CASE REPORT

Patient Identity Name Age Sex : Mr. M : 16 years old : Male

Date of admittance : 23th June 2013 No. MR : 615468

History Ta ing : C!ief com"#ain History of i##ness : Pain at the left thigh : Suffered since 3 hours before ad itted to the hos!ital due

to a traffic accident. "istory of unconsciousness #$%& nausea #$% 'o iting #$%. "istory of !re'ious illnesses #$% Mec!anism of tra$ma : Patient (as a !assenger of a bi)e (hen he fell do(n and rolled on the road as the rider (as trying to a'oid car fro "istory of unconscious #$%& nausea #$%& 'o iting #$% Prior treat ent at Pang)e! hos!ital. o!!osite direction.

P!ysica# Examination *eneral Status + Moderate illness , -ell nourished , .o !os /ital Sign+ 0+ 120,80 "g etrical 1+ 88 2, inutes& regular P+ 33 202, in regular& s!ontaneous thoracoabdo inal ty!e& sy S+ 36&45 . %oca# Stat$s %eft fem$r region 6 6 Ins"ection: defor ity #7%& he ato a #7%& s(elling #7%& (ound #$% Pa#"ation: 0enderness #7%
1

entis

6 6

ROM+ 8cti'e and !assi'e e'aluated due to !ain.

otion of hi! 9oint and )nee 9oint cant be

N&D: Sensibility is good& dorsalis !edis artery and tibialis !osterior artery !al!able& .a!illary refill ti e :2;

Rig!t 8<< 0<< <<> .linical ?indings =8 =3 2c

%eft =6 =1

<aboratory ?indings -@. + 10.000, "*@ + 13&5 3@. P<0 Ar .r g,dl

3 3 3

.0 @0

+ 8C00; + 2C00;

+ 5.260.000, + 25=.000, + 30 + 0&=

"bs8g + non reacti'e *>S + 42 Dle)trolit 1a + 136 E + 5&0 .l + 102

*B0 + 61 *P0 + 60

3adiological ?indings

'em$r (S) AP*%atera# +ie, -.ray

Pe#+ic -.ray S$mmary 8 16 years old boy (as ad itted to the hos!ital (ith !ain at the left fe ur& (hich (as suffered since 3 hours ago due to a traffic accident. 0he !atient (as a !assenger of a otorcycle an then suddenly got hit by a car fro behind& fell do(n& and then rolled on otion of hi! the road. 8t the anterior as!ect of the fe ur& defor ity #7%& he ato a #7%& and ede a #7%. 0he region (as tender on !al!ation& (ith li ited acti'e and !assi'e .a!illary refill ti e :2; Diagnosis .losed fracture 1,3 Management F F 1on 6 o!erati'e + $ $ S)in traction 8nalgeti) iddle of the left fe ur 9oint and )nee 9oint due to !ain. Sensibility is good& dorsalis !edis artery is !al!able&

B!erati'e + B3G? #B!en 3eduction Gnternal ?i2ation%

4

DISC/SSION
0. 'emora# S!aft 'ract$re 8 fe oral shaft fracture is a fracture of the fe oral dia!hysis occurring bet(een 5 c distal to the lesser trochanter and 5 c !ro2i al to the adductor tubercle. 0he fe oral uscles. 0his !ro'ides ad'antages and uscle contraction dis!laces the fractureH ore than s!lit shaft is circu ferentially !added (ith large disad'antages+ reduction can be difficult as a source of esenchy al ste

ho(e'er& healing !otential is i !ro'ed by ha'ing this (ell$'asculariIed slee'e containing cells& and o!en fractures often need no thic)ness s)in grafts to obtain satisfactory co'er. 1. Anatomy 0he fe ur is the largest tubular bone in the body and is surrounded by the largest ass of uscle. 8n i !ortant feature of the fe oral shaft is its anterior bo(. 0he edial corte2 is under co !ression& (hereas the lateral corte2 is under tension. 0he isth us of the fe ur is the region (ith the s allest intra edullary #GM% dia eterH the dia eter of the isth us affects the siIe of the GM nail that can be inserted into the fe oral shaft.

0he fe oral shaft is sub9ected to #gluteus edius and

a9or

uscular defor ing forces + 8bductors

ini us%+ 0hey insert on the greater trochanter and abduct the

!ro2i al fe ur follo(ing subtrochanteric and !ro2i al shaft fractures. Glio!soas+ Gt fle2es and e2ternally rotates the !ro2i al frag ent by its attach ent to the lesser trochanter. 8dductors+ 0hey s!an ost shaft fractures and e2ert a strong a2ial and 'arus load to the bone by traction on the distal frag ent. *astrocne ius+ Gt acts on distal shaft fractures and su!racondylar fractures by fle2ing the distal frag ent. ?ascia lata+ Gt acts as a tension band by resisting the edial angulating forces of the adductors.

0he thigh

usculature is di'ided into three distinct fascial co !art ents +

8nterior co !art ent+ 0his is co !osed of the Juadrice!s fe oris& ilio!soas& sartorius& and !ectineus& as (ell as the fe oral artery& 'ein& and ner'e& and the lateral fe oral cutaneous ner'e. Medial co !art ent+ 0his contains the gracilis& adductor longus& bre'is& agnus& and obturator e2ternus uscles along (ith the obturator artery& 'ein& and ner'e& and the !rofunda fe oris artery. Posterior co !art ent+ 0his includes the bice!s fe oris&
6

se itendinosus& and se i e branosus& a !ortion of the adductor cutaneous ner'e.

agnus

uscle&

branches of the !rofunda fe oris artery& the sciatic ner'e& and the !osterior fe oral

@ecause of the large 'olu e of the three fascial co !art ents of the thigh& co !art ent syndro es are uch less co on than in the lo(er leg. ainly fro the !rofunda 0he 'ascular su!!ly to the fe oral shaft is deri'ed

fe oral artery. 0he one to t(o nutrient 'essels usually enter the bone !ro2i ally and !osteriorly along the linea as!era. 0his artery then arboriIes !ro2i ally and distally to !ro'ide the endosteal circulation to the shaft. 0he !eriosteal 'essels also enter the bone along the linea as!era and su!!ly blood to the outer one$third of the corte2. 0he endosteal 'essels su!!ly the inner t(o$thirds of the corte2. ?ollo(ing ost fe oral shaft fractures& the endosteal blood su!!ly is disru!ted& ay further and the !eriosteal 'essels !roliferate to act as the !ri ary source of blood for healing. 0he edullary su!!ly is e'entually restored late in the healing !rocess. 3ea ing obliterate the endosteal circulation& but it returns fairly ra!idly& in 3 to 4 (ee)s. ?e oral shaft fractures heal readily if the blood su!!ly is not e2cessi'ely co !ro ised. 0herefore&

it is i !ortant to a'oid e2cessi'e !eriosteal stri!!ing& es!ecially !osteriorly& (here the arteries enter the bone at the linea as!era. 2. Mec!anism of In3$ry 0his is usually a fracture of young adults and results fro other(ise. Gn children under 4 years the !ossibility of !hysical abuse a high energy in9ury. ust be )e!t in ind. >ia!hyseal fractures in elderly !atients should be considered K!athologicalC until !ro'ed ?racture !atterns are clues to the ty!e of force that !roduced the brea). 8 s!iral fracture is usually caused by a fall in (hich the foot is anchored (hile a t(isting force is trans itted to the fe ur. 0rans'erse and obliJue fractures are angulation or direct 'iolence and are therefore !articularly co be co inuted& or the bone ay be bro)en in ore often due to ay on in road accidents.

-ith se'ere 'iolence #often a co bination of direct and indirect forces% the fracture

ore than one !lace #a seg ental fracture%.

4. 'emora# S!aft 'ract$res C#assification -inJuistCs classification reflects the obser'ation that the degrees of soft$tissue da age and fracture instability increase (ith increasing grades of co is still at least 50 !er cent cortical contact bet(een the butterfly frag ent in'ol'es a seg ental fracture. inution. Gn 0y!e 1 there is only a tiny cortical frag ent. Gn 0y!e 2 the Kbutterfly frag entC is larger but there ain frag ents. Gn 0y!e 3 the ore than 50 !er cent of the bone (idth. 0y!e 4 is essentially

5. Diagnose
8

0here is s(elling and defor ity of the li b& and any atte !t to

o'e the li b is

!ainful. -ith the e2ce!tion of a fracture through !athological bone& the large forces needed to brea) the fe ur usually !roduce acco !anying in9uries nearby and so eti es further afield. .areful clinical scrutiny is necessary to e2clude neuro'ascular !roble s and other lo(er li b or !el'ic fractures. 8n i!silateral fe oral nec) fracture occurs in about 10 !er cent of cases and& if !resent& there is a one in three chance of a significant )nee in9ury as (ell. 0he co bination of fe oral shaft and tibial shaft fractures on the sa e side& !roducing a Kfloating )neeC& signals a high ris) of do inate the clinical !icture. Gt 3oo ay be difficult to obtain adeJuate 'ie(s in the 8ccident and D ergency setting& es!ecially 'ie(s that !ro'ide reliable infor ation on !ro2i al or distal ulti$syste in9ury in the !atient. ay 0he effects of blood loss and other in9uries& so e of (hich can be life$threatening&

fracture e2tensions or 9oint in'ol'e entH these can be !ost!oned until better facilities and easier !atient !ositioning are !ossible. @ut ne'er forget to 2ray the hi! and )nee as (ell #?igure 2=.21%. 8 baseline chest 2$ray is useful as there is a ris) of adult res!iratory distress syndro e #83>S% in those (ith notedH it (ill for 6. Treatment 1ono!erati'e .urrently& closed anage ent as definiti'e treat ent for fe oral shaft edical anage ent is contraindicated. 0he goal of s)eletal a guide to treat ent. ulti!le in9uries. 0he fracture !attern should be

Skeletal Traction fractures is largely li ited to adult !atients (ith such significant co orbidities that o!erati'e !ainful s!as s& and

traction is to restore fe oral length& li it rotational and angular defor ities& reduce ini iIe blood loss into the thigh. easure before surgery to S)eletal traction is usually used as a te !oriIing

stabiliIe the fracture and !re'ent fracture shortening. 0(enty to 40 lb of traction is usually a!!lied and a lateral radiogra!h chec)ed to assess fracture length. >istal fe oral !ins should be !laced in an e2traca!sular location to a'oid the !ossibility of se!tic arthritis. Pro2i al tibia !ins are ty!ically !ositioned at the le'el of the tibial tubercle and are !laced in a bicortical location. Safe !in !lace ent is usually fro edial to lateral at the distal fe ur #directed a(ay fro the fe oral
=

artery% and fro

lateral to

edial at the !ro2i al tibia #directed a(ay fro

the

!eroneal ner'e%. Proble s (ith use of s)eletal traction for definiti'e fracture treat ent include )nee stiffness& li b shortening& !rolonged hos!italiIation& res!iratory and s)in ail ents& and B!erati'e B!erati'e stabiliIation is the standard of care for ost fe oral shaft fractures. ulti!ly in9ured !atient. alunion.

Surgical stabiliIation should occur (ithin 24 hours& if !ossible. Darly stabiliIation of long bone in9uries a!!ears to be !articularly i !ortant in the Gntra edullary #GM% 1ailing& this is the standard of care for fe oral shaft fractures. D2ternal ?i2ation& use as definiti'e treat ent for fe oral shaft fractures has li ited edication. Plate fi2ation for fe oral shaft stabiliIation has decreased (ith the use of GM nails. 7. Com"#ications 1er'e in9ury+ 0his is unco encased in traction or co !ression during surgery. /ascular in9ury+ 0his adductor hiatus. .o !art ent syndro e+ 0his occurs only (ith significant bleeding. Gt !resents as !ain out of !ro!ortion& tense thigh s(elling& nu bness or !aresthesias to #sa!henous ner'e distribution%& or !ainful !assi'e Juadrice!s stretch. Gnfection #:1L incidence in closed fractures%+ 0he ris) is greater (ith o!en 'ersus closed GM nailing. *rades G& GG& and GGG8 o!en fractures carry a lo( ris) of infection (ith GM nailing& (hereas fractures (ith gross conta ination& e2!osed bone& and e2tensi'e soft tissue in9ury #grades GGG@& GGG.% ha'e a higher ris) of infection regardless of treat ent ethod. 3efracture+ Patients are 'ulnerable during early callus for ation and after hard(are re o'al. Gt is usually associated (ith !late or e2ternal fi2ation. 1onunion and delayed union+ 0his is unusual. >elayed union is defined as healing ta)ing longer than 6 onths& usually related to insufficient blood su!!ly #i.e.& e2cessi'e !eriosteal stri!!ing%& uncontrolled re!etiti'e stresses& infection& and hea'y s o)ing. 1onunion is diagnosed once the fracture has no further !otential to unite.
10

on because the fe oral and sciatic ner'es are

uscle throughout the length of the thigh. Most in9uries occur as a result of ay result fro tethering of the fe oral artery at the

edial thigh

Malunion+ 0his is usually 'arus& internal rotation& and,or shortening o(ing to uscular defor ing forces or surgical techniJue. ?i2ation de'ice failure+ 0his results fro es!ecially (ith !late fi2ation. "eteroto!ic ossification ay occur. nonunion or MNOcyclingMNP of de'ice&

11

RE'ERENCES 1. Eo'al E.J& Quc)er an J.>. Handbook of fractures 3rd edition 2006. 2. Solo on <& -ar(ic) >& 1ayaga ed. 2010. "odder 8rnold 3. 0ho !son& Jon .. 1etterCs .oncise Brtho!aedics 8nato y 2nd Ddition S..Apleys System of Orthopedic and Fracture 9th

12