tibial plateau fracture

Tibial plateau case

Identitas pasien

• Nama: Bp. S• Umur: 47 tahun• Pekerjaan: buruh• Tgl masuk: 22 oktober 2014

Anamnesis

Keluhan utama

• Nyeri pada kaki kanan

Riwayat penyakit sekarang:

• HMRS, pasien jatuh dari motor, terpental dan kaki kanan terbentur trotoar. Pasien tidak mengingat jelas kejadian. Nyeri dirasakan dikaki kanan, nyeri terutama dirasakan jika digerakkan dan berkurang saat istirahat, bengkak (+).• Saat kejadian pasien sadar, pasien dibawa ke rumah sakit. Mual dan

muntah disangkal, pusing dan nyeri kepala disangkal.

Status Generalis

• KU : CM, sedang (E4V5E6)• Vital Sign :

TD : 130/80N : 83 kpmRR : 20 kpmT : 36 oc

Primary Survey

• AIRWAY : bicara jelas, snoring (-), gurgling (-) clear• BREATHING : Simetris, KG (-) ,RR 20 kpm clear• CIRCULATION : akral hangat, WPK <2dtk, TD 130/80 HR 83 kpm

clear• DISABILITY : E4V5M6 clear

Status lokalis regio cruris dextra

Look: terdapat vulnus laceratum ukuran 7 cm, dasar otot, keadaan kotor, deformitas (+), edema (+).Feel: NT (+), akral hangat, WPK <2 detik, pulsasi arteri dorsalis pedis dan tibialis posterior (+), fungsi sensoris dbnMovement: fungsi motoris distal dbn.

DIAGNOSIS KLINIS

Susp. Open fracture cruris Dextra GA IIIA

Pemeriksaan penunjang

CBCX-ray (regio cruris dextra) AP dan lateralAlbumin

Lab

• AL : 9,8 mg/dl• AE : 4,1 mg/dl• Hb : 10,1 mg/dl• Hct : 3,9 mg/dl• Plt : 273 mg/dl• Albumin : 3,5

X-Ray Cruris DextraAP/Lat

Diagnosis

• OF Right Tibial Plateau Gustillo II-IIIA

Manajemen

• Debridement• Immobilisasi• Medikamentosa :

- Inj. ATS IM 250 IU- Inj. Ceftriaxone 1g - Inj. Ketorolac 30mg- Inj. Ranitidine 25mg

Definitif• Debridement + ORIF dengan plat.

Pembahasan

Open Fracture

Definition

• An open fracture refers to osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma

• Soft tissue injuries in an open fracture may have three important consequences:• Contamination of the wound and fracture• Crushing, stripping, and devascularization that results in soft tissue

compromise and increased susceptibility to infection.• Destruction or loss of the soft tissue envelope may affect the method of

fracture immobilization

Clinical evaluation –Initial Management-• Patients with open fractures may have multiple injuries, a rapid

general assessment is the first step and any life threatening conditions are addressed• Primary survey involve ABCDE : Airway, Breathing, Circulation,

Disability and Exposure.

Clinical Evaluation

• Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure.• Initiate resuscitation and address life-threatening injuries.• Evaluate injuries to the head, chest, abdomen, pelvis, and spine.• Identify all injuries to the extremities. Assess the neurovascular status of injured

limb(s).• Assess skin and soft tissue damage• Identify skeletal injury; obtain necessary radiographs.

Classification -Gustilo and Anderson-

Grade I: Clean skin opening of <1 cm, usually from inside to outside; minimal muscle contusion; simple transverse or short oblique fractures

Grade II: Laceration >1 cm long, with extensive soft tissue damage; minimal to moderate crushing component; simple transverse or short oblique fractures with minimal comminution

Grade III: Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with a severe crushing component

IIIA: Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping

IIIB: Extensive soft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination

IIIC: Vascular injury requiring repair

Treatment

After initial trauma survey and resuscitation for life-threatening injuries • Perform a careful clinical and radiographic evaluation • Wound hemorrhage should be addressed with direct pressure rather than

limb tourniquets or blind clamping.• Initiate parenteral antibiotic• Assess skin and soft tissue damage; place a saline-soaked sterile dressing on

the wound.• Perform provisional reduction of fracture and place a splint.• Operative intervention: open fractures constitute orthopaedic emergencies,

because intervention less than 8 hours after injury has been reported to result in a lower incidence of wound infection and osteomyelitis.

Principle of Treatment

• Antibiotic prophylaxis.• Urgent wound and fracture debridement.• Stabilization of the fracture.• Early definitive wound cover.

• Grade I, II: First-generation cephalosporin• Grade III: Add an aminoglycoside• Farm injuries: Add penicillin and an aminoglycoside

Tetanus Prophylaxis

• Should also be given in the emergency room. • The current dose of toxoid is 0.5 mL regardless of age; for immune

globulin,• the dose is 75 U for patients <5 years of age, • 125 U for those 5 to 10 years old, and • 250 U for those >10 years old. • Both shots are administered intramuscularly, each from a different syringe

and into a different site

Operative Treatment

• Adequate irrigation and debridement are the most important steps in open fracture treatment:

- The wound should be extended proximally and distally to examine the zone of injury.

- The clinical utility of intraoperative cultures has been highly debated and remains controversial.

- Meticulous debridement should be performed, starting with the skin and subcutaneous fat

Factors of muscle viability

Color Normally beefy red; rarely, carbon monoxide exposure can be deceiving

Consistency Normally firm, not easily disrupted

Capacity to bleed Can be deceiving because arterioles in necrotic muscle can bleedTypically reliable

Contractility Responsive to forceps pinch or low cautery settingTypically reliable

• Meticulous hemostasis should be maintained, because blood loss may already be significant and the generation of clot may contribute to dead space and nonviable tissue.• Fasciotomy should be considered, especially in the forearm or leg.• Historically, it has been advocated that traumatic wounds should not

be closed. One should close the surgically extended part of the wound only. More recently, certain centers have been closing the open wound after debridement with close observation for signs or symptoms of sepsis.• The wound, if left open, should be dressed with saline-soaked gauze,

synthetic dressing, a vacuum assisted closure (VAC) sponge, or an antibiotic bead pouch.• Serial debridement(s) should be performed every 24 to 48 hours as

necessary until there is no evidence of necrotic soft tissue or bone.

Fracture StabilizationExternal fixation• Periarticular fractures• Definitive• Distal radius• Elbow dislocation• Selected other sites

• Temporizing• Knee• Ankle• Elbow• Wrist• Pelvis

• Distraction osteogenesis• In combination with screw

fixation for severe soft tissue injury• Severe contamination: any site

Fracture StabilizationInternal fixation• Periarticular fractures• Distal/proximal tibia• Distal/proximal femur• Distal/proximal humerus• Proximal ulnar radius• Selected distal radius/ulna• Acetabulum/pelvis• Diaphyseal fractures

• Femur• Tibia• Humerus• Radius/ulna

Soft Tissue Coverage and Bone Grafting• Wound coverage is performed once there is no further evidence of

necrosis.• The type of coverage ”delayed primary closure, split-thickness skin

graft, rotational or free muscle flaps”is dependent on the severity and location of the soft tissue injury.• Bone grafting can be performed when the wound is clean, closed, and

dry. The timing of bone grafting after free flap coverage is controversial. Some advocate bone grafting at the time of coverage; others wait until the flap has healed (normally 6 weeks).

Limb Salvage Immediate or early amputation may be indicated if:• The limb is nonviable: irreparable vascular injury, warm ischemia time >8

hours, or severe crush with minimal remaining viable tissue.• Even after revascularization the limb remains so severely damaged that

function will be less satisfactory than that afforded by a prosthesis.• The severely damaged limb may constitute a threat to the patient™s life,

especially in patients with severe, debilitating, chronic disease.

COMPLICATIONS

• Infection: cellulitis or osteomyelitis, despite aggressive, serial debridements, copious lavage, appropriate antibiosis, and meticulous wound care. • Compartment syndrome: severe loss of function, especially in tight

fascial compartments including the forearm and leg. It may be avoided by a high index of suspicion with serial neurovascular examinations accompanied by compartment pressure monitoring, prompt recognition of impending compartment syndrome, and fascial release at the time of surgery.

Tibial Plateu Fractures

Epidemiology

• Tibial plateau fractures constitute 1% of all fractures and 8% of fractures in the elderly.• Isolated injuries to the lateral plateau account for 55% to 70% of

tibial plateau fractures, as compared with 10% to 25% isolated medial plateau fractures and 10% to 30% bicondylar lesions.• There is a wide spectrum of fracture patterns that involve the medial

tibial plateau (10% to 23%), the lateral tibial plateau (55% to 70%), or both (11% to 31%).• From 1% to 3% of these fractures are open injuries.

Mechanism of injury

• Fractures of the tibial plateau occur in the setting of varus or valgus forces coupled with axial loading. Motor vehicle accidents account for the majority of these fractures in younger individuals, but elderly patients with osteopenic bone may experience these after a simple fall.• The direction and magnitude of the generated force, age of the

patient, bone quality, and amount of knee flexion at the moment of impact determine fracture fragment size, location, and displacement.• A bicondylar split fracture results from a severe axial force exerted on

a fully extended knee.

Clinical evaluation

• Neurovascular examination• Hemarthrosis • Open injuries • Compartment syndrome (4P)• Assessment for ligament

ASSOCIATED INJURY

• Soft tissue injury (90%).• Meniscal tears occur (50%)• Collateral or cruciate ligament rupture(30%).• Peroneal nerve injuries• Arterial injuries

RADIOGRAPHIC EVALUATION

• Anteroposterior and lateral views supplemented by 40-degree internal (lateral plateau) and external rotation (medial plateau) oblique projections • A 10- to 5-degree caudally tilted plateau view • Avulsion of the fibular head, the Segond sign (lateral capsular

avulsion) and Pellegrini–Steata lesion (calcification along the insertion of the medial collateral ligament) > ligamentous injury.• A physician-assisted traction view • Stress views, preferably with the patient under sedation or anesthesia

and with fluoroscopic image intensification.

CLASSIFICATION

Schatzker (Fig. 36.1)

TREATMENT

Nonoperative• Indicated for nondisplaced or minimally displaced fractures and in

patients with advanced osteoporosis.• Protected weight bearing and early range of knee motion in a hinged

fracture brace are recommended.• Isometric quadriceps exercises and progressive passive, active-assisted,

and active range-of-knee motion exercises are indicated.• Partial weight bearing (30 to 50 lb) for 8 to 12 weeks is allowed, with

progression to full weight bearing.

TreatmentOperative• Surgical indications• The reported range of articular depression that can be accepted varies from <2

mm to 1 cm.• Instability >10 degrees of the nearly extended knee compared to the

contralateral side is an accepted surgical indication. Split fractures are more likely to be unstable than pure depression fractures in which the rim is intact. (Fig. 36.3)• Open fractures.• Associated compartment syndrome.• Associated vascular injury.

COMPLICATIONS 

• Arthrofibrosis: This is common, related to trauma from injury and surgical dissection, extensor retinacular injury, scarring, and postoperative immobility. More common in higher energy injuries.

• Infection: This is often related to ill-timed incisions through compromised soft tissues with extensive dissection for implant placement.

• Compartment syndrome• Malunion or nonunion: This is most common in Schatzker VI fractures at the metaphyseal–

diaphyseal junction, related to comminution, unstable fixation, implant failure, or infection.• Posttraumatic osteoarthritis• Peroneal nerve injury.• Popliteal artery laceration (rare).• Avascular necrosis of small articular fragments: This may result in loose bodies within the

knee.

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