CASE REPORT

OPEN COMMINUTIVE FRACTURE OF THE RIGHT

TIBIA AND SEGMENTAL FRACTURE OF THE FIBULA
GRADE IIIA

Irham Khairi
C 111 10 820
Advisor:
dr. M. Luthfi Muammar
dr. Andika
Supervisor:
dr. Muhammad Sakti, Sp.OT

Department of Orthopedic and Traumatology

Faculty of Medicine Hasanuddin University
Makassar
2015

PATIENT IDENTITY
Name
:B
Age / Sex : 50 years old/ male
Address
: Emmy Saelan Makassar
Admission : January 8th, 2015
MR
: 479019

HISTORY TAKING

Chief complain : Wound at the right leg

Anamnesis : Suffered since 15 minutes before
admitted to the hospital due to traffic accident
Mechanism of trauma : The patient was cross the
street then got hit by a motorcycle from the right
side.
History of unconsciousness (-), nausea (-), vomited
(-).

Primary Survey
A : Patent
B : RR = 20 x/min, spontan, thoracoabdominal type.
C : BP = 120/80 mmHg, RR = 7 x/min, regular,
strong palpable.
D : GCS 15 (E4M6V5), pupil isochors, : 2.5 mm /2.5
mm , light reflex +/+
E : T = 36.5o C (axillar temp)

Secondary Survey
Right Leg Region
I : Lacerated wound at middle side from anterior aspect
extend to medial aspect, sized 10 x 5 x 2 cm, deformity
(+), swelling (+), hematoma (+), muscle exposed (+),
bone exposed (+).
P : Tenderness (+)
ROM : active and passive motion at knee and ankle joint are
limited due to pain
NVD : sensibility is good, the pulse of dorsalis pedis artery is
palpable, capillary refill time < 2

LABORATORY FINDINGS
WBC
RBC
HGB
HCT
PLT
CT
BT

14,72 x 103 /uL

4,02 x 106 /uL
12,4 gm/dL
36,3 %
223 x 103 /uL
7 00
230

CLINICAL PICTURES

Radiologic findings

Diagnosis
Open comminutive fracture of the right tibia
grade III A
Open segmental fracture of the right fibula
grade III A

MANAGEMENT
IVFD
RL
Antibiotic
Anti tetanus
Analgesic
Debridement
Immobilize fracture with long leg back slab

Planning :
1. Plan for ORIF

SUMMARY

Male 50 years old, admitted to the hospital with

chief complain of wound at right leg region due to
traffic accident.
On physical Examination lacerated wound sized
10cm x 5cm x 2 cm at at anterior aspect extend to
medial aspect, deformity (+), swelling (+),
hematoma (+), muscle exposed (+), bone exposed
(+).
ROM of knee joint and ankle joint was limited due to
pain.
NVD: within normal limited
On radiologic examination, there are comminutive
fracture at the right tibia and segmental fracture at
the right fibula

DISCUSSION
FRACTURE OF TIBIA
AND FIBULA

INTRODUCTION
Open fracture means that bone
penetrated skin resulting in open wound
and exposed to external environment.
Tibia is the major weight bearing of the
leg (85% of the whole load), while
fibula responsible for 6% -17% of
weight bearing load.

Anatomy

COMPARTMENTS OF THE LOWER

LEG

Anterior Compartement

Thompson,JD. Netter's concise atlas of orthopedic

Lateral Compartement

Thompson,JD. Netter's concise atlas of orthopedic

anatomy.2004.

Superficial Posterior
Compartement

Thompson,JD. Netter's concise atlas of orthopedic

anatomy.2004.

Deep Posterior
Compartement

Thompson,JD. Netter's concise atlas of orthopedic

anatomy.2004.

innervatio
n

Thompson,JD. Netter's concise atlas of orthopedic

anatomy.2004.

Vascularitation

Thompson,JD. Netter's concise atlas of orthopedic

anatomy.2004.

Mullers Classification
PROXIMAL

DISTAL

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys

system of orthopaedic and fractures. 8th edition. New York: Oxford University

MECHANISM OF INJURY
Indirect

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys

system of orthopaedic and fractures. 8th edition. New York: Oxford University

Gustilo and Anderson

Classification for open fracture
Type

Wound

Level of
contamination

Soft tissue injury

Bone injury

< 1 cm
long

Clean

Minimal

Simple, minimal
comminution

II

> 1 cm
long

Moderate

Moderate, some muscle

damage

Moderate
comminution

IIIA

Usually
> 10 cm

High

Severe with crushing

Usually comminuted;
soft tissue coverage of
bone possible

IIIB

Usually
> 10 cm

High

Very severe loss of

coverage; usually require
soft tissue reconstruction
surgery

Bone coverage poor;

variable may be
moderate to severe
comminution

IIIC

Usually
> 10 cm

High

Vascular injury requiring

repair

Kenneth Koval, et al. Handbook of fractures third edition. 2006. Lippincott Williams and

TYPES OF TIBIA AND FIBULA SHAFT

FRACTURES

Thompson, Jon C. Netter Concise Orthopaedic Anatomy 2nd Ed. China : Saunders.

Clinical features

Soft tissue damage :

bruise
severe swelling
crushing or tenting of skin
open wound
circulatory changes
weak or absent pulses
diminution or loss of sensation and ability to move the
toes

Deformity
Alert for impending compartment syndrome

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys

system of orthopaedic and fractures. 8th edition. New York: Oxford University
Press Inc; 2001.

Diagnosis

History Taking :
History of illness,
Mechanism of trauma

Physical examination:
LOOK, FEEL, MOVE (examine the good limb
the bad limb)

X- ray, with rule of 2:

2 view, 2 limb, 2 joint, 2 occasion, 2 injuries

Laboratory examination

Goals of fracture management

Recognize

Management

Low energy fracture

Non operative:

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys

system of orthopaedic and fractures. 8th edition. New York: Oxford University

High energy fracture

Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys system of

orthopaedic and fractures. 8th edition. New York: Oxford University Press Inc; 2001.

Complication
Early complications
Compartment syndrome
Vascular injury
Infection
Late complications
Malunion
Delayed union
Non union
Joint stiffness
Solomon L, Warwick D, Nayagam S. Injuries of the knee&leg. In: Apleys system of
orthopaedic and fractures. 8th edition. New York: Oxford University Press Inc; 2001.

THANK YOU