BAGIAN ORTOPEDI DAN TRAUMATOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

CASE PRESENTATION FEBRUARY 2014

CLOSED FRACTURE 1/3 MIDDLE OF THE LEFT TIBIA AND FIBULA CLOSED FRACTURE OF THE LEFT MEDIAL MALLEOLUS

OLEH: M. A. AIRLANGGA C111 09 258

PEMBIMBING: dr. Mervin O. O. Jakarimilena dr. Michael Horeb

SUPERVISOR: Dr. Muhammad Sakti, Sp.OT

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK BAGIAN ORTOPEDI DAN TRAUMATOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN MAKASSAR 2014

Patient Identity Name MR Sex Age Date of admission : Mrs. N : 652670 : Female : 45 years old : February 26th 2014

Anamnesis Chief complain: Pain at the left leg History of illness: Suffered since 5 days before admitted to Dr Wahidin Sudirohusodo Hospital due to traffic accident. Pain increases when she try to move her left leg. History of treatment in RS Ibnu Sina with long leg back slab on the left leg. History of unconscious (-), nausea (-), vomit (-) Mechanism of trauma: Patient was crossing the street and was hit by a motorcycle from the left and she fell to the ground.

Physical Examination General Status: Conscious/ Well-nourished Vital sign: Blood Pressure Heart rate Respiratory rate Temperature : 120/70 mmHg : 80 bpm, regular. : 18 tpm : 36,7 C (axilla)

Localized status (Left Leg Region) Inspection Palpation ROM Deformity (-), swelling (+), hematoma (+), wound (-) Tenderness (+) Active & passive movement of the knee and ankle joints cannot be evaluated due to pain

 NVD

Sensory : Sensibilitas is good Motoric : extend big toe Vascular : dorsalis pedis artery is palpable, capillary refill time is less than 2 seconds

CLINICAL PICTURES

LABORATORIUM FINDING WBC RBC HB PLT GDS Ur/Cr : 6.3 x103/mm3 : 4.51 x 106/mm3 : 11.6 g/dL : 177 x 103/mm3 : 110mg/dl : 17 / 0.60 mg/dL

SGOT/SGPT : 37 / 29 u/L CT/BT : 6.30 / 2.00 minutes

RADIOLOGY FINDING

X-Ray position AP/lateral (Left Leg)

DIAGNOSIS Closed Fracture 1/3 middle of the left tibia Closed Fracture 1/3 middle of the left fibula Closed Fracture 1/3 middle of the left medial maleolus

MANAGEMENT Analgetic Apply long leg back slab Plan for ORIF

RESUME A 45 years old woman came to the hospital with pain at the left leg suffered since 5 days ago due to traffic accident and prior treatment long leg back slab at RS Ibnu Sina. From the physical examination on the left lower extremity : Oedem (+) hematom (+) deformity (-), palpation: Tenderness (+) and movement cannot be evaluated due to pain. NVD: normal. From radiologic finding: fracture at 1/3 middle left tibia and fibula, fracture at left medial maleolus. Laboratory finding: normal.

DISCUSSION: FRACTURE OF TIBIA DAN FIBULA

1. Introduction

A fracture is a break in the structural continuity of bone. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is complete and the bone fragments are displaced. If the overlying skin remains intact it is a closed (or simple) fracture; if the skin or one of the body cavities is breached it is an open (or compound) fracture, liable to contamination and infection.(1) Fractur divides into fractur because of trauma, stress, and pathological fracture. Trauma fracture divides into direct trauma and indirec trauma. Stress fracture usually happens to athletic people with repetitive movement on the same place. Pathological fracture happens may occur even with normal stresses if the bone has been weakened by a change in its structure example in osteoporosis.(1)

2. Epidemiology Tibial and fibular fractures are the third most common pediatric long bone injuries (15%) after femoral and radial/ulnar fractures (1,2). The prevalence of tibial fractures in both boys and girls has increased since 1950 (3). The average age of occurrence is 8 years, and the frequency of occurrence does not change significantly with age (4). Seventy percent of pediatric tibial fractures are isolated injuries; ipsilateral fibular fractures occur with 30% of tibial fractures (2,5,6). Fifty to 70% of tibial fractures occur in the distal third, and 19% to 39% in the middle third. The least commonly affected portion of the tibia is the proximal third, yet these may be most problematic. Thirty-five percent of pediatric tibial fractures are oblique, 32% comminuted, 20% transverse, and 13% spiral. Tibial fractures in children under 4 years of age usually are isolated spiral or sharp oblique fractures in the distal and the middle one third of the bone. Most tibial fractures in older children and adolescents are at the ankle. Rotational forces produce an oblique or a spiral fracture and are responsible for approximately 81% of all tibial fractures without fibular fractures. Bicycle spoke injuries occur in children 1 to 4 years of age, whereas most tibial fractures in children 4 to 14 years of age occur in sporting or traffic accidents. Over 50% of ipsilateral tibial and fibular fractures result from

vehicular trauma. Most isolated fibular fractures result from a direct blow (1,4). The tibia is the second most commonly fractured bone in abused children. Approximately 16% to 26% of all abused children with a fracture have an injured tibia. (2) 3. Etiology

Direct
o

High-energy: motor vehicle accident

Transverse, comminuted, displaced fractures commonly occur. The incidence of soft tissue injury is high.

Penetrating: gunshot

The injury pattern is variable. Low-velocity missiles (handguns) do not pose the problems from bone or soft tissue damage that high-energy (motor vehicle accident) or high-velocity (shotguns, assault weapons) mechanisms cause.

Bending: three- or four-point (ski boot injuries)

Short oblique or transverse fractures occur, with a possible butterfly fragment.

Crush injury occurs. Highly comminuted or segmental patterns are associated with extensive soft tissue compromise.

Must rule out compartment syndrome and open fractures.

Fibula shaft fractures: These typically result from direct trauma to the lateral aspect of the leg.

Indirect
o

Torsional mechanisms

Twisting with the foot fixed and falls from low heights are causes. These spiral, nondisplaced fractures have minimal comminution associated with little soft tissue damage.

Stress fractures

In military recruits, these injuries most commonly occur at the metaphyseal/diaphyseal junction, with sclerosis being most marked at the posteromedial cortex.

In ballet dancers, these fractures most commonly occur in the middle third; they are insidious in onset and are overuse injuries.

Radiographic findings may be delayed several weeks.(handbook of fracture). (3)

4. Anatomy of Tibia and Fibula The tibia is a long tubular bone with a triangular cross section. It has a subcutaneous anteromedial border and is bounded by four tight fascial compartments (anterior, lateral, posterior, and deep posterior) Blood supply The nutrient artery arises from the posterior tibial artery, entering the posterolateral cortex distal to the origination of the soleus muscle. Once the vessel enters the intramedullary (IM) canal, it gives off three ascending branches and one descending branch. These give rise to the endosteal vascular tree, which anastomose with periosteal vessels arising from the anterior tibial artery. The anterior tibial artery is particularly vulnerable to injury as it passes through a hiatus in the interosseus membrane. The peroneal artery has an anterior communicating branch to the dorsalis pedis artery. It may therefore be occluded despite an intact dorsalis pedis pulse. The distal third is supplied by periosteal anastomoses around the ankle with branches entering the tibia through ligamentous attachments. There may be a watershed area at the junction of the middle and distal thirds (controversial). If the nutrient artery is disrupted, there is reversal of flow through the cortex, and the periosteal blood supply becomes more important. This emphasizes the importance of preserving periosteal attachments during fixation.

The fibula is responsible for 6% to 17% of a weight-bearing load. The common peroneal nerve courses around the neck of the fibula, which is nearly subcutaneous in this region; it is therefore especially vulnerable to direct blows or traction injuries at this level. (3)

Picture 1 - Tibia and Fibula(4)

Picture 2 Compartment of the leg(4)

Anterior tibialis muscle

Extensor digitorum longus muscle

Extensor hallucis longus muscle

Picture 3 The Anterior Compartment(4)

Fibularis (peroneus) longus muscle and tendon Fibularis (peroneus) brevis

Picture 4 Lateral Anterior(4)

Gastrocnemius muscle

Soleus muscle Plantaris muscle

Picture 5 Superficial Posterior Compartment(4)

Polpiteal muscle

Flexor digitorum longus muscle Tibialis posterior muscle Flexor hallucis longus muscle

Picture 6 Deep Posterior Compartment(4)

Picture 7 Fibrosseus Compartment of the Leg(2)

5. Fracture Type of Tibia and Fibula

Picture 8 Fracture Type of Tibia and Fibula(4)

Tscherne Classification for Closed Fracture

This classifies soft tissue injury in closed fractures and takes into account indirect versus direct injury mechanisms

Grade 0: Grade I:

Injury from indirect forces with negligible soft tissue damage Closed fracture caused by low-moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture

Grade II:

Closed fracture with significant muscle contusion, with possible deep, contaminated skin abrasions associated with moderate to severe energy mechanisms and skeletal injury; high risk for compartment syndrome

Grade III: Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, with arterial disruption or established compartment syndrome

Picture 9 - The Tscherne classification of closed fractures(2)

6.

Clinical Features The signs and symptoms associated with tibial and fibular diaphyseal fractures vary with the severity of the injury and the mechanism by which it was produced. Pain is the most common symptom. An isolated fibular fracture normally produces mild pain, whereas tibial fractures produce more severe pain. Children with stress fractures of the tibia or fibula complain of pain on weightbearing, but rarely have pain at rest. Children with fractures of the tibia or fibula have swelling at the fracture site, and the area is tender to palpation. Young children with nondisplaced fractures may refuse to walk. If there is significant injury to the periosteum, a bony defect or prominence may be palpable in patients with a complete fracture. Neurologic impairment is rare except with fibular neck fractures caused by direct trauma. (2)

7. Radiographic Evaluation Radiographic evaluation must include the entire tibia (anteroposterior [AP] and lateral views) with visualization of the ankle and knee joints. Oblique views may be helpful to further characterize the fracture pattern. Postreduction radiographs should include the knee and ankle for alignment and preoperative planning. A surgeon should look for the following features on the AP and lateral radiographs:
o o

The location and morphology of the fracture should be determined. The presence of secondary fracture lines: These may displace during operative treatment.

o o

The presence of comminution: This signifies a higher-energy injury. The distance that bone fragments have traveled from their normal location: Widely displaced fragments suggest that the soft tissue attachments have been damaged and the fragments may be avascular.

o o o

Osseous defects: These may suggest missing bone. Fracture lines may extend proximally to the knee or distally to the ankle. The state of the bone: Is there evidence of osteopenia, metastases, or a previous fracture?

Osteoarthritis or the presence of a knee arthroplasty: Either may change the treatment method selected by the surgeon.

Gas in the tissues: These are usually secondary to open fracture but may also signify the presence of gas gangrene, necrotizing fasciitis, or other anaerobic infections.

X-ray examination is mandatory. Remember the rule of twos: Two views A fracture or a dislocation may not be seen on a single x-ray film, and at least two views (anteroposterior and lateral) must be taken. Two joints In the forearm or leg, one bone may be fractured and angulated. Angulation, however, is impossible unless the other bone is also broken, or a joint dislocated. The joints above and below the fracture must both be included on the x-ray films. Two limbs In children, the appearance of immature epiphyses may confuse the diagnosis of a fracture; x-rays of the uninjured limb are needed for comparison. Two injuries Severe force often causes injuries at more than one level. Thus, with fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine. Two occasions Some fractures are notoriously difficult to detect soon after injury, but another x-ray examination a week or two later may show the lesion. Common examples are undisplaced fractures of the distal end of the clavicle, scaphoid, femoral neck and lateral malleolus, and also stress fractures and physeal injuries wherever they occur. (1) Computed tomography and magnetic resonance imaging (MRI) usually are not necessary. Technetium bone scanning and MRI scanning may be useful in diagnosing stress fractures before these injuries become obvious on plain radiographs. Angiography is indicated if an arterial injury is suspected. (3) 8. Treatment Non-operative Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for isolated, closed, low-energy fractures with minimal displacement and comminution.

Cast with the knee in 0 to 5 degrees of flexion to allow for weight bearing with crutches as soon as tolerated by patient, with advancement to full weight bearing by the second to fourth week.

After 4 to 6 weeks, the long leg cast may be exchanged for a patella-bearing cast or fracture brace.

Union rates as high as 97% are reported, although with delayed weight bearing related to delayed union or nonunion.

Acceptable Fracture Reduction

Less than 5 degrees of varus/valgus angulation is recommended. Less than 10 degrees of anterior/posterior angulation is recommended (<5 degrees preferred).

Less than 10 degrees of rotational deformity is recommended, with external rotation better tolerated than internal rotation.

Less than 1 cm of shortening; 5 mm of distraction may delay healing 8 to 12 months.

More than 50% cortical contact is recommended. Roughly, the anterior superior iliac spine, center of the patella, and base of the second proximal phalanx should be colinear.

Time to Union

The average time is 164 weeks: This is highly variable, depending on fracture pattern and soft tissue injury.

Delayed union is defined as >20 weeks. Nonunion: This occurs when clinical and radiographic signs demonstrate that the potential for union is lost, including sclerotic ends at the fracture site and a persistent gap unchanged for several weeks. Nonunion has also been defined as lack of healing 9 months after fracture.

Tibia Stress Fracture

Treatment consists of cessation of the offending activity. A short leg cast may be necessary, with partial-weight-bearing ambulation.

Fibula Shaft Fracture

Treatment consists of weight bearing as tolerated. Although not required for healing, a short period of immobilization may be used to minimize pain. Nonunion is uncommon because of the extensive muscular attachments. (3)

Operative Treatment Intramedullary (IM) Nailing

IM nailing carries the advantages of preservation of periosteal blood supply and limited soft tissue damage. In addition, it carries the biomechanical advantages of being able to control alignment, translation, and rotation. It is therefore recommended for most fracture patterns.

Locked versus unlocked nail

o

Locked nail: This provides rotational control; it is effective in preventing shortening in comminuted fractures and those with significant bone loss. Interlocking screws can be removed at a later time to dynamize the fracture site, if needed, for healing.

Nonlocked nail: This allows impaction at the fracture site with weight bearing, but it is difficult to control rotation. Nonlocked nails are rarely used.

Reamed versus unreamed nail

o

Reamed nail: This is indicated for most closed and open fractures. It allows excellent IM splinting of the fracture and use of a larger-diameter, stronger nail

Unreamed nail: This is designed to preserve the IM blood supply in open fractures where the periosteal supply has been destroyed. It is currently reserved for higher-grade open fractures; its disadvantage is that it is significantly weaker than the larger reamed nail and has a higher risk of implant fatigue failure.

Flexible Nails (Enders, Rush Rods)

Multiple curved IM pins exert a spring force to resist angulation and rotation, with minimal damage to the medullary circulation.

These are rarely used in the United States because of the predominance of unstable fracture patterns and success with interlocking nails.

They are recommended only in children or adolescents with open physes.

External Fixation

Primarily used to treat severe open fractures, it can also be indicated in closed fractures complicated by compartment syndrome, concomitant head injury, or burns.

Its popularity in the United States has waned with the increased use of reamed nails for most open fractures.

Union rates: Up to 90%, with an average of 3.6 months to union. The incidence of pin tract infections is 10% to 15%.

Plates and Screws

These are generally reserved for fractures extending into the metaphysis or epiphysis.

Reported success rates as high as 97%. Complication rates of infection, wound breakdown, and malunion or nonunion increase with higher-energy injury patterns.

Proximal Tibia Fractures

These account for about 7% of all tibia diaphyseal fractures. These fractures are notoriously difficult to nail, because they frequently become malaligned, the commonest deformities being valgus and apex anterior angulation.

Nailing requires use of special techniques such as blocking screws. Use of a percutaneously inserted plate has had recent popularity.

Distal Tibia Fractures

The risk for malalignment also exists with the use of an IM nail.

With IM nailing, fibula plating or use of blocking screws may help to prevent malalignment.

Use of a percutaneously inserted plate has had recent popularity.

Tibia Fracture with an Intact Fibula

If the tibia fracture is nondisplaced, treatment consists of long leg casting with early weight bearing. Close observation is indicated to recognize any varus tendency.

Some authors recommend IM nailing even if tibia fracture is nondisplaced. A potential risk of varus malunion exists, particularly in patients >20 years.

Fasciotomy

Evidence of compartment syndrome is an indication for emergent fasciotomy of all four muscle compartments of the leg (anterior, lateral, superficial, and deep posterior) through one or multiple incision techniques. Following operative fracture
(3)

fixation,

the

fascial

openings

should

not

be

reapproximated. 9. Complication

o Malunion: This includes any deformity outside the acceptable range. o Nonunion: This associated with high-velocity injuries, open fractures (especially Gustilo grade III), infection, intact fibula, inadequate fixation, and initial fracture displacement. o Infection may occur. o Stiffness at the knee and/or ankle may occur. o Knee pain: This is the most common complication associated with IM tibial nailing. o Hardware breakage: Nail and locking screw breakage rates depend on the size of the nail used and the type of metal from which it is made. Larger reamed nails have larger cross screws; the incidence of nail and screw breakage is greater with unreamed nails that utilize smaller-diameter locking screws.

o Thermal necrosis of the tibial diaphysis following reaming is an unusual, but serious, complication. Risk is increased with use of dull reamers and reaming under tourniquet control. o Reflex sympathetic dystrophy: This is most common in patients unable to bear weight early and with prolonged cast immobilization. It is characterized by initial pain and swelling followed by atrophy of limb. Radiographic signs are spotty demineralization of foot and distal tibia and equinovarus ankle. It is treated by elastic compression stockings, weight bearing, sympathetic blocks, and foot orthoses, accompanied by aggressive physical therapy. o Compartment syndrome: Involvement of the anterior compartment is most common. Highest pressures occur at the time of open or closed reduction. It may require fasciotomy. Muscle death occurs after 6 to 8 hours. Deep posterior compartment syndrome may be missed because of uninvolved overlying superficial compartment, and results in claw toes. o Neurovascular injury: Vascular compromise is uncommon except with high-velocity, markedly displaced, often open fractures. It most commonly occurs as the anterior tibial artery traverses the interosseous membrane of the proximal leg. It may require saphenous vein interposition graft. The common peroneal nerve is vulnerable to direct injuries to the proximal fibula as well as fractures with significant varus angulation. Overzealous traction can result in distraction injuries to the nerve, and inadequate cast molding/padding may result in neurapraxia. o Fat embolism may occur. o Claw toe deformity: This is associated with scarring of extensor tendons or ischemia of posterior compartment muscles. (3)

DAFTAR PUSTAKA 1. Nalyagam S. Principles of Fractures. In: Solomon L. Apleys System of Orthopaedics and Fractures. Ninth edition. UK: 2010. p. 687-693 2. Bucholz, Robert W.; Heckman, James D. Fractures of The Tibia and Fibula. In: CourtBrown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. UK: Lippincott Williams & Wilkins. 2006. p. 2080-2143. 3. Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition. USA: Lippincott Williams & Wilkins. 2006.p. 340-352 4. Thompson, John C. Leg and Knee in: Netter's Concise Orthopaedic Anatomy. Second Edition.Philadelphia: Saunders Elsevier. 2010.p. 294, 315-322