Case Report Tibia

8/21/2019 Case Report Tibia

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Case Report

I. PATIENTS IDENTITY

NAME : Mr. D

AGE : 14 years old

GENDER : Male

DATE OF ADMISSION : 14th

May 2014

MEDICAL RECORD : 662802

II.

HISTORY TAKING

CHIEF COMPLAINT: Deformity at the Right Leg

Suffered since 1 months before admitted to Wahidin General Hospital due to traffic

accident. The patient was riding his motorcycle and was hit by car at his right side.

History of unconscious (-), vomit (-), nausea (-) . The patient refuse to be operated

immediately because of financial issues. The patient has a history of going to a

bone setter. The patient has been walking using a crutch

III. PHYSICAL EXAMINATION

GENERAL STATUS

Conscious/ poor-nourished

height = 165 cm, weight = 48kg (BMI = 17.7 kg/m)

Vital Signs

Blood Pressure : 110/90 mmHg

Pulse Rate : 88 bpm

Respiratory Rate : 18 bpm (Thoracoabdominal)

Temperature : 36.8 C (Axillary)


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LOCAL STATUS

RIGHT LEG REGION :

Look :

Deformity (+), Swelling (-), haematoma (-), Wound (-)

Feel :

Tenderness (+). Sensibility is good, pulsation of a. dorsalis pedis is

palpable. CRT < 2

Move :

Active and passive movement of the knee joint is normal

Active and passive movement of the ankle joint :

Plantar Flexi 0-300

Dorsoflexi 0-100

IV. CLINICAL PICTURE

Fig. 1. Anterior View


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Fig. 2. Medial View

Fig. 3 Lateral View

Leg Length Discrepencies:

Right Left

Apparent leg length 96 cm 97 cm

True leg length 85 cm 86 cmLeg Length discrepancy 1 cm


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V. LABORATORY FINDINGS:

Date: 14/5/2014

WBC 7.1 x 10 /mm BT 3

RBC 4.52 x 10 /mm CT 7

HGB 12.7 g/dL HbsAg Non reactive

HCT 40%

PLT 263 x 10 /mm

VI. RADIOLOGICAL FINDINGS Right cruris film AP and lateral


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Result : Neglected Fracture 1/3 distal right tibia and fibula

- Right Ankle Joint AP/Lateral View

Result : Displaced commnited fracture 1/3 distal right tibia and fibula

VII. RESUMEMan, 14 year old came to the hospital with deformity of the right leg since

1 months before admitted to Wahidin General Hospital due to traffic accident. The

patient refuse to be operated immediately because of financial issues. The patient

has a history of going to a bone setter. The patient has been walking using a crutcth

From physical examination of the right leg, there are deformity with no

swelling, Haematoma and wound. There are Tenderness . The sensibilities are good,

a. dorsalis pedis is palpabe,CRT < 2

ROM of the knne joint is normal..ROM of the ankle joint are Plantar Flexi

0-300and Dorso Flexi 0-10

0


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Radiological findings shows features of fracture of 1/3 distal right tibia and

fibula.

VIII. DIAGNOSIS Neglected Closed Fracture 1/3 Distal Right Tibia and Fibula

IX. THERAPYInitial treatment

IVFD Analgesic Apply long leg back slab

Planning

- Internal Fixation (ORIF)


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DISCUSSION : FRACTURE OF THE MIDDLE TIBIA AND FIBULA

I. EPIDEMIOLOGYFractures of the tibia and fibula shaft are the most common long bones fractures. In

an average population, there are about 26 tibia diaphyseal fractures per 100.000

population per year. The highest incidence of adult tibia diaphyseal fractures seen in

young males is between 15 and 19 years of age, with an incidence of 109 per

100,000 population per year. The highest incidence of adult tibia diaphyseal

fractures seen in women is between 90 and 99 years of age, with an incidence of

49 per 100,000 population per year. The average age of a patient sustaining a tibia

shaft fracture is 37 years, with men having an average age of 31 years and women

54 years. Diaphyseal tibia fractures have the highest rate of nonunion for all long

bones.(2)

II. MECHANISM OF FRACTUREFractures can result from injury, repetitive stress or abnormal weakening of the

bone (a pathological fracture).(6)

1. Fracture due to injury:

Most fractures are caused by sudden and excessive force, which may be

direct or indirect. With a direct force the bone breaks at the point of impact; the soft

tissues also are damaged. A direct blow usually splits the bone transversely or may

bend it over a fulcrum so as to create a break with a butterfly fragment. Damage to

the overlying skin is common; if crushing occurs, the fracture pattern will be

comminuted with extensive soft-tissue damage.(2,6)

With an indirect forcethe bone breaks at a distance from where the force is

applied; soft-tissue damage at the fracture site is not inevitable. Although most

fractures are due to a combination of forces (twisting, bending, compressing or

tension), the x-ray pattern reveals the dominant mechanism:


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Twisting causes a spiral fracture Compression causes a short oblique fracture. Bending results in fracture with a triangular butterfly fragment Tension tends to break the bone transversely; in some situations it may simply

avulse a small fragment of bone at the points of ligament or tendon insertion.

(2,6)

2. Fracture due to repititive stress:

These fractures occur in normal bone which is subjected to repeated heavy

loading, typically in athletes, dancers or military personnel who have gruelling

exercise programmes. These high loads create minute deformations that initiate thenormal process of remodelling a combination of bone resorption and new bone

formation in accordance with Wolffs law. When exposure to stress and

deformation is repeated and prolonged, resorption occurs faster than replacement

and leaves the area liable to fracture. A similar problem occurs in individuals who

are on medication that alters the normal balance of bone resorption and

replacement.(2,6)

3. Pathological fracture:

Fractures may occur even with normal stresses if the bone has been

weakened by a change in its structure (e.g. in osteoporosis, osteogenesis imperfecta

or Pagets disease) or through a lytic lesion (e.g. a bone cyst or a metastasis).(6)


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Figure 1: Some fracture patterns suggest the causal mechanism: (a)spiral pattern(twisting); (b)short oblique pattern (compression); (c)triangular butterfly fragment

(bending) and (d)transverse pattern (tension). Spiral and some (long) oblique patterns

are usually due to low-energy indirect injuries; bending and transverse patterns are

caused by high-energy direct trauma.

III. TYPES OF FRACTURES

Figure 2: Varieties of fracture. Complete fractures: (a)transverse; (b)segmental and

(c)spiral. Incomplete fractures: (d)buckle or torus and (e,f) greenstick.


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There are variables type of fractures, depending on its appearance. First type of fracture

is called as complete fracture. The bone is split into two or more fragments, which then can

be further classified as transverse, oblique or spiral type. For transverse fracture, the

fragments usually remain in place after reduction meanwhile for oblique or spiral fracture,

they tend to shorten or displace if the bone is splinted. In an impacted fracture, the

fragments are jammed tightly together and the fracture line is indistinct. In comminuted

fracture, there are more than one fragments and there is poor interlocking of the fracture

surfaces. Second type of fracture is incomplete fracture. The bone is incompletely divided

and the periosteum remains intact. The examples for this fractures are greenstick fractures

and compression fractures.(1)

IV. ANATOMYThe tibia and fibula are the bones of the leg. The tibia articulates with the

condyles of the femur superiorly and the talus inferiorly and in doing so transmits

the body's weight. The fibula mainly functions as an attachment for muscles, but it

is also important for the stability of the ankle joint. The shafts (bodies) of the tibia

and fibula are connected by a dense interosseous membrane composed of strongoblique fibers.

(3)

A. Tibia

Tibia is located on the anteromedial side of the leg, nearly parallel to the

fibula, the tibia is the second largest bone in the body. The proximal end widens to

form medial and lateral condyles and there is tibial plateau, which articulate with

the lateral and medial condyles of the femur and the lateral and medial menisci

intervening. Separating the upper articular surfaces of the tibial condyles are

anterior and posterior intercondylar areas lying between these areas is the

intercondylar eminence.(3,4)


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The shaft of the tibia is triangular in cross section, presenting three borders

and three surfaces. Its anterior and medial borders, with the medial surface between

them, are subcutaneous. At the junction of the anterior border with the upper end of

the tibia is the tuberosity, which receives the attachment of the ligamentum patellae.

The anterior border becomes rounded below, where it becomes continuous with the

medial malleolus. The lateral or interosseous border gives attachment to the

interosseous membrane. The lower end of the tibia is slightly expanded and on its

inferior aspect shows a saddle-shaped articular surface for the talus. The lower end

is prolonged downward medially to form the medial malleolus.(3,4)

B. FibulaThe fibula is the slender lateral bone of the leg. It takes no part in the

articulation at the knee joint, but below it forms the lateral malleolus of the ankle

joint. It takes no part in the transmission of body weight, but it provides attachment

for muscles. The fibula has an expanded upper end, a shaft, and a lower end. The

upper end, or head, is surmounted by a styloid process. It possesses an articular

surface for articulation with the lateral condyle of the tibia. The shaft of the fibula is

long and slender. Typically, it has four borders and four surfaces. The medial or

interosseous border gives attachment to the interosseous membrane. The lower end

of the fibula forms the triangular lateral malleolus, which is subcutaneous. On the

medial surface of the lateral malleolus is a triangular articular facet for articulation

with the lateral aspect of the talus. Below and behind the articular facet is a

depression called the malleolar fossa.(3,4)


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Figure 3: Anatomy of tibia and fibula.

Blood supplyo The nutrient artery arises from the posterior tibial artery, entering the

posterolateral cortex distal to the origination of the soleus muscle. Once the

vessel enters the intramedullary (IM) canal, it gives off three ascending

branches and one descending branch. These give rise to the endosteal

vascular tree, which anastomose with periosteal vessels arising from the

anterior tibial artery.

o The anterior tibial artery is particularly vulnerable to injury as it passesthrough a hiatus in the interosseus membrane.

o The peroneal artery has an anterior communicating branch to the dorsalispedis artery. It may therefore be occluded despite an intact dorsalis pedis

pulse.


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o The distal third is supplied by periosteal anastomoses around the ankle withbranches entering the tibia through ligamentous attachments.

o There may be a watershed area at the junction of the middle and distal thirds(controversial).

o If the nutrient artery is disrupted, there is reversal of flow through the cortex,and the periosteal blood supply becomes more important. This emphasizes

the importance of preserving periosteal attachments during fixation.

Figure 4: Compartments of lower leg.


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There are 4 muscles in the anterior compartment of the leg, which are tibialis

anterior, extensor digitorum longus, extensor hallucis longus and fibularis tertius.

Collectively they act to dorsiflex and invert the foot at ankle joint. The muscles are

innervated by deep fibular nerve and blood is supplied via anterior tibial artery. (2, 3)

The posterior compartments of leg contains seven muscles, organized into two

layers, superficial and deep. The two layers are separated by a band of fascia.

Superficial posterior compartment comprise of gastrocnemius, soleus and plantaris. The

gastrocnemius is the most superficial of all the muscles in the posterior leg, which has

two heads, medial and lateral that converge to form a single muscle belly. The plantaris

is a small muscle with a long tendon. The muscle descend medially, condensing into a

tendon that runs down the leg, between gastrocnemius and soleus. The tendon blends

with the calcaneal tendon. The soleus is located deep to the gastrocnemius. It narrows in

the lower part of the leg and joins the calcaneal tendon.(2, 3)

There are four muscles in the deep compartment of the posterior leg. The popliteus

acts only on the knee joint. The remaining three muscles act on ankle and foot. The

popliteus located superiorly in the leg. It lies behind the knee joint, forming the base of

popliteal fossa. The tibialis posterior is the deepest out of 4 muscles. it lies between the

flexor digitorum longus and the flexor hallucis longus. The flexor digitorum longus is a

small muscle than the flexor hallucis longus. It is located medially in the posterior leg.

Flexor hallucis longus is found on the lateral side of leg. Both superficial and deep

posterior compartment is innervated by tibial nerve.(2, 3)

For lateral compartment, there are two muscles, which are the peroneus longus and

peroneus brevis. Peroneus longus act on eversion and plantarflexion of the foot. It also

supports the lateral and transverse arch of the foot. The peroneus brevis muscles is

deeper and shorter than peroneus longus. It acts on eversion of the foot. Lateral

compartment is innervated by superficial peroneal nerve.(2, 3)


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Figure 5: Innervation of lower leg by tibial nerve


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Figure 6: Innervation of lower leg by peroneal nerve.


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V. CLASSIFICATIONMechanism of injury for tibia and fibula fractures will determine the appearance of

the fractures. A twisting force causes a spiral fractures of both tibia and fibula bones at

different levels. An angulatory force produces transverse or short oblique fractures,

usually at the same level. The behavior of these injuries and choice of treatments

depends on following factors.(1)

a. The state of soft tissuesThe risk of complications and the progress to fracture healing are directly

related to the amount and type of soft-tissue damage. Closed fractures are

best described using Tschernes (Oestern and Tscherne,1984) method. For

open injuries, Gustilos grading is more useful (Gustilo et al., 1984).(1, 4)

b. The severity of the bone injuryHigh-energy fractures are more damaging and take longer to heal than low-

energy fractures; this is regardless of whether the fracture is open or closed.

Lowenergy breaks are typically closed or Gustilo I or II, and spiral. High-

energy fractures are usually caused by direct trauma and tend to be open

(Gustilo III AC), transverse or comminuted. (1, 4)

c. Stability of fractureConsider whether it will displace if weight-bearing is allowed. Long oblique

fractures tend to shorten; those with a butterfly fragment tend to angulate

towards the butterfly. Severely comminuted fractures are the least stable of

all, and the most likely to need mechanical fixation.(1, 4)

d. Degree of contaminationThis factor is an important additional factors in open fractures.

(1, 4)


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Figure 7 : Johner and Wruhs Classification System for tibial shaft fractures.

Blocking screws placed posteriorly and laterally to the central axes of the

proximal fragments. Neither displacement nor soft tissue injury is

considered in this system.

Tscherne Classification is used to evaluate the grade of soft tissue injury in closed-

fracture.(1, 4)

Grade 0a simple fracture with little or no soft tissue injury Grade 1 a fracture with superficial abrasion or bruising of the skin and

subcutaneous tissue

Grade 2a more severe fracture with deep soft-tissue contusion and swelling. Grade 3 a severe injury with marked soft-tissue damage and a threatened

compartment syndrome.

The more severe grades of injury are more likely to require some form of

mechanical fixation. This is due to good skeletal stability aids in soft tissue recovery.

VI. CLINICAL FEATURESThe limb should be carefully examined for signs of soft-tissue damage: bruising,

severe swelling, crushing or tenting of the skin, an open wound, circulatory

changes, weak or absent pulses, diminution or loss of sensation and inability to


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move the toes. Any deformity should be noted before splinting the limb. Always be

on the alert for signs of an impending compartment syndrome. Pain out of

proportion to the injury is the most reliable sign of compartment syndrome.(1,2,4)

The entire length of the tibia and fibula, as well as the knee and ankle joints,

must be seen. The type of fracture, its level and the degree of angulation and

displacement are recorded. Rotational deformity can be gauged by comparing the

width of the tibio-fibular interspace above and below the fracture. Spiral fractures

without comminution are low-energy injuries. Transverse, short oblique and

comminuted fractures, especially if displaced or associated with a fibular fracture at

a similar level, are high-energy injuries.(1,2,4)

VII. COMPLICATION

a. Early complication:

Vascular Injury :

Fractures of the proximal half of the tibia may damage the popliteal artery.

Damage to one of the two major tibial vessels amy also occur and go unnoticed if

there is no critical ischaemia.(1)

Compartment syndrome:

Tibial fractures, both open and closed are among the commonest causes of

compartment syndrome in the leg. The combination of tissue edema and bleeding

(oozing) causes swelling in the muscle compartment and this may precipitate

ischaemia. Additional risk factors are proximal tibial fractures, severe crush injury,

a long ischaemic period before revascularization ( type IIIC open fractures).

The diagnosis is usually suspected on clinical grounds. Warning symptoms

are increasing pain, a feeling of tightness or bursting in the leg and numbness in

the leg or foot. These complaints should always be taken seriously and followed by

careful and repeated examination for pain provoked by muscle stretching and loss of

sensibility and/or muscle strength.(1)


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Neurovascular injury:

Vascular compromise is uncommon except with high-velocity, markedly

displaced, often open fractures.It most commonly occurs as the anterior tibial artery

traverses the interosseous membrane of the proximal leg. It may require saphenous

vein interposition graft. The common peroneal nerve is vulnerable to direct injuries

to the proximal fibula as well as fractures with significant varus angulation.

Overzealous traction can result in distraction injuries to the nerve, and inadequate

cast molding/padding may result in neurapraxia.(2)

Compartment syndrome:

Involvement of the anterior compartment is most common. Highest

pressures occur at the time of open or closed reduction. It may require fasciotomy.

Muscle death occurs after 6 to 8 hours. Deep posterior compartment syndrome may

be missed because of uninvolved overlying superficial compartment, and results in

claw toes.(2)

Late complication:

Malunion

Slight shortening (up to 1.5 cm) is usually of little consequence, but rotation

and angulation deformity, apart from being unsightly, can be disabling because the

knee and ankle no longer move in the same plane. Angulation should be prevented

at all stages; anything more than 7 degrees in either plane is unacceptable.

Angulation in the sagittal plane, especially if accompanied by a stiff equinus ankle,

produces a marked increase in sheer forces at the fracture site during walking; this

may result in either refracture or non-union.(1)


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Delayed union

High-energy fractures are slow to unite and liable to non-union or fatigue

failure if a nail has been used. If there is insufficient contact at the fracture site,

either through bone loss or comminution, prophylactic bone grafting as soon as

the soft tissues have healed is). If there is a failure of union to progress on x-ray by

6 months, secondary intervention should be considered. The first nail is removed,

the canal reamed and a larger nail reinserted. If the fibula has united before the tibia,

it should be osteotomized so as to allow better apposition and compression of the

tibial fragments.(1)

Non-union

This may follow bone loss or deep infection, but a common cause is faulty

treatment.Either the risks and consequences of delayed union have not been

recognized, or splintage has been discontinued too soon, or the patient with a

recently united fracture has walked with a stiff equinus ankle. Hypertrophic non-

union can be treated by intra - medullary nailing (or exchange nailing) or

compression plating. Atrophic non-union needs bone grafting in addition. If the

fibula has united, a small segment should be excised so as to permit compression of

the tibial fragments. Intractable cases will respond to nothing except radical Ilizarov

techniques.(1)


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REFERENCES

1. Koval KJ, Zuckerman JD. Closed fracture. Handbook of Fracture. 3rd ed. NewYork: William & Wilkins; 2006. p. 20-28.

2. Koval KJ, Zuckerman JD. Tibia Fibula Shaft. Handbook of Fracture. 4th ed. NewYork: William & Wilkins; 2006. p. 387-97.

3. Moore, Keith L, Dalley, Arthur F. Tibia and Fibula. Clinically Oriented Anatomy.5th ed. New York: Lippincott Williams & Wilkins; 2006. p. 567-653.

4. Snell RS. The Lower Limb. Clinically Anatomy by Regions. 8th ed. New York:Lippincott Williams & Wilkins; p. 614-7.

5. Thompson JC. Leg and Knee. Netter Concise Orthopaedic Anatomy. 2nd ed.Saunders Elsevier. p. 316-22.

6. Solomon L, Warwick D, Nayagam S. Principle of Fracture. Apley's System ofOrthopaedics and Fractures. 9th ed. London: Hodder Arnold; 2010. p. 706-904.

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Case Report Tibia

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