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CASE
REPORT
“Open Fracture 1/3 Distal
Tibia and Fibula Sinistra”

Andriyani Setiarini
Supervisor :
30101507378
dr. Wisnu Murti, Sp.OT
 INTRODUCTION
• Tibia and fibula fractures are often called cruris fractures which often occur
compared to other long bone fractures and are often found in orthopedic cases.
Tibia and fibula are two long calf bones.
• Of these two bones, the tibia is the only bone that holds weight. Tibial fractures
are commonly associated with fibula fractures, because the force is transmitted
along the interosseous membrane to the fibula.
• The periosteum lining the tibia is rather thin, especially the frontal path that is
only covered by the skin so the bones break easily and fracture fragments usually
shift because it is directly under the skin so that most of the fractures in the lower
limbs open more frequently. . Even in closed fractures, soft tissue can be
disrupted.
 INTRODUCTION
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• Open fracture is the relationship between the fracture fragment and the
outside world due to skin injury (the tip of the fracture that penetrates from
the inside to the surface of the skin or the surface of the skin that penetrates
sharp objects from the outside to the inside).
• Open fractures often arise complications (infection). Infection can be caused
by flora normal in the skin (Staphylococus, Micrococus and Corynebacterium)
or pathogenic bacteria especially gram (-) bacteria, depending on the
exposure (contamination) of the environment at the time of the fracture.
• Gustilo and Anderson reported that 50.7% of patients had positive culture
results on their wounds during the initial evaluation. While 31% of patients
had a negative culture at first, it became positive at definitive closure.
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ANATOMI
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MECHANISM OF INJURY

direct
causes direct pressure on if trauma is delivered to
the bone and fractures areas farther away from
occur in the pressure
area. Fractures that occur the fracture area and
are communicative and usually soft tissue
soft tissue is damaged. remains intact
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 FRACTURE HEALING PROCESS
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 MANAGEMENT
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1. Recognition: anamnesis slide
to the patient 2the chronology of the accident
regarding
and complaints felt by the patient to determine the diagnosis.
2. Fracture reduction: the return of bone to an anatomic position
• Open reduction  With surgery, install internal fixation devices (pens, wires,
screws, plates, nails and metal rods).
• Closed reduction  Extremities are maintained with gips, traction, braces,
splints and external fixators.
3. Immobilization. After being reduced, bone fragments must be immobilized or
maintained in the correct position and alignment until fusion occurs. The
immobilization method is carried out by external and internal fixation.
4. Maintain and restore functions:
• Maintain reduction and immobilization
• Elevate the fracture area to minimize swelling
• Monitor neuromuscular status
• Control anxiety and pain
• Isometric exercises and muscle settings
• Return to the original activity gradually
 PATIENT IDENTITY
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Name : An. Wilda Azzahra
Ramadhani
Age : 6 years old
Gender : Female
Religion : Moslem
Come to Hospital : August 7, 2019
Room : Kenanga 2
No CM : 585195
Address : Sidomakmur
 PRIMARY
SURVEY
Airway
Look : Agitation (-), cyanosis (-), nasal lobe breathing (-), use of
breathing muscles (-).
Listen : Snoring (-), gurgling (-), stridor (-), hoarsness (-)
Feel : Breath through the mouth and nose (+), There is no tracheal
deviation

Assessment : Airway patent  clear

 PRIMARY
SURVEY
Breathing
Look : Spontaneous breathing, injury (-), breath frequency 22 x /
minute, symmetrical chest wall development
Listen : Vesicular breath sounds (+ / +)
Feel : Tenderness (-), crepitation (-), sonor in all lung fields

Assessment : Adequate breathing

 PRIMARY
SURVEY
Circulation
Look : Active bleeding (-)
Feel : Capillary refill <2 seconds, cold Akral (-), HR: 110 x / minute,
regular, load strong voltage

Assessment : Adequate Circulation  infus RL 10 tpm, splinting

on the lower left leg
 PRIMARY
SURVEY
Dissability
• GCS E4 V5 M6
• Pupil ø 2mm/2mm, isokor
• Refleks Cahaya (+)N / (+)N

Exposure
• Jejas thoraks (-)
• Jejas abdomen (-)
• Jejas pelvis (-)
• Jejas pada kaki kiri bawah (+)
 ANAMNESIS
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• Main Problem: Pain in the lower left leg.
• Current medical history: Patients come to the
emergency room of RSUD dr. H. Soewondo Kendal on
Wednesday, August 7, 2019 at 14.45 WIB with complaints
of pain in the left leg after falling from a bicycle on
Sunday, August 4, 2019. When falling, the patient was
immediately taken to the clinic near the house and carried
out staining. Then the next day the patient was brought to
BALKESMAS for a rongen photo. Results of rongen taken
on Wednesday, August 7, 2019.
• Past Medical History
a. History of drug allergy: denied
b. History of asthma: denied
c. History of Heart Disease: denied
d. History of injuries : denied
e. History of Operation : denied

• Family Medical History

a. History of injuries: denied
b. History of drug allergy: denied
c. History of asthma: denied
d. History of Heart Disease: denied
e. History of Operation : denied

• Socialeconomic History
BPJS patient
 PHYSICAL EXAMINATION

• General Situation : Fussy

• Awareness : Composmentis
• GCS : E4V5M6 (15)
• Vital Sign
• Pulse  110 x / minute
• Respiration  22 x / minute
• Temperature  36.5 ˚C
• General Status
• Head : mesochepal, wound (-)
• Eyes : anemic conjunctiva (- / -), jaundice sclera (- / -), isochoric pupils Ø 2 mm
/ 2 mm, light reflexes (+ / +)
• Ear : normal form, tragus tenderness (- / -), auricular pull pain (- / -), otorhea
(- / -)
• Nose : normal form, deviation of septum (-), deformity (-), Rhinorea (-)
• Mouth : cyanosis (-), laceration (-)
• Neck : symmetrical, swollen (-), pain (-)
• Skin : turgor (<2 seconds)
 THORAX PHYSICAL EXAMINATION
EXAMINATION RESULTS
Inspection normochest, symmetrical, retraction (-), injury (-), RR:
22x / minute, ictus cordis (-)
Palpation pain (-), mass (-), symmetrical vocal vermitus (+),
crepitation (-), palpable ictus cordis (+)
Percussion Sonor (+)
Auscultation vesicular (+), Whezzing (-), Ronchi (-), regular I-II
heart sounds, gallops (-), murmurs (-)
Interpreta Normal
tion
ABDOMEN PHYSICAL EXAMINATION
EXAMINATION RESULTS
Inspection flat (+), symmetrical (+), matrix (-), striae (-), mass
(-), injury (-)
Auscultation bowel sounds (+) normal
Percussion timpani (+)
Palpation Supple (+), tenderness (-), loose pain (-), mass (-),
defance muscular (-)
Interpretati Normal
on
 EXTREMITY EXAMINATION
Superior Inferior
Oedema -/- -/+
Cold -/- -/-
Extremity
Sianosis -/- -/-
CRT <2” <2”
Distal Radialis : + /+ Dorsalis pedis : + /+
Pulsation
ROM +/+ +/-
 LOCAL STATUS
Left Leg

• Look : eritem (+), wound (+), deformity (+), Swelling (+)

• Feel : pain (+), sensibility (+), Dorsalis pedis artery pulsation (+),

crepitation (+)

• Movement : Dissability of ROM and pain of movement

 LABORATORY
Hematology
• Hemoglobin: 10,6 gr/dL (11,5-16,5)
• Leukosit : 8.100 /µL(4-10)
• Trombosit : 229.000 /µL (150-500)
• Hematokrit : 32,4 % (35-49)
• PT : 14,7 detik (11,3-14,7)
• APTT : 32,5 detik (27,4-39,3)
 RADIOLOGY

Radiology cruris sinistra (AP-

LATERAL) position

efore operation on August 7, 2019

 RADIOLOGY

Radiology cruris dextra (AP-

LATERAL) position after operation
on August 9, 2019
ASSESMENT
• Clinical Diagnosis : Open fracture tibia and fibula sinistra 1/3 distal

INITIAL PLAN
IGD : Post Operative :
 Infus RL 10 tpm
 Infus RL 10 tpm  Inj. Cefazolin 2x250 mg
 Inj. Cefazolin 2x250 mg  Inj. Hypobac 2x25 (1
day)
 Inj. Ceftriaxon 650 mg / 24 jam
 Inj. Metamizole 2 x ½
 Inj. Ketorolac ½ amp / 8 jam amp
 Inj. Ranitidin ½ amp / 12 jam  PO : Cefixime syr 2x200
Ibuprofen syr 2x1
Osfit syr 1x1
Operative  Treat injury (day 2)
• ORIF August 9, 2019  ROM Exercise
 NWB
Ip. Monitoring
• General condition
• Bleeding
• Vital sign
• The result of supporting examination

Education
• Educate patients and parents to treat injuries after surgical treatment
• Educate patients and parents to do some simple exercises after treatment is
received

PROGNOSIS
• Quo ad vitam : dubia ad bonam
• Quo ad sanam : dubia ad bonam
• Quo ad fungsionam : dubia ad bonam
 CONCLUSSION
• Lower limb fractures include tibia and fibula fractures. Of these two bones, the
tibia is the only bone that holds weight.

• Tibial fractures are commonly associated with fibula fractures, because the force
is transmitted along the interosseous membrane to the fibula.

• The periosteum lining the tibia is rather thin, especially the pathway in the front
area which is only covered by the skin so that the bones break easily and fracture
fragments usually shift because it is directly under the skin so that most of the
fractures in the lower limbs open more frequently. Even in closed fractures, soft
tissue can be disrupted.

• The causes of tibia and fibula fractures are divided into 2 namely direct and
indirect.

• The diagnosis of tibial shaft fractures is obtained by history taking, physical

examination, and radiographic examination.

• As with all fractures, pain management must be a major concern. Fracture

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Thank You