Hikban Fiqhi K.

C11108104
Advisors:
dr. Hendra Hermanto
dr. Aries Freddy Hutabarat
Supervisor:
dr. M. Ruksal Saleh, Ph.D, Sp.OT. (K)



Department of Orthopaedic dan Traumatology
Faculty of Medicine Hasanuddin University
Makassar
2014
Delayed Union 1/3 Proximal Right Tibia
Non Union 1/3 Proximal Right Fibula
Name : Mr. M
Age : 19 years old
Admission : February 25
th
, 2014
Registration : 652221

Identity

Anamnesis
Chief complain : Limping gait
Suffered since 5 months ago.
History of trauma : patient got traffic accident 7
months ago and got treatment by bonesetter for 2
months. There are excoriated wound at the right leg
after trauma but no history previous treatment by a
doctor.
Patient is an active smoker ( 1 pack/day )
History Taking
General Status :
Conscious, Good Nourish
Vital Sign :
BP : 120/80 mmHg
HR : 88 times/minute
RR : 20 times/minute
T : 36, 7 C



Physical Examination
Right leg region :
I : Deformity (+), swelling (-), scar at anterior
proximal aspect size 1 cm x 0,5 cm.
P : Tenderness (-)
NVD : Sensibility is good, dorsal pedis artery palpable,
CRT <2

Localized Status
Right
( )
Left
( )
Knee Flexion 140 140
Extension 0 0
Ankle Plantarflexion

50 50
Dorsoflexion

0 20
ROM
Right Left
Apparent Leg Length 90 cm 93 cm
True Leg Length 82 cm 85 cm
Leg Length
Discrepancy
3 cm
Right Left
Thigh
Circumference
31 cm 34 cm 3 cm

Clinical Findings

Clinical Findings

Clinical Findings

Clinical Findings
Radiology Finding
Test Result Normal Value
WBC
6,6 x 10
3
/uL
4,0 10,0
RBC
4,98 x 10
6
/uL
4,5 6,5
HGB
15,3 gr/dl
12,0 16,0
HCT
47,4 %
37,0 48,0
PLT
267 x 10
3
/lU
150 - 400
GDS 87 [mg/dL] <200
HbsAg Non Reactive Non Reactive
Laboratory Findings
A man, 19-years-old, was admitted to the hospital
with the chief complain limping gait that suffered
since 5 months ago. Patient is an active smoker ( 1
pack/day ).
On physical examination, there are leg length
discrepancy at the right lower limb; atrophy of the
right thigh; at right leg region there are deformity, scar
wound. No neurological deficit. Limited ROM at the
right ankle

Summary
Delayed union 1/3 proximal right tibia
Non union 1/3 proximal right fibula
Diagnosis

Plan for ORIF (Open Reduction Internal Fixation)

Management
Fracture : Loss of continuity of bone structure,
cartilage joint and epiphyseal cartilage
Intact skin closed fracture (simple)
Skin or one of the body cavities is breached open
(or compound) fracture

Introduction
Mark D. Miller. Review of Orthopaedics, 4th edition. Philadelpia:Elsevier.2004
Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.
Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.

Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.

Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.


Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.

Dermatome

Thompson,JD. Netter's concise orthopedic anatomy 2
nd
edition.2010.

Torsional mechanisms

Stress fracture
Indirect injury
(usually low
energy)
Transverse, comminuted,
displaced fractures
The incidence of soft tissue
injury is high
Example: motor vehicle
accident
Direct (usually a
high-energy
injury)
Mechanism of Injury
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New
York: Arnold. 2010.

Delayed Union
as healing taking longer than 6 months
insufficient blood supply
uncontrolled repetitive stresses
infection
heavy smoking.
Nonunion
once the fracture has no further potential to unite.
Malunion
fragments join in an unsatisfactory position (unacceptable
angulation, rotation or shortening)
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York: Arnold. 2010.
Koval, KJ, Zuckerman, JD. Hand book of fractures .3rd editon.2006

Biological
Inadequate blood
supply
Severe soft tissue
damage
Periosteal stripping
Biomechanical
Imperfect splintage
Over-rigid fixation
Infection
Causes of Delayed Union
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York:
Arnold. 2010.

Causes of Non Union
Injury-related causes include segmental bone loss,
extensive soft-tissue damage, and loss of adequate
blood supply.
Treatment-related factors include quality of
reduction, amount of distraction, and length of
immobilization.
Inadequate fracture stabilization is a common cause
of fracture nonunion.
Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H. Title: 5-Minute Orthopaedic Consult, 2nd Edition

Clinical Evaluation
Fracture tenderness
Evaluate neurovascular status : dorsalis
pedis and posterior tibial artery pulses
Assess soft tissue injury.
Monitor for compartment syndrome.
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York:
Arnold. 2010.

Radiographic Evaluation
AP and Lateral view with visualization of the ankle and
knee joints
X-ray : fracture line remains visible, there is incomplete
callus formation or periosteal reaction


Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York:
Arnold. 2010.
TREATMENT
NONOPERATIVE
OPERATIVE
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York:
Arnold. 2010.
Nonoperative
Fracture reduction : a long leg cast used for isolated, closed
and low energy fractures.
Acceptable Fracture Reduction :
<5 of varus or valgus.
<10 of anterior or posterior.
<10 of rotational deformity.
< 1 cm of shortening; 5 mm of distraction may delay
healing 8 - 12 months.
>50% cortical contact.




TREATMENT FOR TIBIAL FRACTURES

Cast with the knee 0 - 5 of flexion to allow for weight
bearing with crutches as soon as tolerated by patient,
with advancement to full weight bearing by the second
to fourth week.
After 4 - 6 weeks, the long leg cast exchanged patella-
bearing cast or fracture brace.

Operative
Intramedullary (IM) Nailing
Flexible Nails
External Fixation
Plates and Screws




Open Reduction
closed reduction fails.
there is a large articular fragment that needs accurate
positioning.
for traction (avulsion) fractures in which the fragments are
held apart.
As a rule, however, open reduction is merely the first step to
internal fixation.


Closed Reduction
the distal part of the limb is pulled in the line of the bone
after it has been reduced.
Skeletal or skin traction for several days allows for soft-
tissue tension to decrease and a better alignment to be
obtained
closed reduction is used for all minimally displaced
fractures, for most fractures in children and for fractures
that are not unstable after reduction and can be held in
some form of splint or cast
Internal Fixation
Screws
Metal plate held by screws
Long intramedullary rod or nail (with or without locking screws)
Properly applied, internal fixation holds a fracture securely so that
movement can begin at once; with early movement the fracture
disease (stiffness and oedema) is abolished.
Solomon. L. et al. Injurys of the Knee and Leg in Apleys System of Orthopaedics and Fractures 9
t\h
Edition. New York:
Arnold. 2010.

External Formation
Fractures associated with severe soft-tissue damage (including
open fractures) or those that are contaminated, where internal
fixation is risky and repeated access is needed for wound
inspection, dressing or plastic surgery.
Fractures around joints that are potentially suitable for internal
Patients with severe multiple injuries.