Distal Tibia Fracture

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  DISTAL TIBIA FRACTURE  Name: Ruzaidi IsmailR/N: 328813 Case Summary: The above is forty years old Malay man, admitted ith a !om lain of ri#ht an$le ain and inability to al$ folloin# a fall from a roof of his house hile ad%ustin# the television antenna& There as no loss of !ons!iousness, heada!he or #iddiness& No ne!$, ba!$ or hi ain&'n e(amination he as alert and !omfortable& )is vital si#ns ere stable& The findin#s !onfined to his ri#ht an$le& )is ri#ht an$le as sollen and deformed and also his ri#ht foot& The an$le as tender and the ran#e of movement as severely limited due to ain& the dorsalis edis and the osterior tibialis ulses ere felt and there as no loss of sensation of the ri#ht foot noted&Radio#ra hi! e(amination reveals that there as a !omminuted fra!ture of the distal tibia involvin# the arti!ular surfa!e and the distal meta hysis re#ion& There as also transverse fibula fra!ture&* dia#nosis of a !omminuted distal tibia fra!ture, Ruedi + *ll#oer ty e II as made&)e as ut on ri#ht !al!aneal tra!tion and his ri#ht le# as elevated ith ohler + raun frame& -old !om ression as also administered& Re#ular !he!$in# of the neurovas!ular status as also done&.olloin# day,  + ray on tra!tion as done& *li#nment of the fra!ture as a!!e table but the arti!ular surfa!e as still dis la!ed& 1  *fter 10 days of tra!tion o en redu!tion and fi(ation as done& The fibula as lated ith 1/3 tubular late and the distal tibia fra#ment as redu!ed ith minimal in!ision and under Ima#e Intensifier the fra#ment as s!reed to the to the main fra#ment& .olloin# that an e(ternal fi(ator as a lied a!ross the an$le and the redu!tion as !he!$ed a#ain under Ima#e Intensifier&osto erative !he!$  + ray shos a #ood redu!tion and ali#nment& )e as dis!har#ed ell three days ost o eratively and as res!ribed ith a non ei#ht  bearin# !rut!h &)e as as$ed to !ome for follo u in 2 ee$s at the !lini!& Discussion: ilon fra!ture is a distal tibia fra!ture, hi!h involved the meta hyseal re#ion and the distal arti!ular surfa!e& This ty e of fra!ture is rare and it involved in about 10 of the tibia fra!tures& To different me!hanisms are believed to be res onsible for the ma%ority of tibial lafond fra!ture& The e(tent of soft tissue in%ury asso!iated ith these fra!tures dire!tly refle!ts the me!hanism of in%ury and the amount of ener#y absorbed at the time of a!!ident&.ra!tures resultin# from rotational for!e ty i!ally have a s iral sha e ith minimal to moderate dis la!ement of the fra!tured fra#ments& This ty e of in%ury usually asso!iated ith minimal soft tissue in%ury, althou#h si#nifi!ant sellin# may o!!ur&*(ial !om ression ty e tibial lafond fra!tures often a result of hi#hener#y trauma and !ommonly o!!urs in a motor vehi!le a!!ident and fall from a hei#ht& This ty e of fra!ture ty i!ally has #reater meta hyseal and arti!ular !omminution, soft tissue in%uries and sellin#& The attern of the fra!tures de ends u on osition of the foot and an$le durin# the trauma& This ty e of in%ury has a hi#her ris$ of develo ment of   osttraumati! arthritis and !om li!ated by soft tissue and bony roblems as noted by 4ellam and 5addell 61779& 2  The most idely used !lassifi!ation is the !lassifi!ation ro osed by Ruedi and *ll#oer 61779& Ty e I fra!tures are a sim le fra!tures ith little or no arti!ular dis la!ement, usually result of lo ener#y indire!t trauma su!h as tistin#& Ty e II fra!tures have dis la!ement of the arti!ular surfa!e ithout !omminution and ty e III have intraarti!ular dis la!ement ith mar$ed !ommunition& The ro#nosis of ty e III fra!tures is !onsiderably orse in vie of #reater arti!ular !omminution , fra!ture fra#ment dis la!ement , #reater !artila#e and soft tissue in%uries& The treatment for ilon fra!tures has been roved to be diffi!ult& To !om onents should be !onsidered& .irstly, the bony !om onent in hi!h involvement of the arti!ular surfa!e and !ommunition fra!tures made the redu!tion and fi(ation diffi!ult& e!ondly, oor mus!le bul$ around the an$le, ro(imity of tendons and the neurovas!ular stru!tures and relatively ti#ht s$in envelo e, ma$in# it rone to ne!rosis and diffi!ult in ound !losure&The initial mana#ement of ilon fra!tures is to revent further soft tissue in%ury and further dis la!ement of the fra!tured bone& This !an be done by immobilization, duration and !old !om ression to revent further sellin#& *ny dislo!ation should be redu!ed as soon as ossible& -a!aneal in !an be used as a method for immobilization and redu!tion of fra!tures by li#amentota(is& *natomi!al redu!tion for ilon fra!tures is very im ortant in vie of the involvement of the %oint surfa!e& oor redu!tion of the %oint surfa!e lead to ost traumati! arthritis and ain at the an$le %oint that may re;uire arthrodesis& Nonsur#i!al mana#ement for the ilon fra!tures !an be reserved undis la!ed fra!tures or severely !omminuted fra!tures, hi!h are unre!onstru!table by, o en redu!tion and internal fi(ation& In undis la!ed fra!tures, !astin# and rolon#ed nonei#ht bearin# eriod of 12 ee$s is a ro riate& In severely !omminuted fra!tures, s$eletal tra!tion !an be a lied for < to = ee$s and folloed by !astin#& 3  The aim of sur#ery in ilon fra!tures is to a!hieve anatomi!al redu!tion of %oint surfa!e and stable redu!tion to allo early mobilization of the an$le& If the fibula is fra!tured, fi(ation of this bone should be done first to a!hieve and maintain the len#th& This folloed by redu!tion and fi(ation of the distal tibia and the arti!ular surfa!e& one #raft is advo!ated hen there is bone defe!t&If o en redu!tion and internal fi(ation is lanned, fe oints should be noted to   revent !om li!ations& The s$in brid#e beteen the medial and lateral in!ision should  be !m or more to revent s$in ne!rosis and the medial in!ision should be made don to the eriosteum and #ently raised and retra!ted as a fla & The fibula must be lated to restore the len#th and folloed by arti!ular re!onstru!tion& *ny bone defe!t should  be #rafted and the tibia !an be lated de end u on the fra!tured site& The ound must  be !losed ithout any tension&'vadia and eals 6178=9 have shon that result of ilon fra!tures treatment de end u on ty e of fra!ture& Results are better in#rou ith better arti!ular redu!tion& Ty e III has a oor ro#nosis&*yeni 617789, have re orted a #ood results in 8 of 11 atients ith !omminuted and dis la!ed ilon fra!tures 6Ty e II and III9 treated ith o en redu!tion and internal fi(ation at avera#e of > years follo u & Ty e II fra!tures hi!h has been treated !onservatively had a oor out!ome& )e also !on!luded that o en redu!tion and internal fi(ation is indi!ated in ty e II and III fra!tures& The main roblem ith o en redu!tion and ri#id internal fi(ation is that its re;uires ide sur#i!al e( osure, more disse!tion of soft tissue and mani ulation of bone fra#ments& 5ith the im lant inside made the tissue !overa#e and ound !losure diffi!ult& These ill lead to devas!ularization of soft tissue and bone and ris$ of tissue ne!rosis and dee infe!tions& Teeny and 5iss 617739, re orted a !om li!ation rates of >0 in =0 ilon fra!tures hi!h is resulted from hi#h ener#y trauma and ere treated ith o en redu!tion and internal fi(ation& These in!lude s$in slou#hs, ound dehis!en!e, dee infe!tions, nonunion, mal union and im lant failure& No dee <
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