CASE REPORT

OPEN FRACTURE 1/3 MIDDLE OF LEFT TIBIA AND FIBULA GRADE IIIA

By: Ivander E P C 111 08 285 Advisors: dr. Evan dr. Fadil dr. Rustam dr. Arief Supervisor: Dr. M. Ruksal Saleh, PhD, Sp.OT (K)

Department of Orthopaedic dan Traumatology Faculty of Medicine Hasanuddin University Makassar 2013

IDENTITY
Name Age Admission Address Occupation Registration :F : boy 9 years old : 13rd August 2013 (14:48) : Jl. Bila Dusun I Kamp Baru : Student : 622 534

HISTORY TAKING
Chief complaint : decrease of consciousness Anamnesis: suffered since 1 day before admitted to the hospital due to traffic accident. Mechanism of trauma : patient was crossing street and suddenly hit by motorcycle from left side Prior treatment at RS. Andi Makassau, Parepare nausea (-), vomit (+)

PRIMARY SURVEY
A B C : Patent : RR = 28 x/min, symmetric, spontaneous, thoracoabdominal type : BP = 100/70 mmHg, HR = 100 x/min, regular, strong : GCS 12 (E3M5V4), light reflex +/+, pupil isochors, d = 2,5 mm/ 2,5 mm : T = 36,5oC (Axillary)

D
E

SECONDARY SURVEY
Temporoparietal Left region Inspection : Excoriated wound (+), hematoma (-), edema (-) Palpation : Tenderness can not be evaluated due to unconscious

SECONDARY SURVEY
Left leg region: Inspection : Stitched wound at anterior aspect of cruris, size 3cm. Deformity (+), swelling (+), hematoma (+). Palpation : Tenderness cant be evaluated due to unconscious ROM : Active and passive movement of the knee and ankle joints cant be evaluated due to unconscious NVD : Sensibility and motoric cant be evaluated, pulsation of the dorsalis pedis artery is palpable. Capillary refilling time <2

Right Appearent Leg Length True Leg Length Leg Length Discrepancy 73 cm 66 cm 1 cm

Left 72 cm 65 cm

CLINICAL PICTURES

RADIOLOGICAL FINDINGS

RADIOLOGICAL FINDING
HEAD CT SCAN

RADIOLOGICAL FINDING
Thorax X-Ray AP

RADIOLOGICAL FINDING
PELVIS X RAY AP

RADIOLOGICAL FINDING
CRURIS AP LATERAL

LABORATORY FINDINGS

HB HT LEU PLT BT CT

7.3 g/ dl 27.9 gr% 14.500 /ul 250.000 /ul 3 minute 30 second 8 minute 30 second

SUMMARY
A boy 9 years old, was admitted to the hospital with decrease of consciousness, suffered since 1 day ago before admitted to the hospital due to traffic accident Patient was cross the street and suddenly hit by motorcycle from the left side On physical examination, there is stitched wound at anterior aspect of cruris, size 3 cm. Deformity (+), swelling (+), hematoma (+) ROM active and passive movement knee and ankle joint can not be evaluated NVD sensibility and motoric can not be evaluated, pulsation of the dorsalis pedis artery is palpable, capillary refill time <2 X-Ray : fracture at 1/3 middle left tibia, fracture at 1/3 middle left fibula CT-Scan: Intra cerebral hematom temporoparietal sinistra

DIAGNOSIS

Moderate head injury Open fracture 1/3 middle Left Tibia Grade IIIA Open fracture 1/3 middle Left Fibula Grade IIIA

MANAGEMENT
IVFD

RL Analgesic Antibiotic and anti tetanus serum Planning ;

Debridement Closed reduction

FRACTURE OF TIBIA AND FIBULA

INTRODUCTION
Open

fracture means that skin around the fracture site has been punctured and exposed to external environment, it increases the risk for bacterial infection. Pediatric tibial fractures, 39% occur in the middle third. Approximately 30% of pediatric diaphyseal fractures are associated with a fracture of the fibula. Occasionally, this is in the form of plastic deformation, producing valgus alignment of the tibia.

Koval KJ, Zuckerman JD. In : Handbook of Fractures Third Edition. USA : Lippincott Williams & Wilkins. 2006

GUSTILO & ANDERSON CLASSIFICATION OF OPEN FRACTURE

Grad e I Wound Contamin Soft tissue size ation <1cm Clean Minimal Bone injury -Simple (transverse, short oblique) -minimal comminution -moderate comminution (transverse, short oblique) -minimal periosteal stripping -soft tissue coverage of bone is possible -moderate to severe comminution -poor bone coverage -poor bone coverage -moderate to severe comminution

II III A

>1cm

Moderate

Moderate -extensive soft tissue laceration - Adequate soft tissue coverage -Extensive soft tissue injury - Need soft tissue reconstruction -severe loss of soft tissue -need NV reconstruction

>10 cm High

III B

>10 cm Massive

III C

>10cm

Massive

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

INNERVATION

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

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

DIAGNOSIS
Anamnesis : history of illness, mechanism of trauma Physical examination : LOOK, FEEL, MOVE (examine the good limb compare with the bad limb) X- ray, with rule of 2: 2 view, 2 limb, 2 joint, 2 occasion, 2 injuries Laboratory examination

Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9th Edition. UK: Arnold. 2010.

TREATMENT
Non operative - Closed reduction Operative Indication: - Open fracture - Fractures in which a stable reduction is unable to be achieved or maintained

Koval KJ, Zuckerman JD. In : Handbook of Fractures Third Edition. USA : Lippincott Williams & Wilkins. 2006

COMPLICATIONS
Compartment syndrome Angular deformity Malrotation Delayed union and nonunion

Koval, Kenneth J.; Zuckerman, Joseph D.. Pediatric Femoral Shaft. Handbook of Fractures, 3rd Edition. New York: Lippincott Williams & Wilkins. 2006.

CRURIS AP LATERAL