ORTHOPEDICS Year 4, MBBS 08/09
CASE WRITE-UP 2 Comminuted Fracture of Tibia
Name: Harith Abdul Malek Matric. No.: 0808-0875 Group: 03 Supervisor: Dr. Alla
TABLE OF CONTENTS No. 1 2 3 4 5 6 7 8
Component Abstract Patient’s Profile Patient’s History Summary Physical Examination List of Problems Clinical diagnosis Investigations
Page 3 4 4 5 6 7 7 7
9 10 11 12 13
Definitive diagnosis Treatment Patient’s Progress Discussion References
10 10 10 11 14
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ABSTRACT This is a case of tibial shaft fracture in a 23 year-old soldier, Corporal MF. The fracture was acquired from a high-energy trauma and was presented as deformity at the casualty department. The fracture was a closed one. Further investigation revealed moderate comminution of the fracture and varus angulation. He was acutely treated with a back-slab cast to the above-knee level before a definitive surgical treatment—internal fixation—was decided. The discussion will focus on the nature, epidemiology, and classifications of tibial shaft fracture, options for treatment and the importance of rehabilitation for fracture patients.
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PATIENT’S PROFILE Patient’s initials: Corporal MF Age: 23 years old Sex: Male Race: Malay Status: Single Occupation: Soldier (Malaysian Army) Address: Terendak Camp Date of admission: 11th April, 2012 PATIENT’S HISTORY Chief complaint Corporal MF came to the emergency department with a deformed right leg and pain over the left thigh for 30 minutes following an alleged motor vehicle accident. History of presenting illness The corporal was standing on the side of a road waiting for his food ordered from a nearby night stall. While he was waiting, a motorcycle came fast towards him and hit him directly on the lateral side of his right leg. The motorcycle was of 110 cc engine and the speed it was going with during the accident was approximated at 80 km per hour. The patient fell on the grass on his left thigh. He was still conscious following the accident and found his right leg to be severely bended outward. The bend was at the mid-shin level. He could not get up by himself and could not walk. He was carried by his friends and brought to the hospital by a car. Upon reaching the hospital, he noticed his right leg was swollen. He only complained of aching pain over the ‘broken’ leg and a minor abrasion wound over the anterior aspect of the leg. The left limb of Corporal MF was relatively normal in comparison to the right one. Beside the localized aching and throbbing pain over the left thigh, no other complaints were made with regard to the limb. The limb could still be mobilized without any problem.
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The patient was conscious all the time. He did not complain of muscle weakness, neck or back pain, headache and dizziness. He had no dyspnea, chest pain, and abdominal pain. The corporal denied any tingling sensation or numbness felt over both lower limbs. No foot drop was noted on the affected limb and no urinary or bowel symptoms were reported. Past medical, surgical, and drug history Corporal MF was previously healthy and suffered from no chronic illness. He had no significant surgical history. No allergy to food or medications was reported by the patient. Family history The patient is not known to have any inherited bleeding disorder or any other familial disease. Other than the fact that his father is a diabetic, no other significant family history was obtained. Social history Corporal MF is a single Malay gentleman. He registered into the army when he was 20 years old and is currently staying at the Terendak Army Camp. He smokes 5-10 cigarettes per day but does not drink. He will complete his recovery process at his parents’ house in Penang. The house is a single-story house and his mother will be at home all the time to look after him.
SUMMARY Corporal MF, a 23 year-old gentleman, came in to the emergency department complaining of a deformed right leg and pain over the left thigh for 30 minutes following an alleged motor vehicle accident. The deformed leg was also swollen and in pain. He had only minor abrasion wound over the affected leg. He suffered from no head or spinal injury or difficulty in breathing.
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PHYSICAL EXAMINATION General inspection From general inspection, Corporal MF was lying supine on the bed, propped up at 30 degrees. The patient was alert, conscious, and oriented to time, place, and person. He was breathing comfortably. The right leg was put on back-slab cast and elevated by pillows. Corporal MF hands were moist. The pulse rate was 84 beats per minute with regular rhythm and good volume. The brachial blood pressure was 130 / 64 mmHg. He was afebrile with a temperature of 37.0 degree Celcius. The respiratory rate was 12 breaths per min. His BMI was 22.1. He was not pale and his tongue was mildly coated. There were two minor abrasion wounds over the ulnar side of his right hand and the right elbow. Regional examination Both legs were in normal attitude. The right leg was somewhat swollen and a minor abrasion wound with a size of 3x4 cm was noted on the anterior aspect of the leg. The wound was inspected and it was not deep enough to provide contact for the both with the external environment. The color of the skin was normal (when compared to the other leg). On palpation, the leg was warm and slightly tender. The swelling was maximal at the mid-shin level and extended to below the tibial tuberosity on one side and just above the ankle joint on the other side. The movement of ankle joint was restricted to limited dorsiflexion and plantarflexion. The movement of all the toes was however in normal range. The sensation over the leg and the foot was still spared. The examination of the other (left) lower limb revealed no abnormality except for the mild tenderness over the lateral aspect of the thigh. Full range of movement was elicited in all the joints of the limb and no sensory deficit was noted from the examination. Other systemic examinations The examination of the eyes was uneventful. Both heart sounds were heard with no additional sound. The respiratory examinations revealed a full chest expansion with vesicular breath sound. No abnormality was elicited from the abdominal examination. 6
LIST of PROBLEMS 1. 2. 3. 4.
Possible closed fracture of the right tibia Possible closed fracture of the right fibula Minor soft tissue trauma on the left thigh Chronic smoking
CLINICAL DIAGNOSIS Closed fracture of the right tibia following a direct high-energy trauma
INVESTIGATIONS Full blood count: No. 1
Component Hemoglobin (Hb)
Value 14.9 g/dL
2
Total White Count 13.1 x 10^9/L (TWC)
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Platelets
380 x 10^9/L
Normal value 11.0 – 16.9 g/dL 4.0 – 11.0 x 10^9/L 150 – 400 x 10^9/L
Remarks Normal level, no anemia Elevated with dominance of lymphocytes (20 %) Approaching the high limit, possibly reactive thrombocytosis
Comment: the full blood count revealed no emerging issue if Corporal MF was ever considered for a surgical procedure.
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Imaging investigations X-ray of right tibia (anterior-posterior view)
Comment: The above is Corporal MF’s plain radiograph of right tibia revealing comminuted spiral wedge fracture of the tibial shaft and transverse fracture of the fibular shaft.
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X-ray of left femur (anterior-posterior and lateral view)
Comment: there is no fracture or abnormal feature seen in the left femur.
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DEFINITE DIAGNOSIS Closed comminuted fracture of the right tibial and fibular shaft
TREATMENT Definitive treatment: Corporal MF was planned to have an open reduction (for both tibia and fibula) and internal fixation (with intermedullary nail for the tibia). Other treatments: While waiting for the procedure, Corporal MF’s right leg was immobilized with back-slab cast until the above knee level. Intra-muscular Voltaren (50 mg) was administered for pain relief. The minor abrasion wound of the right leg, hand and elbow was cleaned and dressed with normal saline. Intravascular injection of Rocephin (1 g BD) was also administered as a pre-caution against infection.
PATIENT’S PROGRESS The patient was on day-3 post-operation and was generally well. Corporal MF did not spike any fever. The blood pressure of the patient was 120 / 78 mmHg and the pulse rate was 64 / minute. He complained of pain only when producing considerable movement. He could still move his right ankle and all of the right toes without any restriction, even though the strength was still 3/5. The surgical wound looked to be healing well. It was still slightly swollen and erythematous; but no discharge was noted to be coming out of the wound. The patient was planned to be discharged on the following day. He would continue the rehabilitation process in a health facility in his hometown.
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DISCUSSION Tibial shaft fracture The tibia is a long tubular bone and it has triangular cross-section. Its anteromedial border is enveloped by subcutaneous tissue and the other aspects are covered by four tight fascial compartments (anterior, lateral, posterior, deep posterior). The fibula is located laterally to the tibia and the common peroneal nerve is located subcutaneously, traveling around the fibular neck, making it particularly vulnerable to direct blows or traction injuries at this level. Tibia is currently leading the rank of fractured bones in the body. Mechanism of injury is variable—ranging from low-energy trauma resulting in twisting and rotation associated fracture to high-energy trauma, most commonly associated with motor vehicle accident (MVA), resulting in fracture of both tibia and fibula. One study in 1992 has reported an annual incidence of 2 tibial fractures per 1000 individuals (Alho et. al, 1992). The average age of patients suffering from this fracture is 37 years old and teenage males make up the largest portion (CourtBrown, McBirnie, 1995). This possibly correlates to the fact that high-speed trauma is the highly associated with this fracture. Fracture of the tibia can be classified in several ways. When the fracture is an open one, Gustillo-Anderson classification can be employed. However, Corporal MF suffered from a closed fracture of the tibia. The Orthopedic Trauma Associaton has offered a system of classification which relies on the radiographic findings. The classification has 3 main categories (A, B, and C) and the case of Corporal MF falls in category C—spiral wedge fractures. Category C has several sub-classifications depending of the number of fragments visible from the radiograph images. Because there were 3 fragments seen in the radiograph, this fracture can be specifically classified as C1.2. Physiological of bone healing A normal fractured bone will heal and be replaced by bone tissues. Bone tissue is the only solid tissue in the body that can do this—as other tissues will be replaced by fibrous tissue and form scars. Bone healing is generally staged into 5 phases—hematoma formation, inflammatory phase, callus formation, consolidation, and remodeling. Currently, Corporal MF is undergoing the first two stages of healing—hematoma and inflammatory phase. The direct trauma disrupted endosteal and periosteal blood supply and maintaining adequate blood supply to
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the fracture site is essential for healing. Disrupted local vascular supply at the injured site creates a hematoma and prompts the migration of inflammatory cells, which stimulate angiogenesis and cell proliferation. Then, the inflammation stage will take place. Options of treatment for tibial shaft fracture Closed tibia fractures can often be treated conservatively. However, potential fracture instability may necessitate open reduction and internal fixation. Operative fixation is required when fractures are unstable. Instability is defined as greater than 1.5 cm of apparent shortening, more than 5 degrees of varus or valgus angulation, 10 degrees of anterior or posterior angulation, and/or less than 50% translation while the leg is already in a cast. From the right leg radiograph, there is approximately 20 degrees of varus angulation. Factors that have been identified to cause instability include the degree of comminution, the presence of ipsilateral fibular fractures, and the location of the fracture along the tibia. Corporal MF suffered from a moderately comminuted tibial fracture with ipsilateral fibular fracture; these increase the risk of fracture instability in him. Fractures with significant displacement or comminution that requires operative intervention can be treated acutely with a posterior long-leg splint or external fixation if significant shortening or severe wound is present. Corporal MF’s fracture did not involve significant shortening or severe contaminated wound; hence, he was only treated with a long-leg back-slab cast when he arrived at the casualty department. Several options can be considered when surgical treatment is definitive: intramedullary nailing, plates and screws. In the Corporal MF’s case, intramedullary nailing with interlocking screws, which by far the most popular technique for tibial shaft fracture, had been chosen. This technique preserves the periosteal blood supply, which is extremely important considering the fact that tibia is quite distal from the central blood supply. And this will optimize the condition for fracture healing. Compartment syndrome should be treated emergently with 4-compartment fasciotomies. However, the patient did not display any sign or symptom of compartment syndrome during the 24-hour monitoring period. Concomitant fractures of the fibula do not require surgical treatment once the tibia has been stabilized.
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Importance of rehabilitation Corporal MF is still a young soldier and has many years ahead of his career. This incident should not hinder his ambition to advance his career in the army. With the availability of physiotherapy and understanding of function restoring process, the patient can achieve his pre-morbid function as a whole. The post-trauma / operative activities that will help in re-gaining the function include reduction of edema, preservation of joint movement, restoration of muscle power, and guiding the patient back to normal life. Elevation of the affected site can prevent edema and this will in turn prevent joint stiffness. Edema is especially expected in patients who have undergone internal fixation procedure like Corporal MF. Hence, it is important for him to maintain elevation of his leg for a few days post-surgery and start active exercise as soon as he can tolerate it. Active exercise will not only help in preventing joint stiffness, but it will also pump away the edema by improving circulation. Physiotherapy will offer the necessary assisted movement in restoring muscle power and guiding the patient to achieve his pre-morbid functional capacity.
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REFERENCES 1) Solomon, Louis. Warwick, David. Nayagam, Selvaduria. Apley’s System of Orthopedics and Fractures. Chapter 23: Principles of fractures by Selvadurai Nayagam. Hodder Education (2010) 2) Dandy & Edwards: Essential Orthopedics and Trauma. 5th Edition. Chapter 4: Basic Science in Orthopedics – Tissue Healing 3) Srinivasan R.C., Tolhurst S., Vanderhave K.L. (2010). Chapter 40. Orthopedic Surgery. In G.M. Doherty (Ed), CURRENT Diagnosis & Treatment: Surgery, 13e. Retrieved on April 27, 2012 from 4) Ronald Lakatos. General Principles of Internal Fixation. Last update: February 7, 2012. 5) Brian K. Konowalchuk. Tibial Shaft Fracture. Last update: February 10, 2012.
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