case report - juliet - closed fracture middle of the left femur

CLOSED FRACTURE 1/3 MIDDLE OF THE

LEFT FEMUR

Orthopaedic and Traumatology DeptMedical Faculty of Hasanuddin University

Makassar, 2013

Presented by:Juliet C G Umbas

Advisor :dr. Salman Al Wahabydr. Syarif Hidayatullah

Supervisor:dr. Notinas Horas, M. Kes, Sp. OT

Patient Identity

• Name : Mr. M• Age : 16 years old• Sex : Male• Date of admittance : 24th June 2013• MR : 615468

History TakingChief Complaint: Pain at the left thigh

History of illness Suffered since 6 hours before admitted to the

hospital due to a traffic accident.

History of unconsciousness (-), nausea (-) vomiting (-)History of previous illnesses (-)

Mechanism of trauma:The patient was a passenger of a motorcycle an then suddenly got hit by a car from behind, fell down, and then rolled on the road.

Primary SurveyPatentA

RR 20x/min regular, spontaneous thoracoabdominal type, symmetricalB

BP 120/80 mmHg HR = 88 x/min regular.C GCS 15 (E4V5M6),

isochoric pupil, Ø : 2.5 mm, light reflex +/+D

T = 36,70 C (axilla) E

LOCALIZED STATUS :Left femur region

– Inspection: deformity (+), swelling (+), haematoma (-)– Palpation: Tenderness (+)– ROM: Active and passive motion of hip joint and knee joint are limited

due to pain.– NVD: Sensibility is good,

dorsalis pedis artery and tibialis posterior artery palpable, Capillary refill time <2”

Secondary Survey

Right LeftALL 98 96

TLL 93 91

LLD 2 cm

Clinical Picture

Laboratory Findings

WBC : 10.000/mm3

HGB : 13,5 mg/dl RBC : 5.260.000/mm3

PLT : 259.000/mm3

Ur : 30 Cr : 0,9

GOT : 61 GPT : 60 CT : 8’00” BT : 2’00” HbsAg : non reactive GDS : 72 Elektrolit

Na : 136K : 5,0Cl : 102

X-ray :Femur (S)

AP/Lateral view 24th June 2013

Fracture 1/3 middle (L) femur

Pelvic X-ray24th June 2013Within normal

limit

Resume•A 16 years old boy came with closed fracture 1/3 middle of the left femur.

•From the physical examination vital sign is normal and at the left femur there are deformity, swelling, hematoma, tenderness.

•ROM is limited and NVD is normal •X-Ray examination is confirm the fracture•Laboratorium findings within normal limit

Diagnosis

Closed fracture 1/3 middle of the left femur

Management

• IVFD RL• Analgesic• Skin traction• Plan for ORIF

Femur Shaft Fracture

Anatomy of Femur

Thompson, Jon C. Netter’s Concise Orthopaedics Anatomy 2nd Edition

MUSCULATURE COMPARTMENT OF THE THIGH

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

Introduction• A fracture is a break in the structural continuity

of bone• A femoral shaft fracture is a fracture of the

femoral diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle.

• Fracture patterns are clues to the type of force that produced the break.

1. Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th Edition2. Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd edition.

Principles of Fracture

• Classification of Fracture– Open versus closed– Level of fracture : proximal, middle, distal third– Fracture pattern : transverse, spiral, or oblique– Comminuted, segmental, or butterfly fragment– Shortening, angulation or rotation deformity

• Fractures result from– Injury– Repetitive stress– Pathological fracture

Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th Edition

Mechanism of Injury

Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th Edition

PATHOLOGY ANATOMY• Fracture displacement often follows a

predictable pattern dictated by the pull of muscles attached to each fragments.– In proximal shaft fracture the proximal fragment is

flexed, abducted and externally rotated because of gluteus medius and iliopsoas pull, the distal fragment is frequently adducted.

– In mid-shaft fracture the proximal fragment is again flexed and externally rotated but abduction is less marked.

– In lower third fractures the proximal fragments is adducted and the distal fragment is tilted by gastrocnemius pull.

Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th Edition

PHYSICAL EXAMINATION• Inspection: deformity, sweling, haematoma.• Present with tenderness• Decreased range of motion at the hip or knee,

depending on the location of the fracture– Hip :

• Flexion 120-135° • Extend 20-30 °• Abduct 40-50 °• Adduct 20-30 °• Internal rotate 30 °• External rotate 50 °

• NVD evaluation

Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th EditionThompson, Jon C. Netter’s Concise Orthopaedics Anatomy 2nd Edition

- Knee :•Flexion : 125 - 135 °•Extend : 5 - 15 °

TREATMENT• Nonoperative

– Skin Traction– Skeletal traction– Casting – Splint

• Operative– Intramedullary Nailing– External Fixation– Plate and Screw Fixation

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

COMPLICATION

Early Late• Shock• Vascular injury• Nerve Injury• Fat embolism• Thromboembolism• Infection

• Non union or delayed union

• Malunion• Joint stiffness• Refracture and

implant failure

Solomon Louis, Warwick David, Nayagam Selvadurai : Apley’s System of Orthopaedics and Fractures 9th Edition

Thank You