Case Presentation

Ahmad Hariz bin Ahmad JaafarGroup D2Batch 22

Patient profile

• Name: Muhammad Muttaqin• Age: 19 years old• Sex: Male• Occupation: Student• Date of Admission: 5th June 2012

Summary of Case

A 19 years old Malay male from Alor Gajah was electively admitted for operative procedure. Patient was apparently well until 4 months ago, where he sustain an injury to the medial side of his right leg, where he was tackled during a rugby match.

Afterwards, there is deformity in the form of dent at medial side of lower 1/3rd of his right leg. His right foot dorsiflexion was restricted but all other movement are intact. No wound at the injury site

He also complain of pain at the site of injury, which is sudden onset. It was intermittent, throbbing in nature , aggravated on movements especially on movement of the right leg and foot, relieved by rest and pain killers. Pain score was 7/10.

There is swelling at the site of fracture afterwards, start insidiously, increasing in size and resolve spontaneously in 3 days time.

He was then sent to Universiti Malaya Medical Centre, where x-ray of his right leg was taken and he was told there is fracture of tibia while the other bone is intact. Above knee P.o.P cast was applied and he was told to come for follow up once in a month.

8 weeks after the injury, x-ray was taken again and the P.o.P cast was removed. He was told the fracture site has not yet heal and there is some gap between the fracture site. On examination by the doctor, he told that the fracture site is mobile and there is no pain.He was put on elective surgery appointment on 6th June 2012 to close the gap at the fracture siteNo history suggestive of tuberculosis, osteomyelitis, intravenous drug user, alcohol intake, smoking or sexual promiscuity. No loss of weight or appetite.

Local examination of right lower limb

• On inspection– Attitude: hip flexed and addcuted, knee extended,

foot dorsiflexed and inverted – Deformity at lower 1/3rd of medial side of right leg– Apparent shortening of the right lower limb– Atrophy of the right thigh

• On palpation– Deformity: bony consistency– Mobile on lateral plane– Crepitus– No tenderness– No local rise in temperature

• Range of movement: Restricted dorsiflexion on right foot (active)

• Galeazzi’s sign : right knee lower and forward• Sensory on thigh, leg and foot are intact. No

functional impairment. Neurovascular examination normal . Power on right lower limb is 4/5.

Differential diagnosis

• Non union of right tibia• Malunion of right tibia

Investigation

• Lab investigation– FBC, ESR, C reactive protein– Total lymphocyte count

• Imaging– X ray of the right leg AP and lateral view, including

knee and ankle joint

- Comminuted fracture of right tibia - Fibula intact- No callus formation- Open medullary canal- Decrease bone density at distal end of tibia

Management

• Principles– Hypertrophic non union• Extensive callus formation, vascular (excellent healing

potential). They are best treated with rigid stabilization with or without compression.

– Atrophic non union• Absence of callus, deficient bone vascularity, and poor

healing potential

• Surgical approach– Fibular osteotomy• Inhibiting compression across the tibial nonunion site

– Removal of necrotic bone– Reamed intramedullary (IM) nail (noninfected)– Compression plating– Adjunctive therapy, such as the use of antibiotic

bone cement or bone substitute beads– Follow up