8/12/2019 Word Angga
1/21
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
8/12/2019 Word Angga
2/21
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
8/12/2019 Word Angga
3/21
NVD : Sensory : Sensibilitas is goodMotoric : extend big toe
Vascular : dorsalis pedis artery is palpable, capillary refill time is
less than 2 seconds
CLINICAL PICTURES
8/12/2019 Word Angga
4/21
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
8/12/2019 Word Angga
5/21
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.
8/12/2019 Word Angga
6/21
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
8/12/2019 Word Angga
7/21
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
8/12/2019 Word Angga
8/21
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.
8/12/2019 Word Angga
9/21
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)
8/12/2019 Word Angga
10/21
Picture 3The Anterior Compartment(4)
Picture 4Lateral Anterior(4)
Anterior tibialis
Extensor hallucis longusExtensor digitorum longus
Fibularis eroneus lon us
8/12/2019 Word Angga
11/21
Picture 5Superficial Posterior Compartment(4)
Picture 6Deep Posterior Compartment(4)
Soleus musclePlantaris muscle
Tibialis posterior
Flexor hallucis longus muscle
Flexor digitorum longus
Polpiteal muscle
8/12/2019 Word Angga
12/21
Picture 7Fibrosseus Compartment of the Leg(2)
5. Fracture Type of Tibia and Fibula
Picture 8Fracture Type of Tibia and Fibula(4)
8/12/2019 Word Angga
13/21
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
8/12/2019 Word Angga
14/21
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?
8/12/2019 Word Angga
15/21
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.
8/12/2019 Word Angga
16/21
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.
8/12/2019 Word Angga
17/21
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)
8/12/2019 Word Angga
18/21
8/12/2019 Word Angga
19/21
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.
8/12/2019 Word Angga
20/21
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)
8/12/2019 Word Angga
21/21
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