripping, and devascularization that results in soft tissue


compromise and increased susceptibility to infection.

Destruction or loss of the soft tissue envelope may affect the method of
fracture immobilization, compromise the contribution of the overlying soft
tissues to fracture healing (e.g., contribution of osteoprogenitor cells), and
result in loss of function from muscle, tendon, nerve, vascular, ligament, or
skin damage.(1)

II.

EPIDEMIOLOGY
Fractures of the tibia and fibula shaft are the most common long bone
fractures. In an average population, there are about 26 tibial diaphyseal fractures per
100,000 population per year. Men are more commonly affected than women, with
the male incidence being about 41 per 100,000 per year and the female incidence
about 12 per 100,000 per year. The average age of a patient sustaining a tibia shaft
fracture is 37 years, with men having an average age of 31 years and women 54
years.(2)

III.

ANATOMY
The tibia and fibula are the bones of the leg. The tibia articulates with the
condyles of the femur superiorly and the talus inferiorly and in doing so transmits
the body's weight. The fibula mainly functions as an attachment for muscles, but it
is also important for the stability of the ankle joint. The shafts (bodies) of the tibia
and fibula are connected by a dense interosseous membrane composed of strong
oblique fibers.(3)
A. Tibia
Tibia is located on the anteromedial side of the leg, nearly parallel to the
fibula, the tibia is the second largest bone in the body. The proximal end widens to
form medial and lateral condyles and there is tibial plateau, which articulate with
the lateral and medial condyles of the femur and the lateral and medial menisci
intervening. Separating the upper articular surfaces of the tibial condyles are
anterior and posterior intercondylar areas lying between these areas is the
intercondylar eminence.(3,4)
The shaft of the tibia is triangular in cross section, presenting three borders
and three surfaces. Its anterior and medial borders, with the medial surface between
them, are subcutaneous. At the junction of the anterior border with the upper end of
the tibia is the tuberosity, which receives the attachment of the ligamentum patellae.
The anterior border becomes rounded below, where it becomes continuous with the
medial malleolus. The lateral or interosseous border gives attachment to the
interosseous membrane. The lower end of the tibia is slightly expanded and on its
inferior aspect shows a saddle-shaped articular surface for the talus. The lower end
is prolonged downward medially to form the medial malleolus.(3,4)

B. Fibula
The fibula is the slender lateral bone of the leg. It takes no part in the
articulation at the knee joint, but below it forms the lateral malleolus of the ankle
joint. It takes no part in the transmission of body weight, but it provides attachment
for muscles. The fibula has an expanded upper end, a shaft, and a lower end. The
upper end, or head, is surmounted by a styloid process. It possesses an articular
surface for articulation with the lateral condyle of the tibia. The shaft of the fibula is
long and slender. Typically, it has four borders and four surfaces. The medial or
interosseous border gives attachment to the interosseous membrane. The lower end
of the fibula forms the triangular lateral malleolus, which is subcutaneous. On the
medial surface of the lateral malleolus is a triangular articular facet for articulation
with the lateral aspect of the talus. Below and behind the articular facet is a
depression called the malleolar fossa. (3,4)

Picture 1: Anatomy of tibia and fibula. (5)


The anterior compartment, or dorsiflexor (extensor) compartment, is located
anterior to the interosseous membrane, between the lateral surface of the tibial shaft

and the medial surface of the fibular shaft, and anterior to the intermuscular septum
that connects them. The anterior compartment is bounded anteriorly by the deep
fascia of the leg and skin. The deep fascia of the leg overlying the anterior
compartment is dense superiorly, providing part of the proximal attachment of the
muscle immediately deep to it. The four muscles in the anterior compartment are the
tibialis anterior, extensor digitorum longus, extensor hallucis longus, and fibularis
tertius. These muscles pass and insert anterior to the transversely oriented axis of
the ankle joint and, therefore, are dorsiflexors of the ankle joint, elevating the
forefoot and depressing the heel. The long extensors also pass along and attach to
the dorsal aspect of the digits and are thus extensors of the toes.(4)
The lateral compartment is the smallest (narrowest) of the leg compartments,
bounded by the lateral surface of the fibula, the anterior and posterior intermuscular
septa, and the deep fascia of the leg. The lateral compartment contains the fibularis
(peroneus) longus and brevis muscles.(4)

Picture 2: Muscles of the cruris.(5)


The posterior compartment (plantar flexor compartment, is the largest of the
three leg compartments. The posterior compartment and the calf muscles within it
are divided into superficial and deep subcompartments/muscle groups by the
transverse intermuscular septum. The tibial nerve and posterior tibial and fibular
vessels supply both parts of the posterior compartment but run in the deep
subcompartment deep (anterior) to the transverse intermuscular septum. Muscles of
the posterior compartment produce plantarflexion at the ankle, inversion at the
subtalar and transverse tarsal joints and flexion of the toes. The superficial group of
calf muscles are the gastrocnemius, soleus, and plantaris. Thus, the muscles of the
posterior compartment of the leg are popliteus, flexor digitorum longus, flexor
hallucis longus, and tibialis posterior.(4)

Picture 3: Muscles of the cruris.(5)

IV.

ETIOPATHOMECHANISM
Fractures result from injury, repetitive stress or abnormal weakening of the bone (a
pathological fracture).(6)

1. Fracture due to injury:


Most fractures are caused by sudden and excessive force, which may be
direct or indirect. With a direct force the bone breaks at the point of impact; the soft
tissues also are damaged. A direct blow usually splits the bone transversely or may
bend it over a fulcrum so as to create a break with a butterfly fragment. Damage to
the overlying skin is common; if crushing occurs, the fracture pattern will be
comminuted with extensive soft-tissue damage.(2,6)
With an indirect force the bone breaks at a distance from where the force is
applied; soft-tissue damage at the fracture site is not inevitable. Although most
fractures are due to a combination of forces (twisting, bending, compressing or
tension), the x-ray pattern reveals the dominant mechanism:

Twisting causes a spiral fracture

Compression causes a short oblique fracture.

Bending results in fracture with a triangular butterfly fragment

Tension tends to break the bone transversely; in some situations it may simply
avulse a small fragment of bone at the points of ligament or tendon insertion. (2,6)

2. Fracture due to repititive stress:

These fractures occur in normal bone which is subjected to repeated heavy


loading, typically in athletes, dancers or military personnel who have gruelling
exercise programmes. These high loads create minute deformations that initiate the
normal process of remodelling a combination of bone resorption and new bone
formation in accordance with Wolffs law. When exposure to stress and
deformation is repeated and prolonged, resorption occurs faster than replacement
and leaves the area liable to fracture. A similar problem occurs in individuals who
are on medication that alters the normal balance of bone resorption and
replacement. (2,6)

3. Pathological fracture:
Fractures may occur even with normal stresses if the bone has been
weakened by a change in its structure (e.g. in osteoporosis, osteogenesis imperfecta
or Pagets disease) or through a lytic lesion (e.g. a bone cyst or a metastasis). (6)

V.

CLINICAL FEATURES
The limb should be carefully examined for signs of soft-tissue damage, bruising,

severe swelling, crushing or tenting of the skin, an open wound, circulatory changes, weak

or absent pulses, diminution or loss of sensation and inability to move the toes. Any
deformity should be noted before splinting the limb.(6)
The open fracture of the long bone can be grading according to the classification of
Gustilo and Anderson. It is classify based on the size of the wound, the level of
contamination, soft tissue injury and bone injury involves.(1,6)

Table 1: Gustilo and Anderson Classification of Open Fractures.(1)

Table 2 : Johner & Wruhs Classification of tibial fracture.

VI.

DIAGNOSTIC TEST
X-ray of the entire length of the tibia and fibula, as well as the knee and
ankle joints, must be seen. The type of fracture, its level and the degree of
angulation and displacement are recorded. Rotational deformity can be gauged by
comparing the width of the tibio-fibular interspace above and below the fracture.
Spiral fractures without comminution are low energy injuries. Transverse, short
oblique and comminuted fractures, especially if displaced or associated with a
fibular fracture at a similar level, are high energy injuries.(6)

VII.

TREATMENT
A. Non-operative
Antibiotics are given as the indication for open fracture to prevent further
infection. the antibiotics used are depends on the grading of the open fracture. The
grade I and II, we use cefalosporin and for grade III is aminoglicoside. Anti tetanus
can be given to prevent tetanus prophylaxis. 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.
(1,6)

External fixation principles are only temporary during application of damage


control. Temporary for highly contaminated fractures. Have higher incidence of
malalignment than IM nails and can be safely converted to IM nail within 7-21
days. Primarily used to treat severe open fractures, it can also be indicated in closed
fractures complicated by compartment syndrome, concomitant head injury, or
burns.Its popularity in the United States has waned with the increased use of reamed

nails for most open fractures.I Union rates:Up to gD%,with an average of 3.6
months to union.The incidence of pin tract infections is l0% to l5%.(2)

B. Operative
Debridement is suggested if the wound are highly contaminated. Besides
that, external fixation and or internal fixation can be suggested if the condition are
indicated. The internal fixation are such as medullary nailing or plate and screw.(1)
While external fixation is an alternative to closed nailing, as it avoids exposure of
the fracture site and allows further adjustment to be made if needed. Then, partial
weightbearing will be used from the start and the external fixator can be replaced by
a functional brace once there are sign of union of the bones.(2)
For the distal Tibia Fractures the risk for malalignment also exists with the
use of an IM nail.With IM nailing, fibula plating or use of blocking screws may
help to prevent malalignment.Use of a percutaneously inserted plate has had recent
popularity. Plates and Screws are generally reserved for fractures extending into the
metaphysis or epiphysis.I Reported success rates as high as 97%.Complication rates
of infection, wound breakdown, and malunion.(2)
VIII. COMPLICATION
a. Early complication:
Vascular Injury :
Fractures of the proximal half of the tibia may damage the popliteal artery.
Damage to one of the two major tibial vessels amy also occur and go unnoticed if
there is no critical ischaemia.(1)
Compartment syndrome:

Tibial fractures, both open and closed are among the commonest causes of
compartment syndrome in the leg. The combination of tissue edema and bleeding
(oozing) causes swelling in the muscle compartment and this may precipitate
ischaemia. Additional risk factors are proximal tibial fractures, severe crush injury,
a long ischaemic period before revascularization ( type IIIC open fractures).
The diagnosis is usually suspected on clinical grounds. Warning symptoms
are increasing pain, a feeling of tightness or bursting in the leg and numbness in
the leg or foot. These complaints should always be taken seriously and followed by
careful and repeated examination for pain provoked by muscle stretching and loss of
sensibility and/or muscle strength.(1)

Infection :
Open fractures are always at risk; even a small perforation should be treated
with respect and debridement carried out before the wound is closed. If the
diagnosis is suspected, wound swabs and blood samples should be taken and
antibiotic treatment started forthwith, using a best guess intravenous preparation;
once the laboratory results are obtained, a more suitable antibiotic may be
substituted. With established infection, skeletal fixation should not be abandoned if
the system is stable; infection control and fracture union are more likely if fixation
is secure. However, if there is a loose implant it should be removed and replaced by
external fixation.(1)
Neurovascular injury:
Vascular compromise is uncommon except with high-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.(2)

Compartment syndrome:
Involvement of the anterior compartment is most common. 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.(2)

Late complication:
Malunion
Slight shortening (up to 1.5 cm) is usually of little consequence, but rotation
and angulation deformity, apart from being unsightly, can be disabling because the
knee and ankle no longer move in the same plane. Angulation should be prevented
at all stages; anything more than 7 degrees in either plane is unacceptable.
Angulation in the sagittal plane, especially if accompanied by a stiff equinus ankle,
produces a marked increase in sheer forces at the fracture site during walking; this
may result in either refracture or non-union.(1)
Delayed union
High-energy fractures are slow to unite and liable to non-union or fatigue
failure if a nail has been used. If there is insufficient contact at the fracture site,
either through bone loss or comminution, prophylactic bone grafting as soon as
the soft tissues have healed is). If there is a failure of union to progress on x-ray by
6 months, secondary intervention should be considered. The first nail is removed,

the canal reamed and a larger nail reinserted. If the fibula has united before the tibia,
it should be osteotomized so as to allow better apposition and compression of the
tibial fragments.(1)

Non-union
This may follow bone loss or deep infection, but a common cause is faulty
treatment.Either the risks and consequences of delayed union have not been
recognized, or splintage has been discontinued too soon, or the patient with a
recently united fracture has walked with a stiff equinus ankle. Hypertrophic nonunion can be treated by intra - medullary nailing (or exchange nailing) or
compression plating. Atrophic non-union needs bone grafting in addition. If the
fibula has united, a small segment should be excised so as to permit compression of
the tibial fragments. Intractable cases will respond to nothing except radical Ilizarov
techniques.(1)

REFERENCES
1. Koval KJ, Zuckerman JD. Open fracture. Handbook of Fracture. 3rd ed. New York:
William & Wilkins; 2006. p. 20-28.
2. Koval KJ, Zuckerman JD. Tibia Fibula Shaft. Handbook of Fracture. 4th ed. New
York: William & Wilkins; 2006. p. 387-97.
3. Moore, Keith L, Dalley, Arthur F. Tibia and Fibula. Clinically Oriented Anatomy.
5th ed. New York: Lippincott Williams & Wilkins; 2006. p. 567-653.
4. Snell RS. The Lower Limb. Clinically Anatomy by Regions. 8th ed. New York:
Lippincott Williams & Wilkins; p. 614-7.
5. Thompson JC. Leg and Knee.

Netter Concise Orthopaedic Anatomy. 2nd ed.

Saunders Elsevier. p. 316-22.


6. Solomon L, Warwick D, Nayagam S. Principle of Fracture. Apley's System of
Orthopaedics and Fractures. 8th ed. London: Hodder Arnold; 2010. p. 706-904.