Tuesday, June 17, 2008

Case Discussion - Fracture of Distal Tibia


Tadi al OC (on call), alhamdulillah ada banyak kes yang datang ke A&E. Antaranya kes multiple fracture & fracture of iliac bone. Tapi sekadar nak kongsi dengan sahabat-sahabat, kes yang al folow daripada patient masuk sampai patient prepare untuk masuk ke ward

Datang dengan komplain sakit di bahagian buku lali kanan (right ankle joint) selepas terjatuh ketika main bola.

How to aproach this patient?
  1. Full history
  2. PE
  3. Set IV line
  4. FBC, BUSE & GSH
  5. X-ray
  6. POP
  7. Plan for internal fixation

This is the an X-ray of right ankle joint (lateral & AP view)
Comment : fracture of distal tibia & fibula. (salter haris type 2 @ Pilon fracture?) & fracture of distal fibula.

This patient was plan to for internal fixation (intramedulary nail/ screw/ plate). Before that, CMR (closed manual reduction) was done & he was put on full lenght POP to hold the fracture until the operation done.

How to do full lenght POP?

Antara perkara yang diperlukan sebelum POP dilakukan
Set IV - Petidine 1 mg/kg , midazolam (dormicum) 0.1 mg/kg, normal saline.
Cardiac monitoring

Inilah gambar full lenght POP selepas dah siap.

Soalan2 yang Dr tanya.
What is the content of POP?
In Full lenght POP, how many degree the ankle & knee joint must be flex? and why?


al-Seronok sangat oncall malam ni!

Selasa I 17 Jun 06 I R308 I Remedial


mohammad faiz said...

askum pin, i do not agree with the diagnosis that u mention . u said that this is salter haris type 2..
from ur x-ray i can not there is fracture on the growth plate .. it just fracture on the distal tibial and fibula...

Type I

Fracture through the growth plate: The epiphysis is completely separated from the end of the bone or the metaphysis, through the deep layer of the growth plate. The growth plate remains attached to the epiphysis. The doctor has to put the fracture back into place if it is significantly displaced. Type I injuries generally require a cast to protect the plate as it heals. Unless there is damage to the blood supply to the growth plate, the likelihood that the bone will grow normally is excellent.
Type II

Fracture through the growth plate and metaphysis: This is the most common type of growth plate fracture. It runs through the growth plate and the metaphysis, but the epiphysis is not involved in the injury. Like type I fractures, type II fractures may need to be put back into place and immobilized. However, the growth plate fracture heals a great deal, especially in younger children. If it is not too displaced, the doctor may not need to put it back into position. In this case, it will strengthen with time.
Type III

Fracture through growth plate and epiphysis: This fracture occurs only rarely, usually at the lower end of the tibia, one of the long bones of the lower leg. It happens when a fracture runs completely through the epiphysis and separates part of the epiphysis and growth plate from the metaphysis. Surgery is sometimes necessary to restore the joint surface to normal. The outlook or prognosis for growth is good if the blood supply to the separated portion of the epiphysis is still intact and if the joint surface heals in a normal position.
Type IV

Fracture through growth plate, metaphysis, and epiphysis: This fracture runs through the epiphysis, across the growth plate, and into the metaphysis. Surgery is frequently needed to restore the joint surface to normal and to perfectly align the growth plate. Unless perfect alignment is achieved and maintained during healing, prognosis for growth is poor, and angulation (bending) of the bone may occur. This injury occurs most commonly at the end of the humerus (the upper arm bone) near the elbow.
Type V

Compression fracture through growth plate: This uncommon injury occurs when the end of the bone is crushed and the growth plate is compressed. It is most likely to occur at the knee or ankle. Prognosis is poor, since premature stunting of growth is almost inevitable.

A newer classification, called the Peterson classification, adds a type VI fracture, in which a portion of the epiphysis, growth plate, and metaphysis is missing. This usually occurs with open wounds or compound fractures, and often involves lawnmowers, farm machinery, snowmobiles, or gunshot wounds. All type VI fractures require surgery, and most will require later reconstructive or corrective surgery. Bone growth is almost always stunted.

and i want to clarify what u mean by pilon fracture,,,,
and from my understanding pilon fracture is a comminuted fracture of the tibia for futher information plz visit

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