Identification/Demographic Data

Name

: Mr. Ariyono Sukat

Age

: 41 years old

Sex

: Male

Race

: Indonesian

Status

: Single

Address

: Sibu, Sarawak

Date of admission

: 23 March 2015

Chief Complaint
Mr. Ariyono was admitted to Hospital Sibu on 23 rd March 2015 for pain and open wounds on his
right leg due to alleged workplace accident.

History of Presenting Illness

Mr. Ariyono, a 41-year old Indonesian gentleman was admitted to the ward with
complaint of pain at the right leg due to alleged workplace accident. He claimed that both his leg
was caught in a wood cutting machine. He was not wearing any personal protective equipment as
required during the time of the accident. He tried to pull out his leg but did not managed to do so.
The stopped the machine and immediately brought him to the hospital via car. He said there was
severe pain which is more at his right leg. He also noticed bleeding but was not sure of the
amount. They also had previously bandaged him at the factory with a cloth to stop the bleeding.
He also said that his bones can be seen along with his muscles. He was not able to ambulate and
also did not have loss of consciousness. Otherwise, he does not have any other injury and no
nausea or vomiting also.
On admission at emergency department, there was 2 open wound seen on his right leg
with bleeding. The wound was over the medial aspect of the right tibia. Sensation was also intact.
His vital signs was also stable on admission. X-rays show tibia and fibula fracture on his right

leg.
Currently, he underwent immediate surgical operation after admission which was wound
exploration, debridement, external fixation and muscle repair. He is also afebrile and unable to
ambulate. There was no dysuria and no hematuria. He also underwent blood transfusion twice
since his admission.

Past medical history

This was his first admission to hospital. There is no relevant past medical history.
Past surgical history
There is no relevant past surgical history.
Drug history
No known drug allergy. Does not taking any traditional drugs.
Family history
Both parents are alive and well. They currently staying in Pontianak, Indonesia. There is
also no family history of malignancy in the family
Allergy history
No known food or drugs allergy
Social history
He is currently in Sibu for work and send money to his parents. He is staying in hostel
with his colleague as provided by the employee. He is also a smoker and smokes 1 pack per day
for almost 20 years. He does not drink alcohol and does not take any illicit drugs.

PHYSICAL EXAMINATION:
General Examination:
He is lying comfortably, alert and conscious. He is not septic looking or dyspnoeic. There
was a branula inserted on his left hand. His right leg is under bandage from ankle to mid tibia
level with an external fixation.

Vital Signs:
Blood Pressure

- 138/76 mmHg

Pulse Rate

- 92 beats/m (normal volume, regular rhythm)

Respiratory Rate

- 19 per minute

Temperature

- 37 C

Face, head, neck & limbs examination

Appearance

: Normal placed eyes, nose and ears, no deformities of lips and nose.

Shape of head

: Normal head shape.

Hair

: No hair loss, no bald spot

Face

: No cyanosis, no pallor and no facial deformities

Oral cavity

: Good oral hygiene, moist mucous membrane, no ulcers and no central

cyanosis

Eyes

: No pallor and no jaundice.

Ear, mouth & throat : No ear and nose discharge, no throat swelling and redness.
Neck

: No thyroid enlargement

Skin

: pink, no rash, no lesions

Impression: No abnormalities

SYSTEMIC EXAMINATION:
Lower limbs examination
On inspection, patient right lower limb is seen with bandage from ankle to mid tibia
level. There was also external fixation seen on his right leg. Meanwhile, the left leg was normal.
There was no scar seen and no other wound seen. There was also no leg length discrepancies.

On palpation of the right lower limb, there is mild tenderness over the bandage area.
Capillary refill time is less than 2 seconds. Sensation is intact but lessen as compared to the left
leg. Dorsalis pedis artery and posterior tibial artery is palpable. On left lower limbs, no
tenderness felt and sensation was intact. Dorsalis pedis artery and posterior tibial artery is
palpable
Movement was limited due to bandage and external fixation for his right leg. Gross
movement and sensation of left lower limb was intact.
Cardiovascular system examination
On inspection, his chest moves symmetrically with respiration.
On palpation, apex beat was felt at left 5th intercostals space, mid-clavicular line. There
was no left parasternal heaves and no thrills at left sternal edge, pulmonary area and aortic area.
On auscultation, normal 1st and 2nd heart sound was heard. There was no additional heart
sound or murmur.

Respiratory system examination

On inspection, the chest moves symmetrically with respiration on both sides.
On palpation, the trachea was centrally located and chest expansion was symmetrical on
both sides.
On auscultation, the air entry was adequate and equal on both sides of the lung. Normal
vesicular breath sound was heard with no abnormal sounds.
Nervous System
He is alert and cooperative with GCS score of 15. His thought is coherent and he is
oriented to person, place and time.
For upper limbs on both sides, there was good muscle bulk and tone at 5/5. Reflex was
normal on both sides. Sensation was intact. Right lower limbs was restricted due to bandages and
external fixation.

Provisional diagnosis
41 years old male with open right distal 1/3 tibia and fibula fracture with Gustillo 3b open
fracture.
Reason for diagnosis
His right leg was caught in a wood cutting machine. There was two wound seen over the medial
aspect of the tibia of his leg. There was also bones and muscle flap seen from the wound with
bleeding. It was an open wound with no extensive bleeding. X-ray shows tibia and fibula fracture
of his right lower limb.

General investigation
Indication: To monitor general condition of the patient and screen the patients status and if there
is any abnormal platelet count and white blood cells count.

Tests

Result

Unit

Normal range

Impression

White Blood Cell

9.4

10^3 L

2-20

Normal

Red Blood Cell

2.58

10^6 L

4.5-6

Low

RBC Distribution Width

35.4

Fl

30-100

Normal

Hemoglobin

7.9

g/dl

10-20

Low

Hematocrit

24.0

30-45

Low

Mean Cell Hemoglobin

30.6

Pg

27-31

Normal

Mean Cell Volume

93.0

Fl

70-86

Normal

Mean Cell Hemoglobin

Concentration

32.5

g/dl

27-33

Normal

Platelet count

199

10^3 L

150-400

Normal

Urea & Electrolytes

Indication: To assess the extent of electrolytes loss that might compromise renal function
Test

Result

Unit

Normal range

Impression

Urea

3.6

mmol/
L

1.7-6.4

Normal

Sodium

140

mmol/
L

135-150

Normal

Potassium

4.0

mmol/
L

3.5-5.1

Normal

Creatinine

56.1

umol/L

27-62

Normal

Chloride

101.0

mmol/
L

98.0-107.0

Normal

X-ray of right tibia (AP view)

The X-ray above is an anteroposterior (AP) view of the right tibia of Mr Ariyono Sukat taken on
23rd March 2015. There is an obvious abnormalities seen. There is an oblique fracture of both
distal 1/3 of tibia and fibula seen. The fractures are completely displaced medially. There is also
shortening seen for both tibia and fibula. No other abnormalities seen.

Impression: Distal 1/3 fracture of right tibia and fibula.

Final Diagnosis
41 years old male with open right distal 1/3 tibia and fibula fracture (Gustillo Grade IIIB)
Management
He was immediately sent for surgical intervention upon admission to emergency
department of Hospital Sibu. He underwent wound exploration, debridement, external fixation
and muscle repair. Operative findings is:
1. Open fracture grade IIIB of right distal 1/3 of tibia and fibula. Tibialis anterior partially
cut at musculotendinious junction.
Postoperative plan
1.
2.
3.
4.
5.
6.

For X-ray recheck of right tibia and fibula.

Continue IV Flagyl 500mg TDS and IV Cefuroxime 750mg TDS
Continue analgesia IV Tramadol 50mg TDS
Daily neurovascular charting of both lower limbs
Elevate bilateral lower limbs
Allow orally

Discussion
Open fractures of the tibia are the commonest of open long-bone fractures, perhaps
because of its thin anteromedial soft-tissue coverage.
They are caused by various mechanisms, ranging from low-energy twisting forces to
high-energy motor vehicle crashes or penetrating injuries (gun shots, blasts). Although the
principles of management for open tibial fractures are constant, the path to the final result may
vary.
Open tibial fractures can present as isolated injuries or in the context of a multiply injured
patient. The patients clinical status must dictate the primary and ongoing treatment of the open
tibial fracture. Thorough evaluation of the entire patient is essential before focusing on the
injured leg.

Clsiification of open fractures

Factors affecting tibial fracture management

Each aspect of an open tibial fracture must be considered in planning initial and definitive
management.
The entire patient, the injured extremity and the specific details of the open fracture itself
must each be considered. Associated arterial injury must be identified and treated urgently to
salvage the limb. Wound debridement will be necessary. Its thoroughness appears to be more

important than how quickly it is done. The severity of the injuries to soft tissues, bone and
neurovascular structures must be identified and used for treatment planning.
Emergency management
As in all open fracture injuries, the patient must receive anti-tetanus prophylaxis and
appropriate antibiotic coverage. Antibiotics should be given intravenously as soon as possible.
Generally, all open fractures are treated with coverage for typical skin bacteria, often a
1st generation cephalosporin. Higher grade open fracture wounds will require additional
coverage for gram-negative organisms. With soil or barnyard injuries, high-dose penicillin
should be added to cover possible clostridial infection (gas gangrene).
After initial inspection the wound should be covered with a sterile dressing which should
not be removed until it is taken down in the OR. A digital photograph of the wound, before
dressing, will remove the temptation for successive attendant to expose the wound for inspection.
A temporary splint may be applied to protect the soft tissues while awaiting the
availability of an operating room.
Definitive classification of the open fracture is best done in the OR.
Dbridement
Patient preparation. The patient is positioned supine in the OR or in a position that
allows best access to the open fracture wounds. Skin preparation and draping should include
access to the major proximal vessels in case their exposure becomes necessary. Tourniquets
should be avoided when possible to prevent additional ischemic injury to the soft tissues.
General principles of debridement.It is important to perform a thorough surgical
dbridement in an organized manner. Starting with the skin, each layer is debrided
systematically. One can imagine a clock face; wound dbridement starts at the 12 oclock
position and continues in a clockwise manner around the circumference of the wound. This is
repeated for each layer down to the level of the bone. Necrotic tissue is removed and only viable
tissue is left behind. The exception is skin, where none is removed unless obviously necrotic.
The quality of the muscle tissue is assessed using the classic 4 Cs:

Color (red or brown)

Consistency (how does the muscle feel)
Capillary Circulation (does it bleed?)
Contractility (responds to pinch or electro-cautery)

Irrigation
After removing visible dirt and necrotic tissue, irrigation with several liters of fluid is a
key component of the decontamination of the injury zone. If available, a balanced salt solution is
routinely used. In more austere environments, any water that is clean enough to drink is
acceptable. Controversies exist regarding the optimal volume and delivery methods. We
recommend large volumes, with low pressure to avoid additional tissue injury. Gravity flow, with
large-bore cystoscopy tubing, is a well accepted method.
Fracture stabilization
External fixation. External fixation can be applied using either modular or uniplanar
techniques. The modular frames have the advantage of being more versatile, avoiding the
complex wounds that are often seen. The disadvantage of a modular frame is, that it is less rigid
than the uniplanar fixator because of its multiple connections. Pin placement outside of the
anticipated zone of the definitive implant is a consideration, although not always possible.
Reduce the fracture as well as possible, to avoid soft-tissue tension.
Definitive treatment
Definitive fixation is considered, when:

The patients clinical status is optimized

The wounds are healthy and the soft-tissue envelope will allow for chosen surgical

approach
A good preoperative plan has been created.