CASE PRESENTATION

CLOSED FRACTURE 1/3 PROXIMAL RIGHT TIBIA

CLOSED​ FRACTURE 1/3 PROXIMAL RIGHT FIBULA

Jefri Usman C111 12 032

Michael D Salim C111 12 896
Niniek Fitriani Muin C111 12 325
Wawan Indrawan M C111 12 272
Advisor:
dr. Yohannes Toban
dr. Moh. Asri Abidin
Supervisor:
dr. Henry Yurianto, M.Phil, Ph.D, Sp.OT (K)

Orthopedic and Traumatology

Faculty of Medicine ,Hasanuddin University
Makassar
2017
 CASE
PATIENT’S IDENTITY
REPORT
PATIENT’S IDENTITY
Name : A.N.A
HISTORY TAKING

PHYSICAL Age : 12 years old / boy

EXAMINATION
Date of Admission : September 25th, 2017
CLINICAL FINDING

Registration : 810136
INVESTIGATION

RESUME

ASSESMENT

THERAPY
 CASE HISTORY TAKING
REPORT
PATIENT’S IDENTITY
• Chief complaint : pain on right leg
• Felt since 1 days ago before admitted to the
hospital
HISTORY TAKING
• Mechanism of trauma: the patient rode motorcycle
PHYSICAL with his cousin, suddenly a car turn left and then
EXAMINATION his cousin suddenly hit the brake that makes the
CLINICAL FINDING patient flew away
• There is no history of vomiting
• The patient was admitted from Jeneponto Hospital
INVESTIGATION
to Wahidin Hospital
RESUME

ASSESMENT

THERAPY
 CASE PRIMARY SURVEY
REPORT
PATIENT’S IDENTITY
A : Clear
B : RR : 20x/min, symmetric, spontaneous,
HISTORY TAKING thoracoabdominal type.
PHYSICAL
C : HR : 100x/min, reguler, strong
EXAMINATION BP : 100/70 mmHg
CLINICAL FINDING D : GCS 15(E4M6V5), light reflex +/+ , pupil
isochoric, Ø : 2.5 mm/2.5mm,
INVESTIGATION E : T = 36.50 C (axillary)
RESUME

ASSESMENT

THERAPY
 CASE SECONDARY SURVEY
REPORT
• Left Leg Region
PATIENT’S IDENTITY – Look :
Deformity (+), swelling (+) , hematome (+), wound (-)
HISTORY TAKING – Feel :
PHYSICAL Tenderness (+)
EXAMINATION – Movement :
Active and passive movement of knee joint cannot be
CLINICAL FINDING evaluated due to pain
Active and passive movement of ankle joint cannot be
INVESTIGATION
evaluated due to pain
RESUME – NVD :
ASSESMENT Sensibility is good, Pulsation of dorsal pedis artery
and tibialis posterior artery are palpable, CRT < 2”
THERAPY
 CASE
LOCAL STATUS
REPORT
PATIENT’S IDENTITY
LLD ( Leg Length Discrepency)
HISTORY TAKING

PHYSICAL
EXAMINATION
ALL TLL
CLINICAL FINDING
R 80 72
INVESTIGATION

RESUME L 80 72
ASSESMENT

THERAPY LLD 0 cm
 CASE
CLINICAL FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY
Anterior Aspect
 CASE
CLINICAL FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY Medial Aspect of Right Leg

 CASE RADIOLOGY FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY

X- Ray Right Genu AP/Lateral

 CASE RADIOLOGY FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY

X- Ray Right Cruris AP/Lateral

 CASE RADIOLOGY FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

RESUME

ASSESMENT

THERAPY

X- Ray Left Genu AP/Lateral

 CASE
RESUME
REPORT
PATIENT’S IDENTITY
Boy, 12 years old, admitted to the
HISTORY TAKING Wahidin Sudirohusodo General Hospital
PHYSICAL with chief complain of pain on right
EXAMINATION
lower leg. Suffered since 1 day before
CLINICAL FINDING admitted due to motorcycle accident.
INVESTIGATION
Patient rode motorcycle with his
cousin, suddenly a car turn left and then
RESUME
his cousin suddenly hit the brake that
ASSESMENT
makes the patient flew away
THERAPY
 CASE
RESUME
REPORT
PATIENT’S IDENTITY From physical examination, deformity
(+) Swelling (+) hematom (+), there is
HISTORY TAKING no wound.
PHYSICAL
EXAMINATION
Active and passive movement of knee
joint cannot be evaluated due to pain.
CLINICAL FINDING
Active and passive movement of knee
INVESTIGATION joint cannot be evaluated due to pain
RESUME Neurovascular distal examination
ASSESMENT within normal limits.
THERAPY
 CASE
RESUME
REPORT
PATIENT’S IDENTITY From the radiology finding, there are :
HISTORY TAKING

PHYSICAL  Fracture of 1/3 proximal right tibia

EXAMINATION

CLINICAL FINDING
 Fracture of 1/3 proximal right fibula
INVESTIGATION

RESUME
ASSESMENT

THERAPY
 CASE
REPORT DIAGNOSIS

PATIENT’S IDENTITY

HISTORY TAKING
• Closed Fracture 1/3 Proximal Right
PHYSICAL
EXAMINATION Tibia
CLINICAL FINDING • Closed Fracture 1/3 Proximal Right
INVESTIGATION
Fibula
RESUME

ASSESMENT
THERAPY
 CASE
THERAPY
REPORT
PATIENT’S IDENTITY
• IVFD Ringer Lactate
HISTORY TAKING • Analgetic
PHYSICAL
EXAMINATION
• Immobilization with long leg back
slab
CLINICAL FINDING
• Elevation and observe NVD status
INVESTIGATION • Plan for conservative treatment
RESUME (circular casting)
ASSESMENT

THERAPY
 DISCUSSION
FRACTURE

ORTHOPAEDIC AND TRAUMATOLGY DEPARTEMENT

HASANUDDIN UNIVERSITY
 INTRODUCTION

If overlying skin

Fracture  a break in the remains intact
structural continuity of bone, Closed fractured
cartilage, joint and growth
plate. If skin not intact
Open Fractured

Nalyagam S. Principles of Fractures. In: Solomon L. Apley’s System of ORTHOPAEDICs and Fractures Ninth edition. 2010
ANATOMY

Thompson JC. Netter’s

Concise Orthopaedic
Anatomy 2nd Edition.
LEG
COMPARTMENT

Anatomy

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd Edition. | Orthobullets

 ANTERIOR
COMPARTMENT

• Tibialis anterior
• Extensor hallucis
longus
• Extensor digitorum
longus
• Peroneus tertius

Anatomy
Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010
 LATERAL
COMPARTMENT

• Peroneus longus
• Peroneus brevis

Anatomy
Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010
 SUPERFICIAL
POSTERIOR
COMPARTMENT

• M. Gastrocnemius
• M. Soleus
• M. Plantaris

Anatomy
Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010
 DEEP POSTERIOR
COMPARTMENT

• M. Posterior tibialis
• M. Flexor hallucis
longus
• M. Flexor
digitorum longus
• M. Popliteus

Anatomy
Thompson JD. Netter's Concise Atlas of Orthopedic Anatomy 2010
 HOW FRACTURES HAPPEN
Direct the bone breaks at the
point of impact
Injury/
Trauma bone breaks at a
distance from
Indirect
where the force is
applied
These fractures
occur in normal
Typically in
Repetitive bone which is
athletes, dancers
stress subject to
or military.
repeated heavy
Fractures
loading.may
occur even with
normal stresses if
Pathological osteoporosis, liytic
the bone has
fracture lesion
been weakened
by system
Solomon, L, Warwick D.L, Nayagam,S. Apley’s a change in itsand fractures. 9th editions.
of orthopedic
2010. p687-8 structure
 Mechanism of fracture

Direct High energy

Indirect Low energy trauma
trauma • Pathologic
• Motor vehicle fractures 
elderly
accident
• Stress fractures 
• Gunshot injury military recruits or
runners

Transvere and
butterfly fracture Spiral and oblique
fracture

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 Fracture of Shaft Tibia

Thompson JD.
Koval,Netter's
Kenneth j.;Concise
Zuckerman,Atlas ofhandbook
joseph d. Orthopedic Anatomy
of fractures, 2010
4th edition
 CHILD VS ADULT
CHILD ADULT

Bones are elastic; bones bend Bones are brittle; high chance
before breaking of breaking many bones
Healing process of broken bone Healing process is slower
is accelerated
A fracture or break through a If a fracture involves an adult
growth plate has the potential growth plate, it doesn’t cause
of stopping growth any special problem other than
permanently the broken bone
Bones continue to grow Bones has stopped growing

The periosteum is thick The periosteum is thin

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

TIBIAL FRACTURE ON PEDIATRIC
 PROXIMAL TIBIAL METAPHYSEAL
FRACTURES
• Most common is force applied to the lateral aspect
of the extended knee that causes the cortex of the
medial metaphysis to fail in tension, usually as
nondisplaced greenstick fractures of the medial
cortex.
• The fibula usually does not fracture, although plastic
deformation may occur

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 DIAPHYSEAL FRACTURES OF THE TIBIA
AND FIBULA
Mechanism of Injury
• Direct: mostly in the form of vehicular trauma or
pedestrian–motor vehicle accident.
• Indirect: most result from torsional forces. These
spiral and oblique fractures occur as the body
mass rotates on a planted foot.

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 FRACTURES OF THE DISTAL TIBIAL
METAPHYSIS
Mechanism of Injury
Indirect: An axial load results from a jump or fall
from a height.
Direct: such as in bicycle spoke injuries in which
a child’s foot is thrust forcibly between the
spokes of a turning bicycle wheel.

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 TODDLER’S FRACTURE

By definition is a spiral fracture of the tibia in

the appropriate age group.
The classic description of the mechanism of a
toddler’s fracture is external rotation of the
foot with the knee in fixed position, producing
a spiral fracture of the tibia with or without
concomitant fibular fracture.

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 STRESS FRACTURES
Mechanism of Injury
A stress fracture occurs when a bone is
subjected to repeated trauma with a strain
that is less than what would have produced an
acute fracture.
Stress fractures in older children and
adolescents tend to be as a result of athletic
participation.
Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition
• Patients typically present with an antalgic gait
that is relieved by rest, although younger
patients may refuse to ambulate.
• The pain is usually described as insidious in
onset, worse with activity, and improved at
night.

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

 How to Diagnose
Chief complain,
Mechanism of trauma,
History of prior
treatment
1. Look
2. Feel
2 3. Move
1 4. NVD
Physical
History Taking Examination (Pain, Swelling, Deformity)

4 1. Two views
3 2. Two joints
Laboratory
X-Ray
Examination 3. Two limbs
(rule of twos) 4. Two injuries
5. Two occasions

Solomon. L. et al. Apley’s System of ORTHOPAEDICs and Fractures 9 th Edition. New York : Arnold. 2010
 Goals of fracture management

Recognize
Fracture site, types of fracture

Reduction
For adequate apposition and normal allignment of bone

Retain
Maintain the reduction

Rehabilitation
Restore function
Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of ORTHOPAEDICs and Fractures 9th Edition. UK: Arnold. 2010.
 Treatment
CONSERVATIVE OPERATIVE

Indication : - Fail Conservative

- Open fracture
- Closed fracture
- Fracture associated with compartment
- Minimal Displaced syndrome
- For traction (avulsion) fractures in which
fragment are held apart
- Severely comminuted fractures
- Associated femoral fracture (floating knee)
Circular Casting
- unstable fractures in which adequate alignment
can not be either attained or maintained
- Patients with multisystem injuries

Internal Fixation
External Fixation

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 4th Edition.

 COMPLICATION

Early
Late
• Compartement syndrome
• Vascular injury
•Delayed union
• Nerve injury
•Non-union
•Malunion
•Joint stiffness

Solomon, L, Warwick D.L, Nayagam,S. Apley’s system of ORTHOPAEDIC and fractures. 8 th editions. 2008.
p695-9
 COMPLICATION
Conservative
• Compartement syndrome
• Angular deformity
• Malrotation
• Progressive valgus angulation Operative
• Premature proximal tibialphyseal closure
• Non union
•Delayed union
• Malunion
•Non-union
•Malunion
•Soft tissue loss
•Nerve injury

Solomon, L, Warwick D.L, Nayagam,S. Apley’s system of ORTHOPAEDIC and fractures. 8th editions. 2008.
p695-9