ACKNOWLEDGEMENT

The internship opportunity I had at Operation Theatre Department, Hospital Slim

River was a great chance for learning and professional development. Therefore, I consider
myself as a very lucky individual as I was provided with an opportunity to be part of it. I am
also grateful for having a chance to meet so many wonderful people who led me though this
internship period.

Bearing in mind previous I am using this opportunity to express my deepest gratitude

and special thanks to our clinical instructor Encik Mahidzir Bin Hassan, Puan Maimunah
Binti Ahmad and our lecturer who in spite of being extraordinary busy with their duties, took
time out to hear, guide and keep me on the correct path and allowing me to carry out my
project at their esteemed organization, extending during the training and giving necessary
advices and guidance and arranged all facilities to make life easier.

It is my radiant sentiment to place on record my best regards, deepest sense of

gratitude to Hospital Slim River and all the staff and doctor at Operation Theatre Department
for their careful and precious guidance which were extremely valuable for my study both
theoretically and practically.

Last but not least, I would like to thank my batch mates who guide me on the correct
path and giving advice during carry out my project.

I perceive as this opportunity as a big milestone in my career development. I will

strive to use gained skills and knowledge in the best possible way, and I will continue to work
on their improvement, in order to attain desired career objectives. Hope to continue
cooperation with all of you in the future.

1
 INTRODUCTION

The tibia is the main bone of the lower leg, forming what is more commonly known as the
shin. It expands at its proximal and distal ends; articulating at the knee and ankle joints
respectively. The tibia is the second largest bone in the body and it is a key weight-
bearing structure.

Overview of the tibia in the human skeleton

Proximal:

The proximal tibia is widened by the medial and lateral condyles, which aid in weight-
bearing. The condyles form a flat surface, known as the tibial plateau. This structure
articulates with the femoral condyles to form the key articulation of the knee joint. Located
between the condyles is a region called the intercondylar eminence – this projects upwards
on either side as the medial and lateral intercondylar tubercles. This area is the main site of
attachment for the ligaments and the menisci of the knee joint. 

The tibial plateau. The tibial condyles articulate with the femoral
condyles to form the knee joint.

2
 Shaft:

The shaft of the tibia is prism-shaped, with three borders and three surfaces; anterior,
posterior and lateral.

 Anterior border – palpable subcutaneously down the anterior surface of the leg as
the shin. The proximal aspect of the anterior border is marked by the tibial tuberosity; the
attachment site for the patella ligament.

 Posterior surface – marked by a ridge of bone known as soleal line. This line is the
site of origin for part of the soleus muscle, and extends inferomedially, eventually blending
with the medial border of the tibia. There is usually a nutrient artery proximal to the soleal
line.

 Lateral border – also known as the interosseous border. It gives attachment to the
interosseous membrane that binds the tibia and the fibula together.

Bony landmarks of the tibial shaft.

Distal:

The distal end of the tibia widens to assist with weight-bearing.The medial malleolus is a

bony projection continuing inferiorly on the medial aspect of the tibia. It articulates with the
tarsal bones to form part of the ankle joint. On the posterior surface of the tibia, there is
a groove through which the tendon of tibialis posterior passes.

Laterally is the fibular notch, where the fibula is bound to the tibia – forming the tibiofibular
joint.

3
 DEFINITION
The tibia, or shinbone, is the most commonly fractured long bone in the body. A tibial shaft
fracture occurs along the length of the bone, below the knee and above the ankle. It typically
takes a major force to cause this type of broken leg. Motor vehicle collisions, for example,
are a common cause of tibial shaft fractures. In many tibia fractures, the smaller bone in the
lower leg (fibula) is broken as well.
The lower leg is made up of two bones: the tibia and fibula. The tibia is the larger of the two
bones. It supports most of your weight and is an important part of both the knee joint and
ankle joint.

The tibia is the larger bone in your lower leg. Tibial shaft fractures occur along the length of the bone.

Types of Tibial Shaft Fractures

Tibia fractures vary greatly, depending on the force that causes the break. The pieces of bone
may line up correctly (stable fracture) or be out of alignment (displaced fracture). The skin
around the fracture may be intact (closed fracture) or the bone may puncture the skin (open
fracture). In many tibia fractures, the fibula is broken as well. Tibia fractures are classified
depending on:
 The location of the fracture (the tibial shaft is divided into thirds: distal, middle,
and proximal)

4
  The pattern of the fracture (for example, the bone can break in different
directions, such as crosswise, lengthwise, or in the middle)
 Whether the skin and muscle over the bone is torn by the injury (open fracture)
The most common types of tibial shaft fractures include:
Transverse fracture: In this type of fracture, the break is a straight horizontal line going across
the tibial shaft.
Oblique fracture: This type of fracture has an angled line across the shaft.

(Left) A transverse fracture has a horizontal line across the

shaft. (Right) An oblique fracture has an angled line across the shaft.

Spiral fracture: 
- The fracture line encircles the shaft like the stripes on a candy cane. This type of fracture is
caused by a twisting force.
Comminuted fracture: 
- In this type of fracture, the bone breaks into three or more pieces.
Open fracture: 
- If a bone breaks in such a way that bone fragments stick out through the skin or a wound
penetrates down to the broken bone, the fracture is called an open or compound fracture.
Open fractures often involve much more damage to the surrounding muscles, tendons, and
ligaments. They have a higher risk for complications—especially infections—and take a
longer time to heal.

5
(Left) A spiral fracture encircles the shaft.  (Middle) A comminuted fracture is broken into three or more pieces. (Right) An open fracture
breaks through the skin. A transverse fracture pattern is shown here, but an open fracture can occur with any fracture pattern. 

ETIOLOGY
Tibial shaft fractures are often caused by some type of high-energy collision, such as a motor
vehicle or motorcycle crash. In cases like these, the bone can be broken into several pieces
(comminuted fracture).
Sports injuries, such as a fall while skiing or a collision with another player during soccer, are
lower-energy injuries that can cause tibial shaft fractures. These fractures are typically caused
by a twisting force and result in an oblique or spiral fracture.

SIGNS AND SYMPTOMS

A tibial shaft fracture usually causes immediate, severe pain. Other symptoms may include:
 Inability to walk or bear weight on the leg
 Deformity or instability of the leg
 Bone "tenting" over the skin at the fracture site or bone protruding through a
break in the skin
 Occasional loss of feeling in the foot

6
 INVESTIGATION

Medical History and Physical Examination

It is important that doctor know the specifics of how hurt the leg. For example, if in a car
accident, it would help a doctor to know how it was going, whether it was the driver or the
passenger, whether the passenger wearing seatbelt, and if the airbags went off. It is also
important for a doctor to know if the person have any other health conditions like high blood
pressure, diabetes, asthma, or allergies. Doctor will also ask if use tobacco products or are
taking any medications.
After discussing the injury and medical history, doctor will perform a careful examination.
He or she will assess an overall condition and then focus on the leg. Doctor will look for:
 An obvious deformity of the tibia/leg (an unusual angle, twisting, or shortening
of the leg)
 Breaks in the skin
 Bruises
 Swelling
 Bony pieces that may be pushing on the skin
 Instability (some patients may retain a degree of stability if the fibula is not
broken or if the fracture is incomplete)
After the visual inspection, doctor will feel along tibia, leg, and foot looking for
abnormalities. If awake and alert, doctor will test for sensation and movement in leg and foot.

Imaging Tests
Imaging tests will provide doctor with more information about the injury.
X-rays. The most common way to evaluate a fracture is with x-rays, which provide clear
images of bones. X-rays can show whether the tibia is broken or intact. They can also show
the type of fracture and where it is located within the tibia. X-rays are also useful for
identifying the involvement of the knee or ankle joints and the presence of a fibula fracture.
Computed tomography (CT) scans.  If a doctor still needs more information after reviewing
the x-rays, he or she may order a CT scan. A CT scan shows a cross-sectional image of the
limb. It can provide doctor with valuable information about the severity of the fracture. For
example, sometimes the fracture lines can be very thin and hard to see on an x-ray. A CT
scan can help doctor see the lines more clearly.

7
 TREATMENTS AND MEDICATIONS

In planning the treatment, doctor will consider several things, including:

 Overall health
 The cause of injury
 The severity of injury
 The extent of soft tissue damage

1) Nonsurgical Treatment
Nonsurgical treatment may be recommended for patients who:
 Are poor candidates for surgery due to their overall health problems
 Are less active, so are better able to tolerate small degrees of angulation or
differences in leg length
 Have closed fractures with minimal movement of the fracture ends
Initial treatment. Most injuries cause some swelling for the first few weeks. Doctor may
initially apply a splint to provide comfort and support. Unlike a full cast, a splint can be
tightened or loosened to allow swelling to occur safely. Once the swelling goes down, doctor
will consider a range of treatment options.
Casting and bracing. Doctor may immobilize the fracture in a cast for initial healing. After
several weeks, the cast can be replaced with a functional brace made of plastic and fasteners.
The brace will provide protection and support until healing is complete. The brace can be
taken off for hygiene purposes and for physical therapy.

2) Surgical Treatment
Surgery may be recommended for certain types of fractures, including:
 Open fractures with wounds that need monitoring
 Fractures that have not healed with nonsurgical treatment
 Fractures with many bone fragments and a large degree of displacement

a) Intramedullary nailing:
Currently, the method most surgeons use for treating tibia fractures is intramedullary nailing.
During this procedure, a specially designed metal rod is inserted into the canal of the tibia.

8
The rod passes across the fracture to keep it in position. The intramedullary nail is screwed to
the bone at both ends. This keeps the nail and the bone in proper position during healing.

Intramedullary nailing provides strong, stable, full-length fixation.

Intramedullary nails are usually made of titanium. They come in various lengths and
diameters to fit most tibia bones. Intramedullary nailing is not ideal for fractures in children
and adolescents because care must be taken to avoid crossing the bone's growth plates.

(Left) X-ray shows a tibial shaft fracture (red arrow) and a fibula fracture (blue
arrow). (Right) The tibial shaft fracture has been treated with intramedullary nailing.

9
b) Plates and screws:
During this operation, the bone fragments are first repositioned (reduced) into their normal
alignment. They are held together with screws and metal plates attached to the outer surface
of the bone. Plates and screws are often used when intramedullary nailing may not be
possible, such as for fractures that extend into either the knee or ankle joints.

(Left) X-ray shows a fibula fracture (blue arrow) and a tibial shaft fracture
(red arrows) that extends into the ankle joint. (Right) Both fractures have been treated with plates and screws.

c) External Fixation:

In this type of operation, metal pins or screws are placed into the bone above and below the
fracture site. The pins and screws are attached to a bar outside the skin. This device is a
stabilizing frame that holds the bones in the proper position so they can heal.

3) Medication:

Most tibial shaft fractures take 4 to 6 months to heal completely. Some take even longer,
especially if the fracture was open or broken into several pieces or if the patients uses tobacco
products.
Pain Management:

10
Pain after an injury or surgery is a natural part of the healing process. Doctor and nurses will
work to reduce pain, which can help recover faster.
Medications are often prescribed for short-term pain relief after surgery or an injury. Many
types of medicines are available to help manage pain. These include acetaminophen,
nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and topical pain medications.
Doctor may use a combination of these medications to improve pain relief, as well as
minimize the need for opioids. Doctor will talk about the side effects of the medications. Be
aware that although opioids help relieve pain after surgery or an injury, they are a narcotic
and can be addictive. It is important to use opioids only as directed by a doctor. As soon as
the pain begins to improve, stop taking opioids. Notify to the doctor if the pain has not begun
to improve within a few days of your treatment.

4) Weightbearing
Many doctors encourage leg motion early in the recovery period. It is very important to
follow doctor's instructions for putting weight on the injured leg to avoid problems. In some
cases, doctors will allow patients to put as much as weight as possible on the leg right after
surgery. However, it may not be able to put full weight on the leg until the fracture has started
to heal. Be sure to follow the doctor’s instructions carefully. When begin walking, it will
probably need to use crutches or a walker for support.

5) Physical Therapy
Because it will likely lose muscle strength in the injured area, exercises during the healing
process are important. Physical therapy will help to restore normal muscle strength, joint
motion, and flexibility. It can also help manage pain after surgery. A physical therapist will
most likely begin teaching specific exercises while still in the hospital. The therapist will also
help teach how to use crutches or a walker.

11
 REAL CASE

Regarding to the real case

A) PATIENT HISTORY

PATIENT’S IDENTIFICATION

Registered number: 0633

Name: Muhammad Shamiel Daniel Bin Alias

Age: 16 years old

Gender: Male

Race: Malay

Occupation: Student

Date of admitted: 20/2/2019

Chief complaint / Presenting complaint

 Painfull and swelling on the right shoulders since 23/2/2020 at 8.10am due to alleged
fall

I. History of presenting complaint

 The patient was alleged fall at home while doing the renovation of his house
 Patient was slipping with his leg resulting hit the floor surface over his right shoulder .
 The patient unable to moved due to the pain and at the same time was realised by his
own family.
 The patient was brought immediately to Emergency Department at Hospital Slim
River by the witness to him for receive immediate medical attention.

12
 II. Past medical history

 No history of medical illness

III. Past surgical history

 Patient does not have surgical history.

IV. Others (Family history / Drugs history / Social history etc)

 Family history:
 Nil

 Drug history:
 Patient does not have any drug history.

 Social history:
 Patient is not an alcoholic and not a drug abuser.
 Patient is a active smoker.

B) PHYSICAL EXAMINATIONS
I. General / On examination
 Alert, conscious, skin are fair and capillary refill time is <2sec.
 Good hydration
 Glasgow Coma Scale(GCS) was 15/15

II. Vital signs

RESULTS at (ED) NORMAL RANGE

BLOOD PRESSURE 107/71 mmHg 120/80 mmHg
TEMPERATURE 37 ℃ 36.5 – 37.5℃
RESPIRATION RATE 20/rpm 16 – 20/rpm
PULSE RATE 113/min 60 – 100/min
SPO2 100% (room air) 95 – 100%
PAIN SCORE 5 0

13
III. Cardiovascular sign
 Dual rhythm, no murmurs
 S1, S2 heard and normal sound

IV. Respiratory system

 Air entry is equal bilaterally
 Clear sound

V. Gastrointestinal system
 Soft and no tender
 Bowel sound active
 No mass
 No scar

VI. Others (Musculoskeletal, Central Nervous System, Upper and lower limbs etc)

Right
clavicle
fracture

 Swelling on the right side of clavicle.

C) DIFFERENTIAL DIAGNOSIS
 Dislocation of the clavicle
 Acromion dislocation

14
  Compartment Syndrome
 Fracture of humerus bone
 Osteoarthiritis

D) INVESTIGATIONS (Lab, X-Ray,etc)

Lab Test

Full blood count Results/ units Ref. ranges

White Blood Cells 8.43 X10^3/uL 4.0 – 10.0 X10^3/uL
Total Red Cells 4.48 X10^6/uL 4.5 – 5.5 X10^6/uL
Haemoglobin 14.5 g/dl 13 - 18 g/dl
HCT 30.6 g/dl 40 – 50 g/dl
MCV 87.9 fL 80 – 100 fL
MCH 30.2 pg 27 – 34 pg
MCHC 34.3 g/dl 32 – 36 g/dl
Platelet Count 194 X10^3/uL 150 – 450 X10^3/uL
Neutrophil% 74.1 % 50 – 70 %
Lymphocyte% 17.8 % 20 – 40 %
Monocyte% 7.1% 0 – 10 %
Eosinophil% 0.6% 0–6%
Basophil% 0.4% 0.0 – 1.0 %
Neutrophil# 6.25 X10^3/uL 2.0 – 7.0 X10^3/uL
Lymphocyte# 1.50 X10^3/uL 0.8 – 4.0 X10^3/uL
Monocyte# 0.60 X10^3/uL 0.0 – 0.8 X10^3/uL
Eosinophil# 0.05 X10^3/uL 0.0 – 0.4 X10^3/uL
Basophil# 0.03 X10^3/uL 0.0 – 0.10 X10^3/uL

i. Fasting Blood Sugar

Fasting Blood Sugar = 5.0 mmol/L

ii. X-ray:

a) Skull x-ray : no fracture seen

b) Chest x-ray: closed clavicle fracture seen

c) Pelvic x-ray: no fracture seen

15
 d) Knee x-ray: no fracture seen

e) Right lower limb: no fracture seen

E) DIAGNOSIS
 Closed Fracture Right Clavicle

Pictures below shows real patient’s x-ray film.

Picture 1: This picture is taken before the operation and taken with patient consent.

- This x-ray is belong to Muhammad Shamiel Daniel Bin Alias,male,16 years old, taken on
20 February 2019, this x-ray shows lateral view of right lower limb tibia and fibula. This x-
ray shows pre operative closed oblique fracture of right midshaft tibia. This x-ray is
inadequate which consist knee joint only and not seen ankle joint.

Picture 2: This picture is taken before the operation and taken with patient consent.

- This x-ray is belong to Muhammad Shamiel Daniel Bin Alias,male,16 years old, taken on
20 February 2019, this x-ray shows anterior view of right lower limb which is tibia. This x-
ray shows closed oblique fracture of right midshaft tibia not deviated to any side. This x-ray
is adequate consist of knee joint and ankle joint seen.

F) MANAGEMENT AND TREATMENT

1. Initial Management:

16
i. Patient came to ED by ambulance due to motor vehicle accident (motorbike vs car)

ii. Vital sign were taken and recorded once arrived.

Bp: 107/71, RR: 20, PR: 113, T: 37℃, and pain score: 5/10

iii. Medical history and mode of incident had been taken.

iv. Physical examination have been done by the doctor which include blood test, chest and
tibia x-ray to find out the abnormalities and to determine the accurate location of
fracture.

v. Patient was plan for surgery for wound debridement and correction of the tibial fracture.

vi. Patient was admitted to the ORTHOPEDIC WARD(Ward 5).

vii. Skin traction 3kg was applied at the right leg of the patient at Ward 5.

viii. Two large bore(16G) intravenous lines was inserted at the both hand.

ix. Intravenous drip 6pint of normal saline was given to the patient over 24hours.

2. Pre operative management:

i. Brief the patient regarding to the surgery procedure,anaesthesia used and blood
transfusion.

ii. Ask the patient consent and signature in the form that according to their agreement.

iii. Patient is nil by mouth for 6hours before the operation.

iv. Vital sign are observed and recorded 4hourly.

v. Assessment to check patient condition which include GCS, drug allergic, vital signs,
CVS system, respiration system and gastro-intestinal system.

vi. Patient was changed into operation gown and ready transferred to operation theatre in the
morning.

vii. For pre-transfer, nurse in charge will check the vital sign and make sure of the correct
patient’s name, identity tag, site of operation marked, case note/bed head tickets(BHT)
and x-ray film before go to operation theatre.

17
viii. When arrived in operation theatre,nurse in charge in the operation theatre will recheck
again patient’s name,identity tag, I/C number, site of operation marked, last oral intake,
check for denture, and ask again regarding the consent of the procedure, anaesthesia
consent, and blood transfusion consent.

ix. Staff nurse also will check again the vital signs of the patient whether patient is stable or
not.

x. After confirmation,the patient is transfer into the operation room.

3. Intra- operative management:

i. Patient was brought into the operation room after the preparation is done.

ii. Patient lying in the supine position and nurse in charge will applied the warmer blanket.
BP cuff, SPO2, chest lead and heart rhythm device for monitored.

iii. Anaesthesia doctor start to put patient under general anaesthesia.

iv. Intubate the patient using laryngeoscope and endotracheal tube size 7.5cm was inserted
and anchored at 23cm.

v. Pre-medication such as Fentanyl 100mcg as analgesic, Propofol 120mg as sedation and

Rocuronium 30mg as muscle relaxant was given by intravenous.

vi. Intravenous drip of normal saline 300ml and Hartman 500ml are given into the patient
along the operation with infusion of Tranexemic acid 1g and Paracetamol 1g.

vii. The surgeon start painting the area that already mark for operation using Povidone Iodine

viii. The surgeon and scrub nurse closed all the part of the patient’s body using sterile
dressing towel and exposed the only part that need to operate.

ix. The operation begin with the procedure of wound debridement and then follow by open
reduction and internal fixation(ORIF)

x. The anaesthesia doctor is monitors and records the blood pressure, Ecg, pulse oximetry,
NIBP and capnometer.

18
xi. After the DCP was done to the patient,the surgeon will ask the radiologist to take a x-ray
to site of the operation,to ensure that the internal fixation is right.

xii. Lastly,when the ORIF was confirmed and successfully implanted into the right tibia,the
surgeon will suture and staple the site of the incision.Then apply with chlorphenicol
ointment at the site of suturing and cover the part with gauze and bandage.

4. Post-operative management:

i. The anaesthesia doctor will wait until the patient conscious from sedation and starts to
extubate the patient.

ii. The patient was given a face mask after extubation.

iii. Then,the patient was brought to recovery room for closed monitor the condition.

iv. The patient was given medication which is Morphine by using Patient Controlled
Analgesia Machine(PCAM).

v. Vital signs was monitored and recorded every 5minutes.

vi. Patient was covered with warm blanket.

vii. Nurse in charge will ask the patient’s pain score to examine their pain ranked. If the pain
is severe, painkiller will prescribed more by the doctor.

viii. Patient was closed monitor for about 1hour until stable.

ix. After patient was in stable condition,the patient then will be transfer to ward for further
management.

19
Picture 1 shows that post-operative x-ray of right tibia with dynamic compression plate(DCP)

5. Routine Ward management:

1. For observation, vital sign monitoring 4 hourly

2. For oral intake, patient is allow orally once fully conscious.

3. For analgesic, capsule Tramal 50mg TDS and Tablet Paracetamol 1g QID was given.

4. I/v Cefuroxime 1.5g stat was given and next 750mg/tds

5. Patient’s positioning is supine and 45 degree

6. Drain charting, no need suture to off and inform if drain profusely.

7. Apply full length back slab on the right tibia.
8. Watch for Fat Embolism Syndrome(FES)/sign

20
MEDICATION FOR GENERAL ANAESTHESIA:

Generic name Sevoflurane

Brand name Ultane
Dosage Using a vital capacity induction technique,
inspired concentrations of 8% sevoflurane
in combination with oxygen (1 L/minute)
and nitrous oxide (2 L/minute) were used to
obtain loss of consciousness followed by a
30 second IV injection of remifentanil (1 to
1.5 mcg/kg). Induction time was 3.4 +/- 2.2
minutes
Indication Pain management and anaesthesia adjunct
Contraindication Respiratory depression,hypersensitivity,
paralytic ileus, acute hepatic disease,
pregnancy, lactation and in children

References Case

21
 (Article A)

According to the article by OrthopaedicsOne Articles. In: OrthopaedicsOne - The

Orthopaedic Knowledge Network. Created Jun 29, 2011 

Introduction

Fractures of the tibial shaft are the most common long bone fractures, with an incidence of
more than 75,000 per year most of these fractures are found in young males (thought to be
related to sports or motor vehicle accidents) with a second peak of incidence among elderly
patients, whose injuries likely resulted from a simple fall.  While intramedullary fixation has
become the mainstay of treatment, many of these fractures are amenable to closed
treatment.     

Treatment

The goals of treatment are to promote bone healing;  to establish and maintain the normal
length, alignment and rotation of the bone; to establish and maintain the normal anatomic 
relationships between the knee and ankle joints for weight bearing, motion and propulsion;
and to foster  pain-free, function of the lower limb. Whether these goals can be best met with
surgery(intramedullary nailing, primarily) or with closed treatment (usually cast
immobilization followed by functional bracing) depends on the particular circumstances of
the injury;

According to experts, the non operative management may be employed when there is
minimal soft tissue injury and when the fracture is not displaced or deformed very much. The
upper limits of tolerable  deformity are said to be:

 5 degrees of angulation in the coronal plane

 10 degrees of angulation in the sagittal plane
 5 degrees of rotational deformity
 shortening of less than 1cm

If pursuing closed treatment, the patient should be placed in a long leg cast with the ankle in
neutral and the knee positioned in 10-15 degrees of flextion to initiate early weight bearing. 
A careful mold should be applied to the supracondylar area to prevent the cast from slipping. 

22
Radiographs should be taken at 1-2 week intervals to verify maitenence of the
reduction.  While some shortening from the initial reduction is to be expected, if greater than
1.5 cm of shortening is noted or the alignment criteria for closed management is no longer
met, operative fixation is indicated.  As soon as the patient can comfortably bear weight,
transition to a patellar bearing functional brace can be made. 

Interlocking reamed intramedullary nailing has become the standard for management of
displaced tibial shaft fractures.  For displaced tibial fractures, or those with significant soft
tissue injuries, multiple studies have demonstrated that intramedullary fixation results in
quicker union, less malunion, and faster return to work than closed management.  

While the SPRINT study group recently reported that reamed IM nails resulted in a lower re-
operation rate than unreamed nails in closed tibial shaft fractures, the debate over reaming is
still on-going.  Reaming may disrupt the endosteal blood supply, theoretically, yet
experimental studies have shown its re-establishment prior to healing and some clinical
studies report better outcomes with reaming.

Reaming of course enlarges the canal and permits insertion of a larger nail, thus reducing the
risk of fatigue failure of the implant.If the fracture is transverse, the mechanical properties of
the bone-implant construct allow for immediate weight bearing.

Careful selection of a starting point and the proper use of blocking screws can help prevent
deformity. Because of the lack of soft tissue covering the tibia and mechanical disadvantage,
internal fixation with plates is generally avoided. Plating is a reasonable treatment option for
management of tibial shaft nonunions or for fractures with articular or periarticular extension.
External fixation may be chosen instead of intramedullary nails in patients with severe soft
tissue injury or in the setting of damage control surgery in polytrauma.  If converting to an
intramedullary nail, the procedure should be done as soon as possible, preferably with four
weeks to minimize the likelihood of pin sepsis 

Articles B

23
According to the article written by Anuar-Ramdhan IM, Azahari IM, Med Orth M.
Malays Orthop J. 2014 Nov;8(3):33-6. doi: 10.5704/MOJ.1411.008

A 16-year old teenage boy had sustained injury to his right knee and leg in motor-vehicle
accident (MVA) in September 2013. Clinical assessment revealed swollen right knee with
tenderness at mid-right shin with no signs of compartment syndrome. The radiographs
showed fracture mid-shaft of right tibia with ipsilateral Posterior Cruciate Ligament (PCL)
avulsion fracture. The diagnoses were closed fracture midshaft right tibia and closed avulsion
fracture of right PCL. He underwent plating of right tibia minimallly invasive plate
osteosynthesis(MIPO technique) and screw fixation of the PCL avulsion fracture.

Patient was positioned supine on the operating table. After the usual preparations of the
operation site, two small skin incisions were made, about 1 cm lateral to the anterior tibial
crest, proximal and distal to the fracture site. The two incisions were aimed for the most
proximal and most distal screw hole of the conventional compression plate. A subcutaneous
tunnel was created onto the periosteum of the lateral tibial surface by using bone lever.

Then, the conventional compression plate was introduced and advanced directly onto the
periosteum on the lateral surface of the tibia. The periosteum itself was not opened. After the
plate was placed in the correct position, it was held temporarily in place with two Kirschner
wires for the most proximal and most distal hole of the plate, respectively. With indirect
reduction of the fracture, the plate was fixed to the bone with percutaneously directed screws,
and the skin wounds closed after irrigation. During the whole procedure fluoroscopic (image
intensifier) control was essential.

DISCUSSION

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There is similarity of the treatment and management of the malleolus fracture in the Real
case, Reference A and Reference B.

The similarity of the treatment that used in Real Case, Reference A and Reference B

The similarity that found in Real case, Reference A and Reference B is using the screw and
plating due to midshaft tibial fracture.

Screw and plate surgery is the commonly used because Locking plate and screw systems
have advantages over the conventional screw systems. Conventional plate/screw systems
require precise adaptation of the plate to the underlying bone. Without this intimate
contact, tightening of the screws will draw the bone segments toward the plate, resulting
in alterations in the position of the osseous segments and the occlusal relationship.
Locking plate/screw systems offer certain advantages over other plates in this regard. The
most significant advantage may be that it becomes unnecessary for the plate to intimately
contact the underlying bone in all areas. As the screws are tightened, they "lock" to the
plate, thus stabilizing the segments without the need to compress the bone to the plate.
This makes it impossible for the screw insertion to alter the reduction. Another potential
advantage in locking plate/screw systems is that they do not disrupt the underlying cortical
bone perfusion as much as conventional plates, which compress the under surface of the
plate.

It means that even if a screw is inserted into a fracture gap, loosening of the screw will not
occur. Similarly, if a bone graft is screwed to the plate, a locking screw will not loosen
during the phase of graft incorporation and healing. The possible advantage to this
property of a locking plate/screw system is a decreased incidence of inflammatory
complications from loosening of the hardware. It is known that loose hardware propagates
an inflammatory response and promotes infection. For the hardware or a locking
plate/screw system to loosen, loosening of a screw from the plate or loosening of all of the
screws from their bony insertions would have to occur. Locking plate/screw systems have
been shown to provide more stable fixation.

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Besides,the similarities of the real case, article A and article B are the anaesthesia given to
the patient is similar. During the surgery procedure, patient is under general anaesthesia.
The general anaesthesia that have been used are sevoflurane which give fully sedation and
pain managing during operation.

The differences between real case and the article A and article B are the technique of the
operation incision. In the real case,the technique that have been done is open reduction
with internal fixation(ORIF) but in article B are using minimallly invasive plate
osteosynthesis(MIPO) technique. Furthermore,there are slightly different in article A
which not using plating and screw,they are using intramedullary nailing(IM nailing) to fix
the site of the tibial fracture compare to others.

As MIPO is well known to have many advantages, include preservation of osteogenic

potential of the fracture hematoma, biologically friendly, and less surgical trauma to the
surrounding soft tissues, it is recommended that all fractures should be preferably be fixed by
this MIPO technique.

This less invasive surgery has been described widely for proximal and distal tibial fractures,
especially fractures at the diametaphyseal region and peri-articular fractures. The outcomes of
this techniques showed good wound healing as well as fracture union. There were limited
literatures mentioning about MIPO technique for mid-diaphyseal or middle-third tibia shaft
fractures, especially lateral placement of the conventional compression plate on the tibia.

In experience of using MIPO for conventional compression plate in diaphyseal tibia fracture
fixation has revealed less soft tissues dissection and periosteal stripping with percutaneous
screw placement through smaller surgical wound and less intra-operative bleeding. The
amount of sutures for closure of the surgical wound was also minimal which is also cost
saving. However, not all tibial shaft fractures are suitable for MIPO technique. Severely
displaced comminuted shaft fractures with unstable ipsilateral fibula fracture are among cases
that are not suitable to be fixed by MIPO approach. Good selection of cases is important in
order to achieve positive outcome of fracture union.

CONCLUSION

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During our two weeks posting at Operation Theatre Department everyone should take 1 case
for 1 case study, document and present in comprehensive and systematic way in real situation
to patient to commit in case study. By this way I also got the chance to have 1 case study in
Operation TheatreDepartment. I gained more knowledge in depth by comparing the
management of patient with the information that I collected from internet, clinical instructor,
lecturer, doctors, nurses, laboratory and radiology test result and compared with the patient in
real situation that I mention in real case result. During my duty period in operation theatre
department, I provide a holistic care, diversional therapy in every aspects such as physical,
emotional, economical, social culture view to the patient. I also gained the knowledge about
the nursing theory, care and application in real situation.

So this case, Closed Fracture Right Midshaft Tibia which I study not only gives the cognitive
domain but also provide us the opportunity to develop psychomotor domain which is very
important in Medical Assistant course, so the patient is the main source of conveying the
knowledge to practice in my posting period.

In conclusion that, initial wound debridement and dynamic compression plate(DCP) of tibial
fracture is necessary due to prevent non-union of the bone which can leads to further
complication. Not only that, daily dressing of the site of the fracture is important to prevent
infection to occurs and promote fast healing. Follow doctor advices and always participate on
doing physiotherapy to regain motor activities again. In order to prevent a compartment
syndrome,always notify a doctor if there are any abnormalities that felt during a healing
process.

REFERENCES

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210280/

http://journal.usm.my/journal/mjms-20-5-0471.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536398/

https://orthoinfo.aaos.org/en/diseases--conditions/tibia-shinbone-shaft-fractures/

https://emedicine.medscape.com/article/1249984-treatment

https://www.uptodate.com/contents/midshaft-femur-fractures-in-adults

https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures

https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

https://www.verywellhealth.com/tibial-shaft-fracture-4119048

https://www.orthopaedicsone.com/display/Main/Fibula+shaft+fractures

https://pdfs.semanticscholar.org/330f/193ef2b36cfc85646c998dcc8586d1f38025.pdf

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