M. Amin, a 47-year-old male, presented with an open comminutive fracture of the left distal tibia and fibula (Gustillo-Anderson type IIIA) after being struck by a falling tree. He underwent debridement and open reduction internal fixation. Post-operatively, he was diagnosed with an open comminutive fracture of the left distal tibia and fibula (Gustillo-Anderson type IIIB) status post debridement and monoplanar fixation. He will receive wound care, antibiotics, and monitoring for potential complications like pin tract infection with the plan for potential delayed flap reconstruction.

1. M. Amin/M/47YO
Open Comminutive Fracture of Left Distal Shaft Tibia
Gustillo-Anderson IIIA
Close Comminutive Fracture Left Distal Shaft Fibula
Performed :
Debridement + ORIF Emergency
(Friday, March 1st 2024)
dr. Javier, dr. Chairi

2. History
Chief complaint : Open Wound at the Left Leg
The patient was referred from Aceh BesarDistrict Hospital with chief complaint of pain and open wound on his right
leg after being struck by a falling tree 10 hours prior to hospital admission. The pain did not radiate to his toes and
was not accompanied by numbness. The patient could move his toes, but not his ankle joint. The patient received
initial care of wound toilet, dressing, splinting, and medicine before referred to Zainoel Abidin General Hospital for
further care.
History of past illness : (-)
History of last medication : Ketorolac, Ranitidine, Ceftriaxone, Metronidazole
History of allergy : (-)

3. Present State
Sens: E4M6V5
BP: 154/87
HR: 88x
RR: 18
T: 36,5oC
General State
•Head
• Eye : Pupil isochor equal 2mm/2mm, sclera normal,
conjunctiva normal
• Nose : normal
• Lips : normal
• Jaw : normal
• Ears : normal
•Neck : Lymph node normal, trachea in the middle
•Chest : Vesicular, rh -/-, wh -/-, heart sound normal,
• Abdomen : Symmetrical , soepel ,tenderness (-), mass (-),
tympanic, shifting dullness (-), peristaltic (+)
normal
•Genitalia : normal
•Extremity : Local State

4. L/S of the Right Leg
Look :
Deformity (+) Open wound size 9cm x 8cm, irregular
borders with gross contamination, skin loss, multi-
fragmentary bone expose and active bleeding
Feel :
Warm. Pain (+) VAS 5-6. CRT <2s
A. Tibialis Posterior (+) A. Dorsalis Pedis (+)
Great Toe – Numbness (-) SatO2 98%
Second Toe – Numbness (-) SatO2 93%
Third Toe – Numbness (-) SatO2 99%
Fourth Toe – Numbness (-) SatO2 98%
Fifth Toe – Numbness (-) SatO2 99%
Move :
AROM Ankle Joint: Dorsiflexion (-) Plantarflexion (-)
AROM Toe Flexion: Great (+) Second (+) Third (+)
Fourth (+) Fifth (+)
Proximal
Distal

5. X-Ray Pre-Operative

6. List of Problems :
• Pain
• Open Wound
• Decreased of Function
Diagnosis:
• Open Comminutive Fracture of Right Distal Shaft Tibia-
Fibula Gustillo-Anderson IIIB (GHOIS 14)
Performed :
• Pus Culture
• Debridement
• OREF
Court-Brown et al: Rockwood and Green’s Fractures in Adults. 8th Ed, Wolter-Kluwers, 2015

7. Ankle Joint Anatomy
Thompson C: Netter’s Orthopaedic Concise Anatomy. 2nd Ed, Elsevier, 2010
Structures Involved:
- Tibia Distal Diaphysis
- Fibula Distal Diaphysis &
Metaphysis
- Peroneus Longus Tendon
- Peroneus Brevis Muscle
- Perforating Branch of peroneal
artery

9. Post-Operative

10. X-Ray Post-Operative

11. Diagnosis:
• Open Comminutive Fracture of Right Distal Shaft Tibia-Fibula Gustillo-Anderson
IIIB (GHOIS 14) post Debridement + Monoplanar OREF
Postoperative Planning :
• Adequate Analgetic
• Antibiotics
• Wound Care with Moist Sterile Gauze + Framycetin Tulle every 2 days
• Monitor for Pin-Track Infection
• Secondary Wound Healing with intention for Internal Fixation Conversion
• Consult Plastic Surgery for Delayed Flap/Staged Reconstruction
Court-Brown et al: Rockwood and Green’s Fractures in Adults. 8th Ed, Wolter-Kluwers, 2015