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PATIENT IDENTITY

Name
:B
Age
: 44 years old
Sex
: Male
Date of Admission :August 23rd, 2015 at
16.30
RM number
: 723290

HISTORY TAKING
Chief Complaint: Pain at right leg
Suffered since 22 hours before being admitted to
Wahidin General Hospital
Patient was riding a motorcycle when he fell down
due to loss of balance
Patients right leg first came into contact with the
ground.
Vomitting (-) nausea (-)
Prior treatment : Pangkep Hospital

PRIMARY SURVEY
Airway : Clear
Breathing: RR = 20x/min, regular, spontaneous,
thoracoabdominal type, symmetrical.
Circulation: BP = 120/70 mmHg,HR = 80 x/min regular,
strong.
Disability : GCS 15 (E4V5M6),isochoric pupil, : 2,5 mm,
light reflex +/+
Exposure : T = 36,70 C (axilla)

SECONDARY SURVEY
Localized status :
Right Leg region
Look:

Deformity (+), swelling (+), hematoma (+),


Wound (-)
Feel : tenderness (+)
Move: Active and passive motions of the knee are
limited due to pain
Active and passive motions of the ankle are
limited due to pain
NVD : Good sensibility, dorsalis pedis and tibialis
anterior pulses are palpable, CRT <2,

CLINICAL FINDINGS

LEG LENGTH DISCREPANCY


Right

Left

ALL

86

87

TLL

82

83

LLD

1 cm

LABORATORY FINDINGS
WBC : 15.400/ ul
RBC : 5.000.000/ ul
HBG : 14.7 g/dl
HCT : 43 %
PLT
: 233.000/mm3
CT
: 730
BT
: 230
HBsAg
: Non reactive

X-RAY RIGHT CRURIS

AP View

Lateral View

DIAGNOSIS
Closed fracture 1/3 distal right tibia
Closed fracture 1/3 distal right fibula

MANAGEMENT
IVFD

RL
Analgesic
Report to Orthopaedic senior, advice:
Apply

Plan

boot slab left lower limb

for ORIF Tibia & Fibula

RESUME
A Boy 44 years old came to the hospital with chief
complaint pain at the left leg, suffered since 22 hours
before admitted to Hospital.
At the anterolateral aspect, there is haematom and edema.The
region was tenderness on palpation, with unknown active and
passive motion of knee joint and ankle joint due to pain.
Sensibility is good and dorsalis pedis artery is palpable, CRT <2 .
laboratory findings are within normal limit,
From radiology finding (X-Ray cruris dextra AP/Lateral)
there is closed fracture 1/3 distal of right tibia and fibula.

Discussion

TIBIA AND
FIBULA

Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010.

NETTERS CONCISE ORTHOPAEDIC ANATOMY, P. 316

NETTERS CONCISE ORTHOPAEDIC ANATOMY, P. 317

NETTERS CONCISE ORTHOPAEDIC ANATOMY, P.


318

TYPES OF FRACTURES

Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010.

Clinical features

Diagnosis

Anamnesis

Physical examination

X- ray, with anteriorposterior and lateral view

Laboratory examination

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,8th edition.

TSCHERNES CLASSIFICATION OF SKIN


LESION IN CLOSED FRACTURES
Grade 0

Injury from indirect forces with negligible soft tissue


damage

Grade I

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

TREATMENT

Conservative
Closed reduction
Apply long leg cast
Functional bracing with Early weight-bearing
Pain medication if needed

TREATMENT

Operative

Internal Fixation
External Fixation

DEFINITIVE TREATMENT
Open Reduction Internal Fixation
Indication of ORIF in this patient is :
ORIF Tibia
Acceptable fracture reduction is not indicated anymore in
this patient
ORIF Fibula
Theres fracture at 3 cm from syndesmosis at X-Ray
findings
Advantage
Adequate reduction
Early movement
Disadvantage
Increase risk of infection, skin problem
A high degree of surgical technique and facilities are
essential

COMPLICATIONS
Early complications

Late complication

Neurovascular injury

Malunion, delay union, nonunion

Compartment syndrome

Joint stiffness
infection