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OPEN COMMINUTIVE FRACTURE

RIGHT TIBIA GRADE IIIA,


OPEN FRACTURE RIGHT FIBULA GRADE IIIA
MUSDALIFA ANDI AHMAD C111 13 059
NURFAIDAH C111 13 060
IKA FITRI C111 13 061
A. TENRI LUWU C111 13 062
MUTMAINNAH C111 13 063

ADVISOR:
DR. KHRISNA YUDHA
DR. ADHIKA NUR S.A
SUPERVISOR:
DR. HENRY YURIANTO, M.PHIL, PH.D, SP.OT (K)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT


MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2018
IDENTITY
• Name : Mr. Z
• Age : 58 years old /male
th
• Admission : November 16 ,2018
at 19.26
• Registration: 863141
HISTORY TAKING
Chief Complaint: pain at right leg
History of illness
• Suffered since 29 hours before admitted to Wahidin General
Hospital.
Mechanism of trauma :
• Patient was riding a motorcycle and suddenly he was hit by ot
her motorcycle from the right side
• There was no history of decreased level of consciousness
• No history of projecting vomiting
• No history of hypertension and diabetic mellitus
• Patient was referred from Polewali General Hospital
PRIMARY SURVEY
Airway • Clear

• RR: 18 times/minute, regular,


Breathing thoracoabdominal

• HR: 84 times/minute, regular, palpable pulse


Circulation • BP: 120/80mmHg

Disability • E4M6V5

Exposure • Temp : 36.5o C


LOCALIZED STATUS
Right Leg Region
Look : Deformity (+), swelling (+), hematom (+), stiched wound at anterior
aspect with sized 9cm x 4cm with bone exposed, lacerated wound at
anterolateral aspect with size 5cm x 3cm with muscle based.
Feel : Tenderness (+)
Move : Active and passive movement of knee joint can not been evaluated
due to pain.
Active and passive movement of ankle joint can not been evaluated
due to pain.
NVD : Sensibility is good. Dorsalis pedis and tibialis posterior arteries
pulsation are palpable. Capillary refill time < 2 seconds.
CLINICAL FINDINGS
CLINICAL FINDINGS
CLINICAL FINDINGS
LEG LENGTH DISCREPANCY

Right Left

TLL 85 cm 87 cm

ALL 91 cm 93 cm

LLD 2 cm
RADIOLOGY
FINDING
LABORATORY FINDING
 WBC : 9,2x103/mm3  SGOT : 26 U/L
 HGB : 12.1 g/dL  SGPT : 15 U/L
 HCT : 38 %  Sodium : 142 mmol/l
 PLT : 159 x 103/mm3  Potassium : 4.0 mmol/l
 CT : 7’’00  Chloride : 110 mmol/l
 BT : 3’’00
 HbsAg : Non Reactive
 Ureum : 31 mg/dl
 Creatinin : 0.98 mg/dl
DIAGNOSIS

• Open Comminuted Fracture 1/3


middle Right Tibia grade IIIA
• Open Fracture 1/3 middle Fibula
grade IIIA
RESUME
Patient, male, 56 years old came with chief complain of pain at right leg
suffered since 29 hours before admitted to Wahidin General Hospital. Patient was
riding a motorcycle and suddenly he was hit by other motorcycle from the right side.
There was no history of decreased level of consciousness. No history of projecting
vomiting. No history of hypertension and diabetic mellitus. Patient was referred
from Polewali General Hospital.
Physical exam revealed a stiched wound at anterolateral aspect with sized
9cm x 4cm with bone based exposed, lacerated wound at anterolateral aspect with
size 5cm x 3cm with muscle based, there was deformity, swelling and tenderness at
the right leg region. Active and passive movement knee joint and ankle joint cannot
be evaluated due to pain. Neurovascular examination was within normal limits.
Radiologic examination revealed a fracture of 1/3 middle right tibia and
fracture of 1/3 middle fibula.
MANAGEMENT
• IVFD RL
• Analgesic
• Antibiotics
• Debridement & external fixation
• Wound care
DISCUSSION
EPIDEMIOLOGY
• Fracture of the tibia and fibula shaft are the most common
long bone fractures.
• In average population, there are about 26 tibial diaphyseal
fractures per 100.000 population per year.
• The highest incidence of adult tibia diaphyseal fractures
seen in young males is between 15 and 19 years of age,
with an incidence of 109 per 100,000 population per year.
• Diaphyseal tibia fractures have the highest rate of non
union for all long bones.

Handbook of Fractures 5th Edition, Chapter 37 : Tibia/Fibula Shaft Fracture


ANATOMY

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENT
OF LEG
Anterior compartment

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENT
OF LEG
Lateral compartment

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENT
OF LEG
Superficial posterior
compartment

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


COMPARTMENT
OF LEG
Deep posterior
compartment

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


MECHANISM OF INJURY
Direct
• High-energy bending: motor vehicle accident
– Transverse, comminuted, displaced fracture commonly occur
– Highly comminuted or segmental patterns are a associated
with extensive soft tissue compromise
– Compartment syndrome & open fractures must be ruled out

• Penetrating: Gunshot
– The injury pattern is variable but usually comminuted
– Low velocity missiles (handguns)

Handbook of Fracture, Chapter 37: Lower Extremity Fracture and Dislocations


MECHANISM OF INJURY
Direct
• Low-energy bending:
– Short oblique or transverse fracture occur, with a
possible butterfly fragment
– Compartment syndrome & open fracture may still occur.

• Fibula shaft fracture: these typically result from direct


trauma to the lateral aspect of the leg. Spiral fractures are
seen proximally with rotational ankle fractures or low-energy
twisting tibial injuries.

Handbook of Fracture, Chapter 37: Lower Extremity Fracture and Dislocations


MECHANISME OF INJURY
Indirect
• Torsional mechanism:
– Twisting with the foot fixed & falls from low heights are causes
– These spiral, nondisplaced fractures have minimal comminutio
n on associated with little soft tissue damaged
– Type 1 open fractures may be seen with this mechanism
• Stress Fracture
– In military recruits, these injuries most commonly occur at the
metaphyseal-diaphyseal junction
– Plain radiographic findings may be delayed several weeks.
Magnetic resonance imaging (MRI) is very sensitive for
detecting these injuries.

Handbook of Fracture, Chapter 37: Lower Extremity Fracture and Dislocations


CLASSIFICATION OF FRACTURE
• Clinical types: open fracture/ close fracture
• Etiology: traumatic fracture/ stress fracture/
pathologic fracture
• Configuration classification:

Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010


GUSTILO & ANDERSON CLASSIFICATION
OF OPEN FRACTURE

Mercer's Textbook of Orthopaedics and Trauma, 10th Edition (2012).pdf


FRACTURE MANAGEMENT
Recognize
Fracture site, types of fracture

Reduction
For adequate apposition and normal alignment of bone

Retention
Immobilize promote soft tissue healing

Rehabilitation
As early as possible by active and passive exercise (restore function)

Pengantar Ilmu Bedah Ortopedi, p. 326


INITIAL MANAGEMENT OF OPEN FRACTURE

Assesment
• Initial Evaluation
• Examination
• Antibiotic
• Role of Cultures in the Emergency
Room
• Radiographic Imaging and Other
Diagnostic Studies

Rockwood and Green’s Fractures in Adults, 8th edition (2015) pdf


Mercer's Textbook of Orthopaedics and Trauma, 10th Edition (2012).pdf
TREATMENT

Non • Close reduction

Operative

• External Fixation
Operative • Open Reduction
Internal Fixation (ORIF)

Kenneth J. Koval, Joseph D. Zuckerman – Handbook of Fracture 3rd edition, 2006


MANAGEMENT
Non-operative
Indications:
• Undisplaced or minimal displ
aced
• Closed fractures
• Low energy trauma
• Minimal soft tissue damage
• Stable fracture pattern
- Closed reduction under general anaesthesia and a long leg circular casting

Miller MD, Stephen R, Jennifer A et al. Trauma: Lower Extremity & Pelvis.In: Review of Orthopedics, 6th edition. Philadelphia. Elsever Saunder
Operative Treatment
Indications :
• Open fracture.
• Unstable fractures, comminuted fracture,
and associated with varying degrees of
soft-tissue trauma
• Associated vascular injury
• Fractures associated with compartment
syndrome.

Solomon. L. et al. Apley’s System of Orthopaedics and Fractures 9th Edition. New York : Arnold. 2010
COMPLICATION

Early Complications Late Complications


• Malunion
• Vascular Injury • Delayed Union
• Compartments Syndrome • Non Union
• Infection • Joints Stiffness

Solomon. L. et al. Apley’s System of Orthopedics and Fractures 9th Edition. New York : Arnold. 2010
THANK YOU
Intravenous Antibiotic Therapy
for Open Fractures

Latest British Orthopaedic Association online re


commendations (Open fractures of lower limb—
September 2009)
• Give antibiotics as soon as possible (within 3 hou
rs).
• Agent of choice co-amoxiclav (1.2 g 8 hourly), or
a cephalosporin (e.g., cefuroxime 1.5 g 8 hourly),
continued until first debridement (excision).
• At the time of first debridement, co-amoxiclav (1.
2 g) or a cephalosporin (such as cefuroxime 1.5 g
) and gentamicin (1.5 mg/kg) should be administe
red and co-amoxiclav/cephalosporin continued u
ntil soft tissue closure or for a maximum of 72 ho
urs, whichever is sooner.

Rockwood and Green’s Fractures in Adults, 8th edition (2015) pdf


• Gentamicin 1.5 mg/kg and either vancomycin 1 g or teicoplanin 800 mg
should be administered on induction of anesthesia at the time of skeletal
stabilization and definitive soft tissue closure. These should not be contin
ued postoperatively. Ideally start the vancomycin infusion at least 90 min
utes before surgery.

• True penicillin allergy (anaphylaxis) clindamycin (600 mg IV pre


-op/qds) in place of co- amoxiclav/cephalosporin. Lesser allergic react
ion to penicillin (rash, etc.) a cephalosporin is considered to be safe an
d is the agent of choice.

Rockwood and Green’s Fractures in Adults, 8th edition (2015) pdf


•Operative
•shortening of long side via epiphysiodesis of femur,
tibia, or both

•indications
•2-5 cm projected LLD

•Nonoperative
•shoe lift or observation only

•indications
•< 2 cm projected LLD at maturity
•outcomes
•not associated with scoliosis or back pain

•limb lengthening of short side

•indications
•> 5 cm projected LLD
•lengthening often combined with a shortening
procedure (epiphysiodesis, ostectomy) on long side
AO Classification