CASE REPORT

PRESENTED BY:
KAMAL FAUZEE
C11108760
ADVISORS:
DR. FADIL MULAPUTRA
DR. AHMAD RIZAN HENDRAWAN
SUPERVISOR:
DR. M. RUKSAL SALEH, PHD, SPOT(K)

Patients Identity
Name

: Ny LB
Age
: 45 years old
Sex
: Female
Date of Admission : 17th June 2014
Medical Record : 668263

History Taking
Anamnesis

: Patient came to Wahidin

Sudirohusodo Hospital with chief complaint of
pain at left lower leg, suffered since 30 minutes
before admission due to traffic accident.

Mechanism of Trauma : Patient cross the road

then suddenly got hit by a motorcycle from the left

side
No history of unconsciousness and vomitted.

Primary Survey:
Airway

: clear
Breathing : RR 18x/min, spontaneous,
thoracoabdominal type,
symmetrical
Circulation

: BP 130/80 mmHg, HR 82x/min,

regular, adequate

Disability : GCS 15 (E4M6V5) , pupil isocor,

: 2.5mm/2,5mm, light reflex +/+

Environment

: T: 36.5C (axillary)

Secondary Survey
Regio: Left Cruris
Look
Deformity (+), edema (+), hematoma (+), wound (+)

excoriation anterolateral aspect sized 2x1 cm

Feel
Tenderness(+)
Movement
Active & Passive movement of knee and ankle joint

cannot be evaluated due to pain.

NVD: normal sensibility, CRT < 2, pulsation of a.

dorsalis pedis is palpable.

Leg Length Discrepencies

Right

Left

ALL

89 cm

89 cm

TLL

82 cm

82 cm

LLD

0 cm

Clinical Findings

Radiology findings

LABORATORY FINDINGS
WBC : 17.0 x 103/mm3
RBC : 3.95 x 106/mm3
HGB : 12.1 g/dL
HCT : 35.8 %
PLT : 269 x 103/mm3
BT
: 30
CT

: 8 0

Resume

45 years old, female admitted with complaint of pain at the

lower left leg since 30 minutes ago due to traffic accident.
From physical examination seen deformity, edema,
hematoma, excoriation anterolateral aspect sized 2x1cm and
tenderness is noted at the wound site.
ROM of the knee and ankle joint cannot be evaluated due to
pain. NVD is normal
From radiological findings, we found that there are oblique
fracture of the 1/3 middle tibia and 1/3 middle fibula

Diagnosis
Closed fracture 1/3 middle left tibia
Closed fracture 1/3 middle left fibula

Management
IVFD
Analgesic
Apply long leg back slab of the left lower limb
Elevation of lower left limb
Observe for compartment syndrome
Plan for operative treatment ( Open Reduction

Internal Fixation )

Discussion

BASE OF DIAGNOSIS

high energy
injury / Direct
trauma
usually oblique
type of fracture
and usually
involve both
tibia and fibula

Anamnesis

Physical
examination:
Left leg region
Excoriated wound
Deformity (+)
angulation
Hematoma(+),
Edema (+)
Tenderness (+),
swelling (+),

Fracture obique
1/3 middle left os
tibia and fracture
oblique 1/3 middle
left os fibula fibula

Radiography

Koval KJ, Zuckerman JD. Tibia Fibula Shaft. Handbook of Fracture. 4th ed. New York: William & Wilkins; 2006. p. 387-97.
.

NVD examination on lower extremities

NERVES
SENSORIC
Superficial Peroneal

MOTORIC
Deep Peroneal

Tibialis

Superficial Peroneal
Deep peroneal

Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed. Saunders Elsevier. p. 316-22.

NVD examination
Artery
Dorsalis pedis
Tibialis Posterior

Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed. Saunders Elsevier. p. 316-22.

Radiology findings

Oblique fracture 1/3 middle left tibia

Oblique fracture 1/3 middle left fibula

Other Possible Injury

Compartment
Syndrome
Pain
Parlour
Pulseless
Paresthesia
Paralysis

If suspected,
The affected limb is place at the level of the heart
Release the bandages and casts
Immobilize the lower leg with the ankle in slight
plantar flexion

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.

Behaviour Of The Injury

TIBIA FIBULA

The severity of the bone injury? Oblique fracture

Stability of the fracture? Unstable
Displacement of the bone? From the radiology photo,

cortical apposition >50%

Soft tissue damage? Minimal to moderate

Influence the choice of treatment

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK:
Arnold. 2010.

Management

Conservative

Operative

Immobilization

Open Reduction
Internal Fixation

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.

Management
Conservative of Tibia Fibula fracture
- Closed reduction under general anaesthesia and a long
leg circular casting

Indication:
Minimal displaced with acceptable alignment

Closed fractures
Low energy trauma
Minimal soft tissue damage
Cortical apposition greater than 50%
Stable fracture pattern

< 5 varus-valgus
angulation
<10 AP/P
angulation
<1cm shortening

Miller DM, Thompson SR, Hart JA. Reviews of Orthopaedics. 6th edition. 2012. Elsevier Saunders. P.761

Management
Operation
Open Reduction Internal Fixation

Indication:
Unstable fractures that cannot be adequately maintained in a

reduced position
Failed non-operative management
Patients with fractures that are known to heal poorly following nonoperative management
Fracture in individuals who would poorly tolerate prolonged
immobilization

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK:
Arnold. 2010.

Complications
Early

Late

Neurovascular injury

Malunion, delayed
union, non-union
Muscle contracture

Compartment
syndrome

Joint stiffness

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK:
Arnold. 2010.