Identification/Demographic Data

Name: Mr. Ariyono Sukat

Age: 41 years old

Sex: Male

Race: Indonesian

Status: Single

Address: Sibu, Sarawak

Date of admission: 23 March 2015

Chief Complaint

Mr. Ariyono was admitted to Hospital Sibu on 23rd March 2015 for pain and open wounds on his right leg due to alleged workplace accident.

History of Presenting Illness

Mr. Ariyono, a 41-year old Indonesian gentleman was admitted to the ward with complaint of pain at the right leg due to alleged workplace accident. He claimed that both his leg was caught in a wood cutting machine. He was not wearing any personal protective equipment as required during the time of the accident. He tried to pull out his leg but did not managed to do so. The stopped the machine and immediately brought him to the hospital via car. He said there was severe pain which is more at his right leg. He also noticed bleeding but was not sure of the amount. They also had previously bandaged him at the factory with a cloth to stop the bleeding. He also said that his bones can be seen along with his muscles. He was not able to ambulate and also did not have loss of consciousness. Otherwise, he does not have any other injury and no nausea or vomiting also.On admission at emergency department, there was 2 open wound seen on his right leg with bleeding. The wound was over the medial aspect of the right tibia. Sensation was also intact. His vital signs was also stable on admission. X-rays show tibia and fibula fracture on his right leg.Currently, he underwent immediate surgical operation after admission which was wound exploration, debridement, external fixation and muscle repair. He is also afebrile and unable to ambulate. There was no dysuria and no hematuria. He also underwent blood transfusion twice since his admission.

Past medical history This was his first admission to hospital. There is no relevant past medical history. Past surgical historyThere is no relevant past surgical history.Drug historyNo known drug allergy. Does not taking any traditional drugs.Family historyBoth parents are alive and well. They currently staying in Pontianak, Indonesia. There is also no family history of malignancy in the familyAllergy historyNo known food or drugs allergySocial historyHe is currently in Sibu for work and send money to his parents. He is staying in hostel with his colleague as provided by the employee. He is also a smoker and smokes 1 pack per day for almost 20 years. He does not drink alcohol and does not take any illicit drugs.

PHYSICAL EXAMINATION:General Examination:He is lying comfortably, alert and conscious. He is not septic looking or dyspnoeic. There was a branula inserted on his left hand. His right leg is under bandage from ankle to mid tibia level with an external fixation.

Vital Signs:Blood Pressure- 138/76 mmHgPulse Rate - 92 beats/m (normal volume, regular rhythm)Respiratory Rate - 19 per minuteTemperature - 37 C

Face, head, neck & limbs examinationAppearance: Normal placed eyes, nose and ears, no deformities of lips and nose.Shape of head: Normal head shape.Hair: No hair loss, no bald spotFace: No cyanosis, no pallor and no facial deformitiesOral cavity: Good oral hygiene, moist mucous membrane, no ulcers and no central cyanosisEyes: No pallor and no jaundice.Ear, mouth & throat: No ear and nose discharge, no throat swelling and redness.Neck: No thyroid enlargementSkin: pink, no rash, no lesionsImpression: No abnormalities

SYSTEMIC EXAMINATION:Lower limbs examinationOn inspection, patient right lower limb is seen with bandage from ankle to mid tibia level. There was also external fixation seen on his right leg. Meanwhile, the left leg was normal. There was no scar seen and no other wound seen. There was also no leg length discrepancies. On palpation of the right lower limb, there is mild tenderness over the bandage area. Capillary refill time is less than 2 seconds. Sensation is intact but lessen as compared to the left leg. Dorsalis pedis artery and posterior tibial artery is palpable. On left lower limbs, no tenderness felt and sensation was intact. Dorsalis pedis artery and posterior tibial artery is palpableMovement was limited due to bandage and external fixation for his right leg. Gross movement and sensation of left lower limb was intact.Cardiovascular system examination

On inspection, his chest moves symmetrically with respiration.

On palpation, apex beat was felt at left 5th intercostals space, mid-clavicular line. There was no left parasternal heaves and no thrills at left sternal edge, pulmonary area and aortic area.On auscultation, normal 1st and 2nd heart sound was heard. There was no additional heart sound or murmur.

Respiratory system examination

On inspection, the chest moves symmetrically with respiration on both sides.

On palpation, the trachea was centrally located and chest expansion was symmetrical on both sides. On auscultation, the air entry was adequate and equal on both sides of the lung. Normal vesicular breath sound was heard with no abnormal sounds.

Nervous System

He is alert and cooperative with GCS score of 15. His thought is coherent and he is oriented to person, place and time. For upper limbs on both sides, there was good muscle bulk and tone at 5/5. Reflex was normal on both sides. Sensation was intact. Right lower limbs was restricted due to bandages and external fixation.

Provisional diagnosis41 years old male with open right distal 1/3 tibia and fibula fracture with Gustillo 3b open fracture.Reason for diagnosisHis right leg was caught in a wood cutting machine. There was two wound seen over the medial aspect of the tibia of his leg. There was also bones and muscle flap seen from the wound with bleeding. It was an open wound with no extensive bleeding. X-ray shows tibia and fibula fracture of his right lower limb.

General investigationIndication: To monitor general condition of the patient and screen the patients status and if there is any abnormal platelet count and white blood cells count.

TestsResultUnitNormal rangeImpression

White Blood Cell 9.410^3 L2-20Normal

Red Blood Cell2.5810^6 L4.5-6Low

RBC Distribution Width35.4Fl30-100Normal

Hemoglobin7.9g/dl10-20Low

Hematocrit24.0%30-45Low

Mean Cell Hemoglobin30.6Pg27-31Normal

Mean Cell Volume93.0Fl70-86Normal

Mean Cell Hemoglobin Concentration32.5g/dl27-33Normal

Platelet count19910^3 L150-400Normal

Urea & ElectrolytesIndication: To assess the extent of electrolytes loss that might compromise renal function TestResultUnitNormal rangeImpression

Urea3.6mmol/L1.7-6.4Normal

Sodium140mmol/L135-150Normal

Potassium4.0mmol/L3.5-5.1Normal

Creatinine56.1umol/L27-62Normal

Chloride101.0mmol/L98.0-107.0Normal

X-ray of right tibia (AP view)

The X-ray above is an anteroposterior (AP) view of the right tibia of Mr Ariyono Sukat taken on 23rd March 2015. There is an obvious abnormalities seen. There is an oblique fracture of both distal 1/3 of tibia and fibula seen. The fractures are completely displaced medially. There is also shortening seen for both tibia and fibula. No other abnormalities seen.Impression: Distal 1/3 fracture of right tibia and fibula.

Final Diagnosis 41 years old male with open right distal 1/3 tibia and fibula fracture (Gustillo Grade IIIB)ManagementHe was immediately sent for surgical intervention upon admission to emergency department of Hospital Sibu. He underwent wound exploration, debridement, external fixation and muscle repair. Operative findings is:1. Open fracture grade IIIB of right distal 1/3 of tibia and fibula. Tibialis anterior partially cut at musculotendinious junction.Postoperative plan1. For X-ray recheck of right tibia and fibula.2. Continue IV Flagyl 500mg TDS and IV Cefuroxime 750mg TDS3. Continue analgesia IV Tramadol 50mg TDS4. Daily neurovascular charting of both lower limbs5. Elevate bilateral lower limbs6. Allow orallyDiscussionOpen fractures of the tibia are the commonest of open long-bone fractures, perhaps because of its thin anteromedial soft-tissue coverage.They are caused by various mechanisms, ranging from low-energy twisting forces to high-energy motor vehicle crashes or penetrating injuries (gun shots, blasts). Although the principles of management for open tibial fractures are constant, the path to the final result may vary.Open tibial fractures can present as isolated injuries or in the context of a multiply injured patient. The patients clinical status must dictate the primary and ongoing treatment of the open tibial fracture. Thorough evaluation of the entire patient is essential before focusing on the injured leg.Clsiification of open fractures

Factors affecting tibial fracture managementEach aspect of an open tibial fracture must be considered in planning initial and definitive management. The entire patient, the injured extremity and the specific details of the open fracture itself must each be considered. Associated arterial injury must be identified and treated urgently to salvage the limb. Wound debridement will be necessary. Its thoroughness appears to be more important than how quickly it is done. The severity of the injuries to soft tissues, bone and neurovascular structures must be identified and used for treatment planning.Emergency managementAs in all open fracture injuries, the patient must receive anti-tetanus prophylaxis and appropriate antibiotic coverage. Antibiotics should be given intravenously as soon as possible.Generally, all open fractures are treated with coverage for typical skin bacteria, often a 1st generation cephalosporin. Higher grade open fracture wounds will require additional coverage for gram-negative organisms. With soil or barnyard injuries, high-dose penicillin should be added to cover possible clostridial infection (gas gangrene).After initial inspection the wound should be covered with a sterile dressing which should not be removed until it is taken down in the OR. A digital photograph of the wound, before dressing, will remove the temptation for successive attendant to expose the wound for inspection.A temporary splint may be applied to protect the soft tissues while awaiting the availability of an operating room.Definitive classification of the open fracture is best done in the OR.Dbridement Patient preparation. The patient is positioned supine in the OR or in a position that allows best access to the open fracture wounds. Skin preparation and draping should include access to the major proximal vessels in case their exposure becomes necessary. Tourniquets should be avoided when possible to prevent additional ischemic injury to the soft tissues.General principles of debridement.It is important to perform a thorough surgical dbridement in an organized manner. Starting with the skin, each layer is debrided systematically. One can imagine a clock face; wound dbridement starts at the 12 oclock position and continues in a clockwise manner around the circumference of the wound. This is repeated for each layer down to the level of the bone. Necrotic tissue is removed and only viable tissue is left behind. The exception is skin, where none is removed unless obviously necrotic. The quality of the muscle tissue is assessed using the classic 4 Cs: Color (red or brown) Consistency (how does the muscle feel) Capillary Circulation (does it bleed?) Contractility (responds to pinch or electro-cautery)IrrigationAfter removing visible dirt and necrotic tissue, irrigation with several liters of fluid is a key component of the decontamination of the injury zone. If available, a balanced salt solution is routinely used. In more austere environments, any water that is clean enough to drink is acceptable. Controversies exist regarding the optimal volume and delivery methods. We recommend large volumes, with low pressure to avoid additional tissue injury. Gravity flow, with large-bore cystoscopy tubing, is a well accepted method.Fracture stabilizationExternal fixation. External fixation can be applied using either modular or uniplanar techniques. The modular frames have the advantage of being more versatile, avoiding the complex wounds that are often seen. The disadvantage of a modular frame is, that it is less rigid than the uniplanar fixator because of its multiple connections. Pin placement outside of the anticipated zone of the definitive implant is a consideration, although not always possible. Reduce the fracture as well as possible, to avoid soft-tissue tension.Definitive treatmentDefinitive fixation is considered, when: The patients clinical status is optimized The wounds are healthy and the soft-tissue envelope will allow for chosen surgical approach A good preoperative plan has been created.