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CLOSED FRACTURE 1/3 DISTAL LEFT TIBIACLOSED FRACTURE 1/3 DISTAL LEFT FIBULA
Presented By:HELDA
c1110727
Advisors:
Dr. Hendra HermantoDr. Aries Freddy Hutabarat
Supervisor:Dr. M. Ruksal Saleh, PhD, SpOT(K)
ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENTMEDICAL FACULTY
HASANUDDIN UNIVERSITY2014
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PATIENT IDENTITY
Name : Mr.B
Age : 23 years old / Male
Admission : June 1 st, 2014 at 10.00
Registration : 665944
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AUTOANAMNESIS
Suffered since 2 weeks before admitted to Wahidin
General Hospital due to traffic accident.Patient was crossing, the street and suddenly get hit by a high-velocity motorcycle.History of unconscious (+), vomit (-), nausea (-)
History of prior treatment at Kaimana Hospital, westPapua.
No histrory of going to bonesetter (-)
Chief Complain : pain at the left leg
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GENERAL STATE
General Appearance :Conscious/ Well NourishedVital sign VAS : 2/10 Blood pressure : 120/80 mmHg Heart rate : 80x/min regular, strong
Respiratory rate : 18x/min, spontaneous,thoracoabdominal Temperature : 36 o C (axilla)
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LOCAL STATELeft Leg Region
I : Excoriated wound at lateral left distal aspectsize 2x1cm. Deformity (+), minimal swelling
(+), hematoma (+)P : Tenderness (+)RoM : Active and passive motion on knee and ankle joints
cannot be evaluated due to painNVD : Sensibility is good, pulsation ofdorsalis pedis artery was palpable, CRT < 2
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Leg Length Discrepencies
Right Left
ALL 97 cm 96 cm
TLL 88 cm 87 cm
LLD 1 cm
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CLINICAL FINDING
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LABORATORY FINDINGWBC 10.9 10 3/mm 3 RBC 6.27 10 6/mm 3 HGB 13.9 g/dLHCT 42.7 %PLT 253 10 3/mm 3 HbsAg ReactiveBT 3 CT 8
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RADIOLOGY FINDING
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RESUMEMale, 23 years old came to Wahidin Hospital with
pain on the left leg suffered 2 weeks before admitteddue to traffic accident.
There is deformity (+) on the left leg withexcoriated wound at lateral distal aspect. Tenderness(+). NVD is good. ROM cant be evaluated. TheLLD shows 1 cm.
Radiologic shows comminuted fracture 1/3 distalof the left tibia and fibula.
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DIAGNOSIS
Closed fracture 1/3 distal left tibia
Closed fracture 1/3 distal left fibula
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MANAGEMENT
IVFDAnalgesic
Apply long leg back slab of the left lower limbPlan for Operative treatment (Open reductioninternal fixation)
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DISCUSSION
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Anamnesis
Hit by a high-velocity motorcycle highenergy trauma
2 weeks already Soft callus formation Compartment syndrome risk
No history of bone setter treatment moresoft tissue damage
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Physical Examination
Excoriated wound mild soft tissue injury(Tscherne grade I)
Deformity Anterior angulation Shortening (LLD=1cm)
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Grade 0 Injury from indirect forces with negligible soft tissue damage
Grade I Closed fracture caused by low-moderate energy mechanisms, withsuperficial abrasions or contusions of soft tissues overlying thefracture
Grade II Closed fracture with significant muscle contusion, with possibledeep, contaminated skin abrasions associated with moderate tosevere energy mechanisms and skeletal injury; high risk forcompartment syndrome
Grade III Extensive crushing of soft tissues, with subcutaneous degloving oravulsion, with arterial disruption or established compartmentsyndrome
Koval, Kenneth J, Zuckerman, Joseph D. Tibia fibula shaft. In: Handbook of fractures. 3rd Edition. USA:Lippincott Williams & Wilkins; 2006. p.470
Tschernes Classification of skin
lesion in closed fractures
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Radiologic finding
Fracture pattern Comminuted type unstable Fibular fracture as level as tibial fracture high-energy trauma associated injury?
Lateral view : Anterior angulation = 5 AP view : Lateral/valgus angulation = 3
Cortical contact : 0-25%
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Management
NonoperativeAcceptable Fracture Reduction
5varus/valgus angulation
10 anterior/posterior angulation10 degrees of rotational deformityMore than 50% cortical contact
Koval, Kenneth J, Zuckerman, Joseph D. Tibia fibula shaft. In: Handbook of fractures. 3rd Edition. USA:Lippincott Williams & Wilkins; 2006.p.471
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Management
Operative Unstable fracture
Associated intra-articular and shaft fractures Open fractures Major bone loss Neurovascular injury Compartment syndrome
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Management
Conservative Operative
Active pts
Unstablefracture
5 angulationdeformity
1cm LLD
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Management
Conservative
Immobilization( full-length cast)
Operative
ORIF( Plate and screw,
Intramedullarynailling)
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Complications
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures
9th Edition. UK: Arnold. 2010.
Early complications Late complication
Neurovascular injury Malunion, delayedunion, non- union
Compartmentsyndrome
Joint stiffness
Infection
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