CASE PRESENTATION

Closed Fracture 1/3 Distal Left Tibia and

Closed Fracture 1/3 Proksimal Left Fibula
PRESENTED BY:
Bonita Sesharika C
C111 11 257

ADVISORS:
dr. Aries Hutabarat
dr. Yohanes Toban

SUPERVISOR:
dr. M. Ruksal Saleh, Ph.D, Sp.OT

ORTHOPAEDIC AND TRAUMATOLOGY

DEPARTMENT
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2016
 PATIENT’S IDENTITY

• Name : Ms. S
• Age : 19 years old
• Sex : Female
• Registration : 750527
• Date of admission : March 21st 2016
 HISTORY TAKING
• Chief Complain : pain at the left lower leg.
• Anamnesis : Suffered since 1 hour before
admitted to Wahidin Sudirohusodo Hospital due
to traffic accident
• Mechanism of Trauma : She was riding a
motorcycle and suddenly a cat crossed over the
street, she tried to avoid it and lose her balance
then she fell down to the left side with
motorcycle fell on to left leg.
• History of loss of consciousness (-), history of
vomiting (-)
• No history of prior treatment
 PRIMARY SURVEY
Airway • Patent, clear

• 20x/min, thoracoabdominal,
Breathing spontaneous, symmetric

• BP 110/70mmHg, HR 86x/min, regular,

Circulation strong on palpation

• GCS 15(E4M6V5), light reflex +/+ ,

Disability pupil isochors, Ø : 2.5mm/2.5mm,

Exposure • Temp 36.8°C (axilla)

 SECONDARY SURVEY

Left leg region

Look Deformity(+), swelling (+),hematoma (+),wound
(-)
Feel Tenderness (+)
Move Active and passive movement of knee joint can
not be evaluated due to pain
Active and passive movement 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”
• Special test: pain of passive stretching (-)
 LEG LENGTH
DISCREPANCY
Right (cm) Left (cm)

ALL 93cm 92cm

TLL 84cm 83cm

LLD 1 cm
CLINICAL FINDING
CLINICAL FINDING
CLINICAL FINDING
RADIOLOGY FINDING

LEFT CRURIS AP/LATERAL

Left Ankle AP/Lateral and Mortis View
 LABORATORY FINDING
Result Normal Level

WBC 7,0 4,00-10,0

RBC 5,23 4,50-6,50

HGB 15,1 14,0-18,0

HCT 45 40,0-54,0

PLT 245 150-400

CT 7,30’ 4-10

BT 3,00’ 1-7

HBsAg Non Reactive Non Reactive

 RESUME
• A 19 years old girl admitted to Wahidin
Sudirohusodo Hospital with chief complain
pain at left lower leg, suffered since 1 hour
before admitted to the hospital due to traffic
accident.
• From physical examination there is no wound,
deformity (+), hematome (+), swelling (+),
tenderness (+). Special test, pain on passive
stretching (-).
• From radiology finding, there are fracture
spiral 1/3 distal left tibia and fracture spiral 1/3
proksimal left fibula
 DIAGNOSIS

• Closed Fracture Spiral 1/3 Distal Left Tibia

and Closed Fracture 1/3 Proksimal Left
Fibula
 INITIAL MANAGEMENT

• IVFD
• Analgesic
• Apply long leg back slab
• Elevation left lower leg
• Plan for closed reduction;
circular casting
 DISCUSSION

TIBIA AND FIBULA SHAFT FRACTURE

DEPARTEMENT OF ORTHOPAEDIC AND TRAUMATIC MEDICAL FACULTY OF

HASANUDDIN UNIVERSITY
 INTRODUCTION
• Fracture → a break in the structural
continuity of bone, cartilage, joint and
growth plate
• If overlying skin remains intact : closed
fracture
• If skin not intact : open fracture

Nalyagam S. Principles of Fractures. In: Solomon L. Apley’s System of Orthopaedics and

Fractures Ninth edition. 2010
ANATOMY TIBIA AND FIBULA

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

Muller’s Classification

PROXIMAL

PROXIMAL

SHAFT 1/3
PROXIMAL

SHAFT 1/3
DISTAL

DISTAL

AO Mueller. AO Principle of Fracture Management. 2000.

FRACTURE SPIRAL

• Spiral are usually due to low-

energy indirect injuries
• Twisting causes a spiral fracture
 Evidence leading To DIAGNOSIS
HISTORY PHYSICAL
TAKING EXAMINATION

• Deformity (+),,hematoma
Chief complain: Pain (+), Swelling(+)
at lower left leg due to
• No wound
low energy trauma.

CLOSED FRACTURE OF LEFT

CRURIS

RADIOLOGY FINDING
(CRURIS AP/LT)
Fracture spiral 1/3 distal • Closed Fracture 1/3
left tibia Distal Left Tibia
Fracture spiral 1/3 • Closed Fracture 1/3
proksimal left fibula Proksimal Left Fibula
POSSIBLE ASSOCIATED
INJURIES OF THIS PATIENT

1. Ankle injury
2. Nervous Peroneus Injury
ANKLE INJURY

No sign of fracture malleolus

lateralis or malleolus medialis
 SYNDESMOSIS INJURY

A
B
C

A. Tibiofibular overlap : 1,2 cm Normal

B. Tibiofibula clearspace : 4 mm Normal
C. Medial clearspace : 3 mm Normal
THERE IS NO RADIOLOGICAL
FINDING FOR SYNDESMOSIS
INJURY
Examination ( Special tests)

• Squeeze test
• Talar Tilt Test
• External rotation stress test
•Anterior drawer test
Peroneus Nerve Injury
Test of peroneal nerve function to
the patient
• Superficial peroneal nerve
Motor function : foot eversion cannot
evaluated due to pain
Sensory function : sensation to dorsum
pedis NORMAL
• Deep peroneal nerve
Motor function : toe extension NORMAL
Sensory function : sensation to
dorsal web space of big toe
NORMAL
 Treatment
CONSERVATIVE OPERATIVE
Indication :
- Fail Conservative
Indication : - Open fracture grade II-III (grossly
contaminate, associated vascular injury)
- Closed fracture - Fracture associated with compartement
syndrome
- Open fracture grade I - For traction (avulsion) fractures
in which fragment are held apart
- Minimal Displaced -
-
Intraarticular fracture
Pathologic fracture.
- Fracture that prone to have non union complication.
- Non union fracture
- Certain types of displaced fracture.
- Unstable fracture.
CLOSED REDUCTION - Fracture with neurovascular injury.
- Fracture with co-morbid patient.
Circular Casting

Internal Fixation
External Fixation
Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 4th Edition.
 COMPLICATION

EARLY LATE
COMPLICATION COMPLICATION
Compartment Joint stifness
Syndrom

Solomon. L. et al. Apley’s System of Orthopedics and Fractures 9th Edition. New
THANK
YOU
DEPARTEMENT OF ORTHOPAEDIC
AND TRAUMATIC MEDICAL FACULTY
OF HASANUDDIN UNIVERSITY