CASE PRESENTATION

Closed Fracture 1/3 Distal Left Tibia

Hariady Salam
C 111 11 261
Advisor:
Dr. Zuwanda
Dr. Thomson
Supervisor:
dr. Muhammad Ihsan Kitta, M.Kes, Sp.OT
Orhtopedic and Traumatology
Faculty of Medicine ,Hasanuddin University
Makassar
2016

CASE
REPORT
PATIENTS
IDENTITY

PATIENTS
IDENTITY

Name

: F.R. S.

Age

: 12 years old / boy

PHYSICAL
EXAMINATION

Date of

: August 22th, 2016

CLINICAL
FINDING

Admission
Registration

: 769181

HISTORY TAKING

INVESTIGATION
RESUME
ASSESMENT
THERAPY

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION

Chief Complaint : Pain at the left

lower
leg since 2 weeks before
Suffered

CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

HISTORY TAKING

admitted to Wahidin Sudirohusodo

General Hospital
Mechanism of trauma : Patient was
playing basketball, and when the
patient jumped and down and landed
with the position of the left food
touches the floor first, patient then
lost his balance and feel his left foot
twisted so that the patient fell.
History of loss of consciousness (-),
vomiting (-), nausea (-).

CASE
REPORT
PATIENTS
IDENTITY

PRIMARY SURVEY

Airway

Patent, clear

HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Breathing
Circulation
Disabilty
Exposure

16x/min, thoracoabdominal,
spontaneous, symetric.
BP 110/80mmHg, HR 80x/min,
regular, strong on palpation
GCS 15(E4M6V5), light reflex +/
+ , pupil isochors, :
2.5mm/2.5mm,
Temp 37C (axilla)

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

SECONDARY SURVEY

Right Leg Region

Look :
Feel :
Tenderness (+)
Movement :
Active and passive movement of knee and ankle
joint cannot be evaluated due to pain
NVD :
Sensibility is good, Pulsation of dorsal pedis
artery and tibialis posterior artery are palpable,
CRT < 2

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

SECONDARY
SURVEY

LLD ( Leg Length

Discrepency)

ALL

TLL

R
L
LLD

0 cm

CASE
REPORT

CLINICAL FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Anterior Aspect

CASE
REPORT

CLINICAL FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Lateral Aspect of Left

Leg

CASE
REPORT

CLINICAL FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Medial Aspect of Left

Leg

CASE
REPORT

RADIOLOGY
FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

X- Ray Left Cruris AP/Lateral

CASE
REPORT

RADIOLOGY
FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

X- Ray Left Ankle AP/Lateral

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

LABORATORY FINDING

Laboratorium
TEST

RESULT

REFERENCE

WBC

4,00-10,0

RBC

4,00-6,00

HGB

12,0-16,0

HCT

37,0-48,0

PLT

150-400

MCV

80-97

MCHC

31.5-35

CT

4-10

BT

1-7

HbSAg

Non Reactive

Non Reactive

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

Boy, 12 years old, admitted to the

Wahidin Sudirohusodo General Hospital
with chief complain of pain at the left
lower leg. Suffered since 2 week before
admission due to accident.
Patient was playing basketball, and
when the patient jumped and down and
landed with the position of the left food
touches the floor first, patient then lost
his balance and feel his left foot twisted
so that the patient fell.

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

From physical
examination, ?????????????????
Deformity (+) Edema (+) hematom (+).
There is tenderness in palpation.
Active and passive movement of
right knee and ankle joint cannot be
evaluated due to pain.
Neurovascular distal examination
within normal limits.

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

From the radiology finding, there

are :

Fracture 1/3 Distal Left Tibia

CASE
REPORT

DIAGNOSIS

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Closed Fracture 1/3

Distal Of The Left Tibia

CASE
REPORT
PATIENTS
IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL
FINDING

INVESTIGATION

RESUME

ASSESMENT
THERAPY

THERAPY

IVFD Ringer Lactate

Analgetic
Antibiotic
Immobilitation with long leg
back slab
Elevation
Plan
for
Open
Reduction
internal Fixation

DISCUSSION
Fracture of Tibia

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. Apleys System of Orthopaedics and Fractures
Ninth edition. 2010

Anatomy

Netters concise orthopaedic anatomy, P. 288

Netters concise orthopaedic anatomy, P. 316

Netters concise orthopaedic anatomy, P. 317

Netters concise orthopaedic anatomy, P. 318

Netters concise orthopaedic anatomy, P. 319

ETIOLOGY
Fracture can caused by trauma, stress fracture, and pathological fractures

MECHANISM OF INJURY
Direct

Some fracture patterns suggest the causal mechanism:

(a) spiral pattern (twisting);
(b) short oblique pattern (compression);
(c) triangular butterfly fragment (bending)
(d) transverse pattern (tension).

Appleys . Sistem Of Orthopaedis & Fracture,8 th editi

687

Netters concise orthopaedic anatomy, P. 294

Gustilo Anderson
Classification

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 4th Edition.

Oblique Fracture

Oblique fracture due to high

energy trauma motocycle
injury

Diagnosis

Anamnesis

Physical examination

X- ray, with anteriorposterior and

lateral view

Laboratory examination

Clinical features
Oedema

Hematoma

Tenderness at the
fracture site.

Decreased range of
motion at the ankle or
knee, depending on the
location of the fracture

If fracture is displaced,
a deformity may be
noted

Appleys . Sistem Of orthopaedis & fracture,8 th edition.

Evidence Leading To Diagnosis

PHYSICAL
EXAMINATION

HISTORY
TAKING
Chief complain: Pain
at lower left leg due
to high energy
trauma.

Stitched wound at right heel region

length 6 cm, excoriated wound at
lateral maleolus extendery proximally
to the lateral aspect of leg sized 20 cm
x 5 cm. Deformity (+) Edema (+)
hematom (+)

CLOSED FRACTURE OF LEFT

CRURIS

RADIOLOGICAL FINDING
(CRURIS AP/LT & ANKLE
AP/LAT)
Fracture 1/3 distal left tibia

Closed fracture 1/3 distal

left tibia

Treatmen
t
CONSERVATIVE
Indication :
- Closed fracture
- Open fracture
grade I-II
- Minimal Displaced
Circular
Casting

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 4th Edition.

OPERATIVE
- Fail Conservative
- Open fracture grade III (grossly
contaminate,
associated vascular injury)
- Fracture associated with
compartment syndrome
- For traction (avulsion) fractures in
which fragment are held apart
- Fractures associated with
compartment syndrome
- Severely comminuted fractures
- Associated femoral fracture (floating
knee)
- Fractures in patients with spasticity
syndromes (cerebral palsy, head
injury)
- unstable fractures in which adequate
alignment can not be either attained
Internal Fixation
or maintained
Fixation
- PatientsExternal
with multisystem
injuries

COMPLICATION

Local
Gene
ral
shock, fat
emboli

Orhtopedic and Traumatology

Faculty of Medicine ,Hasanuddin University
Makassar
2016

THANK YOU

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