CASE REPORT:

OPEN FRACTURE 1/3 DISTAL RIGHT TIBIA GRADE IIIA

OPEN FRACTURE 1/3 DISTAL RIGHT FIBULA GRADE IIIA

PRESENTED BY
GODEBERTA A. P.
c111 10 101

Advisor :
dr. Nurjalaludin Djawie
dr. Anak Agung Gede Putra

Supervisor:
dr. Henry Yurianto, M.Phil, Ph.D, SpOT

Orthopaedic and Traumatology Dept

Medical Faculty of Hasanuddin University
Makassar, 2015
PATIENT IDENTITY

Name :Mr. A
Age :38 Years old
Sex : Male
Date of admission : August 20th 2015
Registry : 044958
HISTORY TAKING
Chief Complaint: Pain at Right Leg
History of Illness
1 day before admitted to the hospital he had an accident at
his workplace.
Mechanism of trauma:
The patient accidentally cut his right leg by a cutting
machine when cutting grass. History of fall (-). History of
unconciousness (-).
History of treatment:
The patient was sutured in Luwuk Banggae Hospital and
referred to Wahidin Sudirohusodo Hospital.
Patient working as labor.
Physical Examination

Generalized Status:
Compos mentis GCS 15/ Well nourished
Vital Sign:
Blood Preassure: 120/70 mmHg
Heart Rate: 74x/minutes
Respiratory Rate: 18x/minutes
Temperature: 36,5 C (axilla)
Numeric Rate Scale: 4/10
 Localized Status:
Right Cruris Region:
Look: Stitched wound size 1 cm at anteromedial
aspect of right cruris as levels distal part,
Deformity (+), swelling (+), hematoma (+).
Feel: Tenderness (+), sensibility is good, pulsation
of the dorsalis pedis artery is palpable, Capillary
refill time < 2
Move: Active and passive movement of the knee
joint are limited due to pain. Active and passive
movement of the ankle joint are limited due to
pain
 R L
ALL 87 cm 86 cm
TLL 83 cm 82 cm
LLD 1 cm
Clinical Picture
X-ray (Right Cruris AP + Lateral)
Laboratory Findings
WBC 20.4 103/mm3
RBC 3.37 106/mm3
HGB 13.8 g/dL
HCT 35 %
PLT 324 103/mm3
HbsAg Non Reactive
BT 3
CT 8
RESUME
Male, 38 y.o, was admitted to the hospital with the chief complaint
pain at his right leg. The onset of this complaint was 1 day before
admission.
The mechanism of trauma: The patient accidentally cut his right leg
by a cutting machine when cutting grass. The patient was sutured in
Luwuk Banggae Hospital and referred to Wahidin Sudirohusodo
Hospital.
From Physical examination, at right leg region from look there was
stitched wound size 1 cm at anteromedial aspect of right cruris as
levels distal part, there is deformity, there is swelling, there is
hematome. From feel, there is tenderness. Neurovascular distal are
within normal limits.
The R.O.M of Knee and Ankle joint cannot be evaluated due to pain
From radiologic finding, theres fracture at one third distal of right
tibia and theres fracture at one third distal of right fibula.
Diagnose

Open fracture of 1/3 distal right tibia grade

IIIA
Open fracture of 1/3 distal right fibula grade
IIIA
Management

IVFD RL
Analgesic
Antibiotic
Tetanus Toxoid
Debridement
Plan for Open Reduction Internal Fixation
Discussion
 INTRODUCTION

Fracture is a break in the structural

continuity of bone

Open fracture - If the skin or one of the

body cavities is breached and liable to
contamination and infection

Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London :
Hodder Arnold. 2010; p.687, 772-5.
 OPEN FRACTURE CLASSIFICATION
(GUSTILO AND ANDERSON)

a) Segmental fractures, farmyard injuries, fractures occuning in a highly contaminated environment, shotgun wounds,
or high-velocity gunshot wounds automatically result in classification as type lll open fractures.

Egol KA, Koval KJ, Zuckerman JD. Handbook of Fracture. 4th Edition. Philadelphia:Wolters Kluwer. 2010.
 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 Anatomy

Thompson,JD. Netter's concise atlas of orthopedic anatomy.2004.

 EPIDEMIOLOGY

The most common long bone fracture

Occur at a frequency of about 26 fractures
per 100,000 population per year
More frequent in males than in females

Bucholz,W. Tibia and Fibula Fracture in Rockwood and Green in Adults.7th ed. Lippincott Williams & Wilkins. 2010.
 MECHANISM OF TRAUMA
DIRECT INDIRECT

Usually a low energy injury

Usually a high-energy With a spiral (torsional
injury mechanism) or long oblique
The most common cause fracture one of the bone
is a motorcycle accident. fragments may pierce the
skin from within.
Stress Fracture
In military recruits and ballet
dancer

Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London : Hodder Arnold. 2010.
Egol KA, Koval KJ, Zuckerman JD. Tibia and Fibula Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010.
DIAGNOSIS

HISTORY PHYSICAL ADDITIONAL

TAKING EXAMINATION EXAMINATION
 TREATMENT

Four principles of open fractures treatment:

Antibiotic prophylaxis
Urgent wound and fracture debridement
Stabilization of the fracture
Early definitive wound cover

Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London : Hodder Arnold.
2010.
 TREATMENT

Conservative Operative

Antibiotic Debridement
Anti tetanus External fixation
Stabilization with long leg Internal Fixation
back slab

Egol KA, Koval KJ, Zuckerman JD. Tibia and Fibula Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010.
Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London : Hodder Arnold. 2010.
 COMPLICATION

EARLY COMPLICATION LATE COMPLICATION

Visceral injury Delayed union
Vascular injury Non-union
Nerve injury Malunion
Compartment Infection
syndrome Nerve compression
Muscle Contracture
Joint Stiffness

Solomon L, et all. Apleys System of Orthopaedics and Fractures. Ninth Edition. London : Hodder Arnold.
2010.
THANK YOU
Indication for External Fixation

Fractures associated with severe soft-tissue

damage (including open fractures) or those that
are contaminated, where internal fixation is risky
and repeated access is needed for wound
inspection, dressing or plastic surgery.
Fractures around joints that are potentially
suitable for internal fixation but the soft tissues
are too swollen to allow safe surgery; here, a
spanning external fixator provides stability until
soft-tissue conditions improve.
 Patients with severe multiple injuries, especially if
there are bilateral femoral fractures, pelvic
fractures with severe bleeding, and those with
limb and associated chest or head injuries.
Ununited fractures, which can be excised and
compressed; sometimes this is combined with
bone lengthening to replace the excised segment.
Infected fractures, for which internal fixation
might not be suitable
Indication for Internal Fixation
Fractures that cannot be reduced except by operation.
Fractures that are inherently unstable and prone to re-displace after
reduction (e.g. mid-shaft fractures of the forearm and some displaced
ankle fractures). Also included are those fractures liable to be pulled
apart by muscle action (e.g. Transverse fracture of the patella or
olecranon).
Fractures that unite poorly and slowly, principally fractures of the
femoral neck.
Pathological fractures in which bone disease may prevent healing.
Multiple fractures where early fixation (by either internal or external
fixation) reduces the risk of general complications and late multisystem
organ failure
Fractures in patients who present nursing difficulties (paraplegics, those
with multiple injuries and the very elderly).
 Type I : Clean skin opening of < 1 cm, usually from inside to outside,
minimal muscle contusion; simple transverse or short oblique
Type II : Laceration > 1 cm long, with extensive soft tissue damage;
minimal to moderate crushing component; simple transverse or short
oblique fracture with minimal comminution
Type III : Extensive soft tissue damage, including muscle, skin, and
neurovascular structures, often a high energy injury with a severe
crushing component.
IIIA : extensive soft tissue laceration, adequate bone coverage,
segmental fractures, gunshot injuries, minimal periosteal stripping.
IIIB : Extensive soft tissue injury with periosteal stripping and bone
exposure requiring soft tissue flap closures usually associated with
massive contamination
III C : vascular injury requiring repair
Egol KA, Koval KJ, Zuckerman JD. Clavicle Fracture. In Handbook of Fracture. Philadelphia:Wolters Kluwer. 2010.
For Gustilo
I, II and IIIA injuries, locked intramedullary nailing is
permissible as definitive wound cover is usually possible
at the time of debridement. For more severe
grades of open tibial fracture, internal fixation should
be performed only at the time of definitive soft tissue
cover. If this is not feasible at the time of primary
debridement, the fracture should be stabilized temporarily
with a spanning external fixator. Exchange of
the fixator for an intramedullary nail can be done at
the point when definitive soft tissue cover is carried
out ideally within 5 days of the injury. Alternatively,
definitive fracture management can be carried out
using external fixation.