BAB I

Name : Mr. MI

Age : 37 years

Gender : Male

Job : Farmer

Date of entry : 17 December 2019

Room : lotus Class 3

Address : South dampel

ANAMNESIS
Main Complaints: Left lower leg bent
Guided History:
1. History of current illness
The patient was hospitalized with complaints of his left lower limb
being bent less than 1 year ago due to a fall from the motorbike. The patient
also complained of pain in the left leg stretching for about 4 months before
entering the hospital.
The mechanism of trauma is that the patient is riding his own
motorcycle home from the garden, then falls due to trying to avoid people in
front of him, when the patient's left foot hit the wood, the patient is still
conscious, not dizzy, nausea, or vomiting. There was an open wound on the
left lower leg. The accident occurred 1 year ago. The patient is then helped by
people who see the incident, then the patient is taken to the puskesmas, where
the patient is treated for injury. Upon arrival at home, the patient's family
takes the patient to an alternative treatment site.
 Previous medical history:
- The patient said there was a history of fracture due to trauma 1 year
before.
- The patient has never had surgery before
Family history of illness:
There is no family history of hypertension (-), diabetes mellitus (-) or
allergic (-), no family member complains of the same thing.
History of alcohol consumption
There is no

III. PHYSICAL EXAMINATION

Generalist status:
• Awareness : Composmentis
• Blood Pressure : 120/80 mmHg
• Pulse : 70x / minute
• RR : 20 x / minute
• Temperature : 36.5oC
Head : Normocepal
Eyes : Anemic conjunctiva - / -, jaundice sclera - / -
Neck : Enlargement of the KGB (-), enlargement of the thyroid gland (-)
Thorax:
Lungs :
 Inspection : Bilateral symmetry, retraction (- / -)
 Palpation : Pain relief (-), right vocal fremitus equal to left.
 Percussion : Sonor + / +, liver and lung borderline SIC VI midclavicula dextra
 Auscultation : Vesicular (+ / +), Rhonki (- / -) wheezing (- / -).
Heart
 Inspection : the ictus cordis Invisible
 Palpation : The ictus cordis pulsation is not palpable
 Percussion : deaf
- Upper cardiac border SIC II parasternal sinistra
-  Lower cardiac border SIC V midclavicula sinistra
- Right heart border SIC IV parasternal dextra
 Auscultation: BJ I / II purely regular

Abdomen:
• Inspeks : Distention (-), lesion (-)
• Auscultation : Peristalsis (+), normal appearance
• Percussion : tympani the entire abdomen
• Palpation : Pain relief (-)

Extremities:
Extremities Superior Inferior
Akral cold -/- -/-
Edema -/- -/-
Sensibility +/+ + /+
Motorik:
Motion free/ Free free/ limited
Strength 5/5 5/5

Examination localist status of regio cruris sinistra:

 
Figure 1.1 Clinical Photos of Patients
a. Look: crooked deformity (+), there is abnormal protrusion and angulation (+),
edema (-), no cyanosis in the distal part of the lesion.
b. Feel: Local tenderness (-), crepitation (-), sensibility (+), feel more prominent
than cruris dextra, normal palpation temperature, NVD (neurovascular
disturbance) (-), normal capillary refill (+), dorsalis pedis artery palpation.
c. Move: Free
Neurological examination:
a. Motoric system
Muscle Strength:
Extremities Dextra Sinistra
upper 5 5
lower 5 5

b. Sensory System
Sensory examination did not experience interference

IV. TEMPORARY DIAGNOSIS

Susp. Neglected Fracture Cruris Sinistra

V. DIFERENTIAL DIAGNOSIS
- Malunion fracture cruris sinistra

VI. ANOTHER EXAMINATION

1. Routine Blood Examination of Blood Chemistry: (17/12/2019)
Result Normal Range
WBC : 8.83x103/ul (3.8 -11.0)
RBC : 4.46 x 106/ul (3.8 – 5.2)
Hb : 15,5g/dl (11,7 – 15,5)
HCT : 45,1% (35 – 47 )
PLT : 195 x 103/ul 150- 400
GDS : 259 mg/dl 74-100
Kreatinin : 1.46 mg/dl 0.60-1.20
Ureum : 28,3 mg/dl 15.0-43.2
SGOT : 25 U/L 8- 33
HbsAg : Non reaktif Non Reaktif

2. Distal cruris X-ray AP / Lateral X-ray (12/17/2019)

Impression:
 - Distal fractures of the tibia et fibula sinistra, callus found, poor
repositioning and realignment.
- Malunion Distal Tibia Et Fibula Sinistra Fracture

VII. RESUME
Patients were hospitalized with complaints of inferior deformity
about 1 year ago due to a fall from a motorbike. The patient also
complained of pain in the left leg for about 4 months before entering the
hospital.
Physical examination of compositional awareness, BP = 120/80
mmHg, P= 70x.minutes, T = 36.5 celcius . Examination of the localis
status of the cruris sinistra region Look: crooked deformity (+), abnormal
protrusion and angulation (+), edema (-), no cyanosis in the distal part of
the lesion. Feel: Local tenderness (-), crepitation (-), sensibility (+), feel
more prominent than cruris dextra, normal palpation temperature, NVD
(neurovascular disturbance) (-), normal capillary refill (+), dorsalis pedis
artery palpasi . Move: Free.
On Neurological examination: Motor System Upper limb muscle strength
5/5, lower extremity 5/5. Laboratory tests obtained WBC = 8.83 x 103 dL,
RBC: 5.46 x 106dL, HB: 1550 g / dL, HCT 45.1%, PLT: 259 X 103 / dL.

VIII. DIAGNOSIS
Malunion Fracture Distal Tibia Et Fibula Sinistra

IX. MANAGEMENT
 Medicine
- Meloxicam 2 X 7.5 mg
  PLAN
- Pro ORIF Recontruction

X. PROGNOSIS
- Ad Vitam : Dubia ad Bonam
- Ad anationam : Dubia ad Bonam
- Ad functionam: Dubia ad Bonam

XI FOLLOW UP
12/18/2019
S : Deformity (+), Pain (+)
O : GS: moderate pain
Awareness: Composmentis
BP : 120/80
R : 20 x / m
P : 80 x / m
T : 36.50c
Examination of regiocruris sinistra
 Look: crooked deformity (+), abnormal protrusion and angulation (+), edema
(-), no cyanosis in the distal part of the lesion.
 Feel: local tenderness (+), crepitation (-), sensibility (+), feel more prominent
than cruris dextra, normal palpation temperature, NVD (neurovascular
disturbance) (-), normal capillary refill (+), dorsal artery palpation pedis.
 Move: Free
A : Malunion Fracture Distal Tibia Et Fibula Sinistra
P : Pro Orif Recotruction Friday 12/20/2020

12/19/2019
S : Deformity (+), Pain (+)
O : GS: moderate pain
Awareness : Composmentis
BP : 120/80
R : 20 x / m
P : 84x / m
T: :36.60c
Examination of the cruris sinistra region
 Look: crooked deformity (+), abnormal protrusion and angulation (+), edema
(-), no cyanosis in the distal part of the lesion.
 Feel: local tenderness (+), crepitation (-), sensibility (+), feel more prominent
compared to cruris dextra, normal palpation temperature, NVD
(neurovascular disturbance) (-), normal capillary refill (+), dorsal artery
palpation pedis.
 Move: Free

A : Malunion Fracture Distal Tibia Et Fibula Sinistra

P : Pro Orif Recotruction Friday 12/20/2020

12/20/2019
S : Deformity (+), Pain (-)
O :GS: moderate pain
Awareness: Composmentis
BP : 130/80
R : 20 x / m
P : 90 x / m
T : 370c
Examination of the cruris sinistra region
 Look: Symmetrical (+), abnormal protrusion and angulation (+), edema (-), no
cyanosis in the distal part of the lesion.
 Feel: local tenderness (-), crepitation (-), sensibility (+), feel more prominent
compared to cruris dextra, normal palpation temperature, NVD
 (neurovascular disturbance) (-), normal capillary refill (+), dorsal artery
palpation pedis.
 Move: Free
A : Malunion Fracture Distal Tibia Et Fibula Sinistra
P : Pro Orif Recotruction
Post OP instructions
- Watch it
- X Ray control
- IVRD RL 20 tpm
- Ambacin injection 1 g / 12 hours
- Ranitidine injection 1 amp / 8 hours / iv
- Ketorolac injection 1 amp / 8 hours / iv

12/21/2019
S : Post Op (+) pain is reduced
O : GS: moderate pain
Awareness : Composmentis
BP : 120/80
R : 20 x / m
P : 82 x / m
T : 36.8 0c
Examination of the cruris sinistra region
 Look: Symmetrical (+), angulation (-), edema (+), no cyanosis in the distal
part of the lesion.
 Feel: Local tenderness (+), crepitation (-), sensibility (+), NVD (neurovascular
disturbance) (-), normal capillary refill (+), dorsalis pedis artery palpation.
 Move: Difficult to evaluate
A : Post OP H1 Malalunion Distal Tibia Et Fibula Sinistra Fracture
P :
- IVRD RL 20 tpm
- Ambacin injection 1 g / 12 hours
 - Ranitidine injection 1 amp / 8 hours / iv
- Ketorolac injection 1 amp / 8 hours / iv

12/22/2019
S : Post Op Pain (+)
O : GS: moderate pain
Awareness : Composmentis
BP : 120/80
R : 20 x / m
P : 86 x / m
T : 36.50c
Examination of the cruris sinistra region
 Look: Symmetrical (+), angulation (-), edema (-), cyanosis is not visible
distally to the lesion.
 Feel: Local (+) tenderness, crepitation (-), sensibility (+), normal palpation
temperature, NVD (neurovascular disturbance) (-), normal refill capillary (+),
dorsal pedis artery palpation.
 Move: Difficult to evaluate
A : Post OP day-2 Malunion Fracture Distal Tibia Et Fibula Sinistra
P :
- IVRD RL 20 tpm
- Ambacin injection 1 g / 12 hours
- Ranitidine injection 1 amp / 8 hours / iv
- Ketorolac injection 1 amp / 8 hours / iv
- Change verban
- -Outpatient

BAB II
DISCUSSION
2.1 PATIENT ANAMNESIS
The diagnosis of distal malunion fracture of the tibia et fibula
sinistra in this patient is made from history, physical examination, and
investigation.In the history of getting a patient in hospital with complaints
of inferior extremity deformity about 1 year ago due to a fall from the
motor. The patient also complained of pain in the left ankle for about 4
months before being admitted to the hospital.
Based on the classical symptoms of fracture theory is a history of
trauma, pain and swelling in the broken bone, deformity (angulation,
rotation, discrepancy), musculoskeletal dysfunction due to pain, broken
bone continuity, and neurovascular disorders. If these classic symptoms
are present, clinically a fracture diagnosis can be established even though
the type of configuration cannot be determined
Anamnesis is done to explore the history of the mechanism of
injury (the position of the incident) and the events associated with the
injury. history of previous injuries or fractures, socioeconomic history,
occupation, medications he consumed, smoking, history of allergies and
history of osteoporosis and other diseases.2

2.2 PHYSICAL EXAMINATION

On physical examination three important things are carried out,
namely inspection / look: deformity (angulation, rotation, shortening,
lengthening), swelling. Palpation / feel (tenderness, crepitus). Neurologic
and vascular status in the distal area need to be examined. Palpate the area
of the extremity where the fracture is, including joints above and below
the injury, areas that experience pain, effusion, and crepitus.
Neurovascularization of the distal part of the fracture includes: arithmetic
pulsation, skin color, capler fluid return, sensation. Examination of
movement / moving is assessed whether there are limitations to the
 movement of joints adjacent to the location of the fracture. Inspection of
trauma in other places includes the head, thorax, abdomen, pelvis.
On examination of the localist regiocruris sinistra status in patients
found:
a. Look: crooked deformity (+), abnormal protrusion and angulation (+),
edema (-), cyanosis is not seen distally in the lesion.
b. Feel: Local tenderness (-), crepitation (-), sensibility (+), feel more
prominent compared to cruris dextra, normal palpation temperature, NVD
(neurovascular disturbance) (-), normal capillary refill (+), arteries dorsalis
pedis palpable.
c. Move: Free

2.3 CRURIS RONTGENT PHOTOS

On the examination of APR lateral distal cruris cruris X-ray on 17
December 2019 before surgery showed the impression of distal tibia et
fibula sinistra, callus was found, repositioning and realignment were not
good.
Based on the radiological examination theory for the location of
the fracture, according to the rule of two, there are two anteroposterior
(AP) and lateral images, containing two joints in the proximal and distal
fracture, containing a picture of two extremities namely the injured limb
and the unaffected limb (in children) and twice, namely before the action
and after the action.3
Results On the x-ray photo, it was obtained the impression of
malunion in Tibia and sinistra fibula, this is due to the process of bone
grafting. The process of connecting the bones according to Apley is
divided into 5 phases, namely the hematoma phase occurs for 1-3 days, the
proliferation phase occurs for 3 days to 2 weeks, the callus formation
phase occurs for 2-6 weeks, the remodeling phase occurs for 6 weeks to 1
year and the consolidation phase occur within 3 weeks-6 months
 Malunion is a state of broken bones that has undergone fusion with
fracture fragments in an abnormal position (bad position). Malunion
occurs because of inaccurate reduction or immobilization that is not
effective in healing

2.4 FRACTURES
A fracture is a discontinuity in the arrangement of bones caused by
trauma or pathological conditions. A fracture is interrupted bone and / or
cartilage continuity which is generally caused by involuntary.4
a. Fracture Mechanism
Although most fractures are caused by a combination of forces
(twisting, bending, compression, or tension) (see Figure 2.1), the
dominant mechanism is revealed by X-rays:
 Twisting causes a spiral fracture.
 Compression causes short obliq fractures.
 Bending produces a fracture with a 'butterfly' triangle fraction.
 Tension tends to damage the bone transversely; in some cases it
may only avulse small fragments of bone at points of ligament
or tendoninsertion.

Figure 2.1 Mechanism of injury. Some fracture patterns show the

causative mechanism: (a) spiral pattern (rotate); (b) short oblique pattern
(compression); (c) triangle 'butterfly' fragments (bending, fragments show
the direction of force) and (d) transverse patterns (tension) ). Spiral and
several (long) obliq patterns are usually due to low energy indirect
injuries; curvilinear and transverse patterns are caused by high-energy
direct trauma

b. Classification of Fractures
Fractures are classified into two types, namely closed fractures and
open fractures. If the surface of the skin remains closed, then it is a
closed fracture (closed fracture) and if the skin or one of the body's
organs is penetrated out, then that open fracture (open fracture) which
is likely to be contaminated with microbes and infection.
Closed fractures are classified based on the degree of soft tissue
damage and the mechanism of indirect injury versus direct injury,
including:
1) Degree 0: Injury due to indirect strength with soft tissue damage
that is not so meaningful.
2) Degree 1: Closed fracture caused by a low to moderate energy
mechanism, with superficial abrasion or bruising on the soft tissue
on the surface of the fracture site.
3) Degree 2: Closed fracture with significant bruising on the muscles,
which may be deep, contaminated skin blisters associated with
moderate to severe energy mechanisms and bone injuries; very at
risk of compartment syndrome.
4) Degree 3: Extensive soft tissue damage, or subcutaneous avulsion,
and arterial disorders or compartment syndrome formation.6
Open fracture is a condition associated with disorders of the bone
where there is damage to the skin and soft tissue under the skin caused
by bone fractures and hematomas (Kenneth et al., 2015). Based on the
severity, open fractures are grouped into three major groups according
to the classification of Gustillo and Anderson, namely:
 1) Degree I: Open skin <1 cm, usually from the inside out, mild bruising
of the muscles, caused by low energy or a fracture with a short inclined
open wound.
2) Grade II: Open skin> 1 cm, without extensive soft tissue damage,
minimal to moderate destruction components, fractures with simple
transverse open injuries with minimal splitting.
3) Degree III: Broader soft tissue damage, including muscle, skin, and
neurovascular structures, injuries caused by high energy with severe
destruction of bone components
 Grade IIIA: Extensive soft tissue laceration, adequate bone
coverage, segmental fracture, minimal periosteal stripping.
 Degree IIIB: Extensive soft tissue injury with periosteal peeling
and bone exposure requiring soft tissue closure; usually
associated with massive contamination
 Degree IIIC: Vascular injury that needs repair
d. Tibia and Fibula fractures
A tibia stem fracture, commonly called a cruris fracture, is a
fracture that often occurs compared to other long bone stem fractures. The
periosteum lining the tibia is rather thin, especially in the front area which
is covered only by the skin, so that the bone is easily broken and usually
the fracture fragments shift. Because it is located directly under the skin is
often found also open tibia fractures
Tibia and shaft fibula fractures are the most common long bone
fractures. In the average population, there are about 26 tibial diaphysis
fractures per 100,000 population per year. The highest incidence of adult
tibial diaphysis fractures seen in young men is between 15 and 19 years,
with an incidence of 109 per 100,000 population per year. The highest
incidence of adult tibial diaphysis fractures seen in women is between 90
and 99 years, with an incidence of 49 per 100,000 population per year. The
average age of patients suffering from tibia shaft fractures is 37 years, with
men experiencing an average age of 31 years and women 54 years.
Diaphysis tibia fractures have the highest level of nonunion for all long
bones.
Radiological features must meet Roentgen's photo requirements to
avoid misdiagnosis. Fractures must be stapled in advance to reduce pain
and prevent closed fractures into open fractures and avoid excessive tissue
damage.1
If the fracture occurs in both the tibia and fibula, the repositioning
of the tibia is considered. Even the lightest angulation and rotation can be
easily seen and corrected. Shortening to one centimeter does not become a
problem because it will be compensated when the patient starts walking;
but it's best to avoid shortening. Closed tibia and fibula fractures with
stable transverse or inclined fracture lines are sufficiently immobilized by
a cast from the toe to the top of the thigh with the knee in the physiological
position, ie mild flexion, to overcome rotation in the fragment area.
Connection to diaphysis fractures usually takes 3-4 months. Angulation in
a cast can usually be corrected by forming a wedge incision on the cast. If
the fracture tends not to dislocate, the legs are allowed to support weight
and the patient can walk. The sooner the fracture is burdened, the faster the
healing. The cast should not be opened before the patient can walk without
pain
Critical fractures where the fracture lines are oblique and spiral are
unstable because they tend to bend and shorten after closed repositioning,
so they should be treated with ORIF or OREF. Fractures with unstable
fragment dislocations require continuous calcaneal traction. After the
callus fibrosis is formed, a cast is placed along the leg from the finger to
the thigh
Complications of tibial and fibular fractures are vascular injury,
nerve injury especially peroneus, persistent swelling, delayed union,
pseudoarthrosis, and ankle joint stiffness. Compartment syndrome is often
found in early lower limb fractures. Signs and symptoms of five P should
be considered on the first day post-injury or after surgery. In addition,
 there is an increase in intracompartment pressure that can be measured
(pressure), disturbance of two-point sensibility, finger contracture in the
flexion position due to contractor flexor muscle. Emergency facotomy of
the three lower limb compartments must be done immediately after the
diagnosis is established
e. Fracture healing
Healing of the fracture is rolled up by the process of forming new
bone by fusion of bone fragments. Bones recover either by primary means
(without callus formation) or healing secondary fractures (by callus
formation). The process of repairing a fracture depends on the type of
bone involved and the amount of movement at the fracture site.
Mechanical tension applied. Absolute stability and compression are
directed at direct (primary) healing, while relatively limited to indirect
rehabilitation (secondary bone recovery). However, excessive movement
can cause delay or non-union. Clinical and experimental studies have
proven that callus formation occurs in response to movement at the
fracture site. This can be used to stabilize possible fragments a prerequisite
needed to bridge the formation of new bone. Therefore, most fixations of
work fractures to: (1) ease pain; (2) ensuring that unity occurs in a good
position; and (3) permit the initial movement of limbs and activate
functions
1) Primary bone healing
If the fracture site is truly stable - for example, an impact fracture
on a cancellous bone, or a fracture held by a metal plate with absolute
stability - there is no stimulus for the callus. Instead, new osteoblastic
bone formation occurs directly between fragments. If the exposed
surface of the fracture is in intimate contact and is held from the
beginning with absolute stability, the internal bridge can sometimes
occur without an intermediate stage (contact healing). The gap
between the fracture surface is attacked by new capillaries and
osteoprogenitor cells that grow from the edge, and new bone is placed
 on an open surface (healing of gaps). Where the gap is very narrow
(less than 200 μm), osteogenesis produces flat bones; wider gaps are
filled first by the bone of bone, which is then renovated into flat bones.
At 3-4 weeks the fracture is solid enough to allow penetration and
bridge the area with bone remodeling units, namely osteoclastic 'cone
cutting' followed by osteoblasts (Figure 2.2). However, with rigid
metal fixation, the absence of callus means that there is a long period
in which bones depend entirely on metal implants for their integrity,
thereby increasing the risk of implant failure. In addition, implants
divert stress from bones, which may become osteoporosis and may not
recover completely until the metal is removed

2) Secondary Bone Healing

Callus healing, although healing occurs indirectly, this has a
distinct advantage: it guarantees mechanical strength while the bones
end up healing, and with increasing stress callus grows stronger and
stronger (according to Wolff's law) .5
At least for secondary bone healing, surgical stabilization is not
always necessary but can prevent malunion. Secondary bone healing is
the most common form of healing in tubular bones; the absence of
rigid fixation, it takes place in five stages (Figure 2.2):
 Hematoma formation
At the time of injury, bleeding occurs from bones and soft tissue.
 Inflammation
The inflammation process starts quickly when a fractured
hematoma is formed and cytokines are released, and it continues
until fibrous tissue, cartilage, or bone formation begins (1–7 days
after the fracture). Osteoclasts are formed to remove necrotic ends
from bone fragments.
 Formation of soft callus
 After 2-3 weeks, the first soft callus is formed. This is a time when
fragments can no longer move freely. The strain applied to cells in
the fracture gap modifies the expression of their growth factors and
stimulated rogenitor cells to become osteoblasts. Cells form woven
cuffs periosteally. Broken bones can now be angled but long stable.
 Formation of hard callus
When the tips of the fractures are joined together, the hard callus
begins and continues until the fragments are firmly joined (3-4
months).
 Remodeling
Bone webbing is slowly replaced by flat bones. This process can
take from several months to several years.

Gambar 2.2 healing Fraktur

f. Fracture Complications
Complications of broken bones become immediate, early, and slow
complications. Complications occur immediately when a fracture occurs
or shortly thereafter; early complications occur within a few days after the
event; and slow complications occur long after a fracture. All three are
subdivided into local and general complications.1
Immediate and local complications are damage caused directly by
trauma, in addition to fractures or dislocations. Skin trauma can be in the
form of contusions (bruises), abrasions, lacerations, or penetrating injuries.
Bruised skin, although still intact, is prone to infections and bleeding
disorders. It was a disaster because it could become an open fracture
accompanied by osteomyelitis. Skin contusion treatment should not cause
stress or tension. Bandages must be loose and the cast should be fitted with
the right bearing. Compartment syndrome must be treated immediately by
freeing blood vessels through laceration repositioning or fracture or
decompression of the compartment with fasciotomy. Damage to blood
vessels due to trauma must also be overcome, if necessary by surgery
Old complications include failure of the union (non-union), wrong link
(malunion), delayed linking (delayed union), ankylosis, contracture,
myositis oscillis, and various diseases due to prolonged bed rest due to
impaired mobilization. Keep in mind that there can also be a growth
disturbance in the fracture injuring the epiphyseal plate. Recurrent
fractures can occur as a result of loading too early. In internal fixation,
excessive loading must be avoided for several weeks. Loading begins with
partial (partial) loading, ie when callus formation has occurred, this
process can be known clinically or radiologically.1
Malunion fracture refers to healing the fracture with incorrect
anatomical alignment. Malunion is a problem that is widely described,
because it can occur in any skeletal area. This may involve flat bones such
as the pelvis or scapula; it can occur in short bones like scaphoid, as well
as tubular bones.
Although many causes of bone healing are unknown, three main
etiological groups are recognized: 7
 Fractures that are initially left in the wrong position and wrong
healing.
 Inadequate fracture fixation in a cast or with internal or external
fixation devices.
 Fractures that are anatomically reduced and are fixed well in a
growing child with an unpredictable bone alignment due to stunted
growth or overgrowth.
 The diagnosis begins with a careful history and examination of the
patient's limbs for various joint movements, tenderness, and deformity.
It is important to check the rotational profile of the limbs to eliminate
malrotation. In the case of a single leg injury, the results of a physical
examination must be compared with an uninjured limb. At this point,
radiography must be examined.7
Sometimes large callus or internal fixation can make diagnosis
difficult, and just looking at the radiograph along with the patient's
clinical examination may not be enough for a proper diagnosis. need to
do a simple malalignment test. This method of diagnosis, systematized
by Paley, provides the possibility of precise mechanical placement and
anatomical axis, joint lines, and measurement of their relationship on
radiography
Tibial malunion is a far more common pathology. Wade et al.,
Argued that there was no consensus regarding indications for tibial
malunion correction, citing both Russell who stated that malalignment
of more than 15 might require corrective osteotomy, and Apley and
Solomon who considered angulation of more than 7 or any rotation to
be unacceptable. Malrotation above 10 can cause unacceptable
functional or cosmetic disorders
One of the complications of a fracture is malunion, which is a
malunion of poor bone healing such as angulation, shortening,
deformity or disability. When the fracture fragment heals in an
abnormal position, it is called a malunion. This can lead to the
following problems: It can cause unpleasant deformations that are
cosmetically pleasing, can cause changes in posture and balance of
lower extremity fractures, can cause shortening, can interfere with
joint function. Changes in the mechanism of weight gain can cause
premature osteoarthritis of the hip and knee joints.8,9
In cases where a history of previous illness can be obtained, the
patient says there is a history of fracture due to trauma 1 year before
 and prefers alternative treatment. On the AP / lateral X-ray cral distal
cruris X-ray examination on 17 December 2019, the distal fracture of
the tibia et fibula sinistra, callus was found, poor repositioning and
realignment, malunion impression on the Tibia and sinistra fibula.
Results On the x-ray photos indicate the state of the bones that have
undergone fusion with the fracture fragments are in an abnormal
position (bad position) due to the fracture which was initially left in the
wrong position and wrong healing.
g. Management
In general, the principle of treating fractures is 4: 2
1) Recognition, diagnosis and assessment of fractures
the first principle is to know and assess the state of the fracture by
history, clinical and radiological examination. At the beginning of
treatment need to be considered:
• Localization of the fracture
• The shape of the fracture
• Determine the appropriate technique for treatment
• Complications that may occur during and after treatment
2) Reduction; fracture reduction if necessary
A fracture fragment restoration is performed to obtain an
acceptable position. Intraarticular fractures require anatomic reduction
and to restore normal function as much as possible and prevent
complications such as stiffness, deformity, and changes in
osteoarthritis in the future.
A good position is:
• perfect alignment
• perfect position
3) Retention; immobilization of the fracture
4) Rehabilitation; restore functional activity as much as possible.
 Operative management of these patients is carried out by refracting
action on the distaltibia et fibula sinistra that is experiencing malunion.
Then performed ORIF (Open Reduction and Interna Fixation) using a
plateand screw and bone-autographs. Medical management is given
after surgery in the form of antibiotic therapy and systemic
antianalgetics.
A prospective randomized trial study shows that the method of
closed reduction and intramullary nailing in tibia fractures has
advantages in terms of duration of surgery, recovery of motion, and
surgery that is more minimal compared to the ORIF technique.
However, the ORIF method has advantages in terms of better
alignment of bone position compared to the Intramedullary Nailing
method. So that the Intramedullary Nailing technique is more
recommended for fractures with extensive soft tissue damage. In this
patient did not get extensive soft tissue damage.
Jansenn et al's research also shows that tibial malaligment tends to
be more common in posttramedullary nailing patients compared to the
ORIF technique.10
Open reduction internal fixation (ORIF) is a surgical method for
repairing fractured bones, generally involving the use of plates and
screws or intra-medullary rods to stabilize the bones.11
Internal fixation is the process of locking the ends or bone
fragments together using surgical hardware, such as with nails, screws,
plates, and rods. In securing directly the bone tip or fragment, some
part of the hardware will come into contact with the fracture site, in the
same way as a carpenter's nail that is moved through two wooden
boards will come in contact with both boards to directly connect it.11
In this case, internal fixation is carried out to stabilize the fracture
site. Internal fixation can also be used to revise or replace previous
internal fixation, such as in cases where the original internal hardware
has been moved or damaged. External fixation is any method for
securing bone tips or fragments in proper anatomical alignment
without directly connecting it to hardware.11
Indications made by ORIF according to Apley: 5
• Fractures that cannot be reduced except by surgery.
• Fractures that are inherently unstable and tend to be shifted again
after reduction, besides fractures that tend to be pulled apart by
muscle work.
• Pathologic fractures where bone disease can prevent healing.
• Multiple fractures, if early fixation reduces the risk of general
complications and organ failure in parts of the system.
• Fractures in patients with difficult treatment. (praplegi, multiple
trauma, parents) 5
Modern orthopedics has discarded many methods of correction and
fixation of malunion. Traditional open osteotomy and plate or stem
fixation have been replaced by minimally invasive percutaneous
osteotomy and external fixation, which have proven to be more
precise. In addition, treatments with external fixation are dynamic and
allow additional re-examination during treatment and the results of
improvement at the end of deformity correction.7
The Ilizarov method is very effective in cases such as the combined
angular and rotational deformities. Tibial angular deformity and
malrotation, with excessive external or internal tibial torsion, are
rather common pathologies. A good quality radiogram with a proper
limb position in combination with a CT scan is very important for pre-
operative planning. After calculating the level of angulation and its
direction as well as the number of malrotations, frame planning and
assembly begin.7
Gradual derotation and angle correction will help avoid the
possibility of traction in neurovascular structures. In cases of
relatively small deformity, acute anatomic correction can be
performed with external fixation as the first stage of surgery, after
which the intramedullary nail with locking can be inserted in the right
position and corrected. The external fixator will be removed after the
locking is complete, because the interlocking nails are stable enough
fixation. This procedure may be done in a minimally invasive way.
Osteotomy can be performed percutaneously and only a small incision
is needed for nail placement and locking
 BAB III
CONCLUSION

1. From the results of history, physical examination, and supporting

examinations carried out by patients in the diagnosis of Malunion Distal Tibia
Fracture Sinistra
2. In cases of complications that have occurred in the form of malunion, due to
fractures that were initially left in the wrong position and wrong healing.
3. Malunion is a condition of broken bones that have experienced a fused with
fracture fragments in an abnormal position (bad position).
4. Operative management of this patient is performed by refracting the distal
tibia et fibula sinistra that is experiencing malunion. Then ORIF (Open
Reduction and Interna Fixation) is done using plate and screw and bone-
autograph.