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ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY


DESEMBER 2015

OPEN FRACTURE 1/3 DISTAL RIGHT FIBULA GRADE IIIB


OPEN FRACTURE SEGMENTAL RIGHT TIBIA GRADE IIIB

Presented by
Ainil Fatima Zainodin

Advisor
dr. Rizan
dr. Jansen
Supervisor
dr. M. Ruksal Saleh, Ph.D, Sp. OT (K)
CASE REPORT
PATIENT’S IDENTITY

Name •N

Register No. • 733403

Sex • Male

Age • 40 years old

Date of admission • November 17th 2015


HISTORY TAKING
Chief Complain : Pain at right leg
 Suffered since 2 hours before admitted to Wahidin
General Hospital due to vehicle accident.
 Mechanisms of trauma : Patient was riding a
motorcycle when suddenly another motorcycle hit
him from the right side.
 History of unconsciousness (-), vomiting (-)

 The patient had prior treatment at Gowa Local


Hospital and was referred to Wahidin General
Hospital.
PRIMARY SURVEY

• Patent
Airway • Airway blockage (-)
• RR: 18x/min, Symmetric
Breathing • Thoracoabdominal type
• 90x/min, regular, strong, full
Circulation • BP: 110/80mmHg

Disability • GCS 15 (E4M6V5), Pupil isokor Ɵ


2,5 mm / 2,5 mm, LR +/+

Environment • 36.8°C (axilla)


SECONDARY SURVEY

Right Leg Region


Look Deformity (+), Swelling (+), Hematoma (-),
Wound (+) at anteromedial aspect as level as 1/3 distal tibia
sized 13 x 8 x 4 cm with bone and muscle exposed.
Feel Tenderness (+).
Move Active and passive motions of knee joint can not be evaluated
due pain.
Active and passive motions of ankle joint can not be
evaluated due to pain.
NVD •Sensibility is good,
•Pulsation of the dorsalis pedis artery and tibialis posterior
artery are palpable.
•CRT <2”
LEG LENGTH DISCREPANCY
R L
ALL 96 cm 97 cm
TLL 87 cm 88 cm
LLD 1 cm
CLINICAL PHOTOS

ANTERIOR VIEW
LATERAL VIEW

MEDIAL VIEW
RADIOLOGY IMAGING

Fracture segmental Os Tibia Dextra

Fracture 1/3 Distal Os Fibula Dextra

RIGHT CRURIS : AP + LATERAL


LABORATORY FINDINGS

Result Normal Level

WBC 13.300/ul 4,00-10,0

RBC 4,81 4,50-6,50

HGB 14,0 14,0-18,0

HCT 41,8 40,0-54,0

PLT 208 150-400

CT 7’ 00’’ 4-10

BT 3’ 00’’ 1-7

HBsAg Non Reactive Non Reactive


RESUME

Male, 40 y.o, with open fracture segmental on right tibia grade


IIIB and open fracture 1/3 distal on right fibula grade IIIB due
to traffic accident with LLD 1cm, normal neurovascular status,
range of motion knee and ankle can’t be evaluated due to pain.
DIAGNOSIS
• Open Fracture 1/3 Distal Right Fibula Grade IIIB
• Open Fracture Segmental Right Tibia Grade IIIB
TREATMENT

o IVFD RL
o Antibiotic
o Analgesic
o Tetanus Prophylaxis
o Plan for Debridement and External Fixation
DISCUSSION
{ FRACTURE TIBIA & FIBULA
EVIDENCES LEADING TO DIAGNOSIS
PATIENT EVALUATION

Right leg region


• Pain on right leg
• Deformity
• History of trauma
• Swelling
• Open wound
• Tenderness
History Physical • Pain on movement
taking Examination • NVD is normal

Open Fracture of Tibia & Fibula


+ No neurovascular complication
+ No tendency into compartment syndrome
EVIDENCES LEADING TO DIAGNOSIS
PATIENT EVALUATION

In this patient had high energy trauma from direct hit in a motor vehicle accident which
results in fracture segmental on Os Tibia Dextra and fracture 1/3 distal Os Fibula Dextra
INJURY CLASSIFICATION FOR OPEN FRACTURE

Gustilo and Anderson classification

In this patient the wound size was >10 cm long, contaminated and the fractured bone
can be adequately covered by soft tissue with high energy trauma from direct hit in a
motor vehicle accident which results in fracture segmental on Os tibia and fracture 1/3
distal Os fibula dextra.
Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition
TREATMENT

Antibiotics
Debridement
Prophylaxis

Early
Stabilization definitive
wound cover
Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of Orthopedics and Fractures 9th Edition. UK: Arnold. 2010.
Debridement
•To remove constraint
•Removal of devitalized tissue
•Wound cleansing
•Prevent severe infection
•Promote healing

Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.
Operative

Indications
• Unstable fracture
• Open fracture
• Intra articular fracture
• Assosiated with vascular complication
• Failed of closed reduction
Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of Orthopaedics and
Fractures 9th Edition. UK: Arnold. 2010.
External Fixation

• Indication of External Fixation for this patient.


• Fracture associated with severe soft tissue damage
(including open fracture) or those that
contaminated, where internal fixation is risky &
repeated access is needed for wound inspection and
dressing.

Complication
• Joint stiffness
• Over distraction
• Pin tract infection

Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.
COMPLICATION

Early Late

Neurovascular injury. Malunion


Delayed union
Compartment syndrome Non-union
Infection Disuse osteoporosis
Joint stiffness

Solomon, L, Warwick D.L, Nayagam,S. Apley’s system of orthopedic and fractures. 8th editions. 2008. p695-9
THANK YOU
{
Questions:

1. Can you explain how compartment


syndrome can occurs in this case?

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