Case Presentation

Ahmad Hariz bin Ahmad Jaafar

Group D2
Batch 22
 Patient profile
• Name: Muhammad Muttaqin
• Age: 19 years old
• Sex: Male
• Occupation: Student
• Date of Admission: 5th June 2012
 Summary of Case
A 19 years old Malay male from Alor Gajah was electively
admitted for operative procedure. Patient was apparently well
until 4 months ago, where he sustain an injury to the medial side
of his right leg, where he was tackled during a rugby match.

Afterwards, there is deformity in the form of dent at medial side

of lower 1/3rd of his right leg. His right foot dorsiflexion was
restricted but all other movement are intact. No wound at the
injury site
He also complain of pain at the site of injury, which is sudden onset. It
was intermittent, throbbing in nature , aggravated on movements
especially on movement of the right leg and foot, relieved by rest and
pain killers. Pain score was 7/10.

There is swelling at the site of fracture afterwards, start insidiously,

increasing in size and resolve spontaneously in 3 days time.

He was then sent to Universiti Malaya Medical Centre, where x-ray of

his right leg was taken and he was told there is fracture of tibia while
the other bone is intact. Above knee P.o.P cast was applied and he was
told to come for follow up once in a month.
8 weeks after the injury, x-ray was taken again and the P.o.P cast
was removed. He was told the fracture site has not yet heal and
there is some gap between the fracture site. On examination by
the doctor, he told that the fracture site is mobile and there is no
pain.
He was put on elective surgery appointment on 6th June 2012 to
close the gap at the fracture site
No history suggestive of tuberculosis, osteomyelitis, intravenous
drug user, alcohol intake, smoking or sexual promiscuity. No loss
of weight or appetite.
 Local examination of right lower limb
• On inspection
– Attitude: hip flexed and addcuted, knee extended,
foot dorsiflexed and inverted
– Deformity at lower 1/3rd of medial side of right leg
– Apparent shortening of the right lower limb
– Atrophy of the right thigh
• On palpation
– Deformity: bony consistency
– Mobile on lateral plane
– Crepitus
– No tenderness
– No local rise in temperature
• Range of movement: Restricted dorsiflexion
on right foot (active)
• Galeazzi’s sign : right knee lower and forward
• Sensory on thigh, leg and foot are intact. No
functional impairment. Neurovascular
examination normal . Power on right lower
limb is 4/5.
 Differential diagnosis
• Non union of right tibia
• Malunion of right tibia
 Investigation
• Lab investigation
– FBC, ESR, C reactive protein
– Total lymphocyte count

• Imaging
– X ray of the right leg AP and lateral view, including
knee and ankle joint
- Comminuted fracture of right tibia
- Fibula intact
- No callus formation
- Open medullary canal
- Decrease bone density at distal end of tibia
 Management
• Principles
– Hypertrophic non union
• Extensive callus formation, vascular (excellent healing
potential). They are best treated with rigid stabilization
with or without compression.
– Atrophic non union
• Absence of callus, deficient bone vascularity, and poor
healing potential
• Surgical approach
– Fibular osteotomy
• Inhibiting compression across the tibial nonunion site
– Removal of necrotic bone
– Reamed intramedullary (IM) nail (noninfected)
– Compression plating
– Adjunctive therapy, such as the use of antibiotic
bone cement or bone substitute beads
– Follow up