CHAPTER I

CASE REPORT

I. IDENTITY
Name : Mrs. Hj. R
Age : 73 years
Sex : Female
Religion : Muslim
Address : Sidrap
Marriage status : Married
RM : 13 29 21
Admission date : July 20th 2017

II. ANAMNESIS
Main complaint: Pain at left hip region.
Patient come to the emergency room A. Makkasau with complaints of pain in the left
thigh about 20 days ago before admission to hospital, the patient complained of pain in
her left hip and difficult to move. A history of slippery in her room was admitted. A history
of fainting (-) headache (-), vomitting (-).
Past history: allergic history was unknown. Hypertension and Diabetic was denied.
Social Economy history: BPJS Insurance.

III. PRIMARY SURVEY

Airway and C-spine control

Patent
Breathing and Ventilation
RR = 20 x/minute, reguler, spontaneous, thoracoabdominal type, symmetric
Circulation and Hemorrhagic Control
BP = 130/80 mmHg, HR = 90 x/minute, reguler, strong pulse, CRT <2 second
 Disability and Neurology Evaluation
GCS 15 (E4M6V5)
Exposure and Environment Control
Axilla temperature= 36.8oC

IV. SECONDARY SURVEY:

Left Hip Joint

Look:

Deformity (+), swelling (+), wound (-).

Feel:

Tenderness (+).

Move:

Active and passive movement of left hip joint was limited due to pain.

NVD:

Sensibility is good, CRT < 2 seconds, pulsation of posterior tibial artery and dorsalis
pedis artery is palpable.

V. LABORATORY
Items Result Unit N Value
Hematology:
WBC 5.80 103/ul 4-12
Eosinofil .213 % 2-4
Basofil .093 % 0-1
Netrofil 3.56 71.5 % 50-70
Limfosit 1.48 23.9 % 25-50
Monosit .457 3.16 % 1-6
RBC 3.97 106/ul 3,8-5,2
Hemoglobin 11.3 g/dl 12,8-16,8
Hematokrit 33.8 % 35-47
MCV 85.2 Fl 80-100
MCH 28.5 Pg 26-34
MCHC 33.5 g/dl 32-36
PLT 151. 103/ul 150-450

Items Result Unit N Value

Imuno-Serologi:
Negative
HBsAg Negatif
(Kualitatif)

Hemostasis:
Minutes < 1500
CT 1000
100 300
BT 130 minutes
VI. RADIOGRAPHY
X-Ray Pelvic AP on July 20th2017

RESUME
Patient, female, 73 years old, was admitted to hospital on July 20th 2017 with pain in
the pelvis of the left since 20 days ago. History of slippery in her room was admitted.
Patients being treated in hospitals Andi Makkasau and planned to referred to Wahidin
Sudirohusodo Hospital.
In physical examination of left hip joint there are deformity, Tenderness (+). Range
of motion; active and passive movement of left hip joint was limited due to pain, Sensibility
is good, CRT < 2 seconds, pulsation of posterior tibial artery and dorsalispedis artery is
palpable.
Radiologic examination of pelvic APshentons line is disrupted and the joint space
is asymmetric.
VII. DIAGNOSE
Closed Fracture Left Neck Femur

VIII. MANAGING
1. IVFD RL 20 dpm
2. Ketorolac 30 mg / 8hrs / IV
3. Ranitidine 50 mg / 12hrs/ IV
4. Apply skin traction Load 3kg at Left Lower Limb
5. Referred to Wahidin Sudirohusodo Hospital
 CHAPTER II
LITERATURE REVIEW

A. DEFINITION

Colum fracture femur is a fracture occurs in volumes the femur. Damage to the
base of the bone continuity that can be caused by direct trauma, indirect trauma, muscle
fatigue, certain conditions such as degeneration of the bones / osteoporosis.

B. ANATOMY AND PHYSIOLOGY FEMUR

In this case, the author will discuss some of the system include: (1) the skeletal
system, (2) the joint system, (3) the muscular system, (4) the nervous system.

Os. Femur
A long bone in the body which is divided into Caput Corpus and collum with the distal
end and proksimal is jointed with the acetabulum in the structure of the pelvic joints and
jointed with the tibia bone in the knee joint (Syaifudin, B.AC 1995). thigh or upper limbs
is longest and largest bone in the body including one-quarter of the length of the thigh
body, bone consists of three parts, namely proximalis epiphysis, diaphysis and distal
epiphysis.
Proximal epiphysis
The tip makes 2/3 ball circle called caput femoris which has facies articularis for middle
acetabulum are jointed with basin called the fovea capitis. Caput continued ourselves as
femoral neck were then rounded lateral side called throcantor major medial direction too
small rounded called trochantor minor. Viewed from the front, both major and minor
spheres are connected by a line called the lineaintertrochanterica (lineaspiralis). Viewed
from the rear, the two spheres are connected by a ridge called the crista
intertrochanterica. Seen from the back anyway, then the medial side of the basin are
major trochantor called trochanteric fossa.

Diaphysis
A long section called transverse corpus is a triangle with the base facing forward. Having
a plateau that is facies medial, lateral facies, facies anterior. The boundary between the
medial and lateral facies appear on the back of a line called the lineaaspera, starting from
the proximal part to the presence of a rough protrusions called gluteal tuberosity. Linea is
divided into two seedlings, namely medial and labium laterale labium, labium medial
itself is a continuation of the lineaintertrochanrterica. Linea aspera distal section forming
a triangle is called Planumpopliseum. From minor trochantor there is a line called the
lineapectinea. At the rear there is a foramen nutricium plateau, also called the lateral
medial labium supracondylaris lateral / medial.

Distal Epiphysis
A pair of dots called condylus medial and proximal lateralis. Beside of condylus these
bumps are again each a small spheres called epicondylus medial and lateral epicondylus.
This is the end of the trip Epicondyluslineaaspera distal portion viewed from the front
there is a wide plain of the joints called faciespatelaris for jointed with os. patella. The
proximal part of intercondyloidea that section there is a line called the
lineaintercondyloidea.
Muscular System
The muscles that will be discussed only with the condition of the patient's postoperative
femoral fracture medial 1/3 dextra with mounting plate and screw are the muscles that
function in all directions like a hip region for flexion-extension, abduction-adduction and
external rotation-internal rotation.

For more details, authors include the muscles associated with these conditions, are as
follows:

Table 2.1Limbs Upper Section Anterior Muscles (Richard, S. 1986)

No Muscle Regio Insertio Fungtion Innerve

1 Sartorius Spina iliace Base medial Fleksi N.

anterior tibia abduis, femoral
superior (SIAS) rotasi, is
lateral arc
coxae

2 Iliacus Fossa illiaca di Throcantor Flexi N.

dalam abdomen femur femoral
is

3 QuadricepFemora
lis
SIAS Tendon m. Flexi arc N.
a. Rectus femoris quadriceps coxae femoral
pada patela, is
vialigamentu
m patellae ke
dalam
tuberositas
 b. Vastus lateralis tibia Extansi
lutut
Ujung
atasdanbatang
N.
femur, septum
c. Vastus femoral
facialislatkedal
medialis is
am Extensi
lutut,
Ujung
menstabilk
atasdanbatang
an patela
d. Vastus femur N.
intermedius Extensilutu
femoral
t
is
Permukaan
anterior dan
lateral batang
femur
N.
femoral
is

Table 2.2 Posterior Limbs Upper Section Muscles (Ricard, S. 1986)

No Otot Regio Insertio Fungsi Inervasi

1 Biceps femoralis Caput Permukaa Flexi Ramus

longum n medial abduksi, tibialis
(tuber tibia rotasi N.
isciadoleum) lateral ischiadic
caput breve arc.Co xae um
(lineaaspera)
crista supra
Semi condilair
 tendonisosis lateral batang
femur)
Medial Flexi,
Tuber tibia rotasi,
Ramus
ischiadikum medial
tibialis
sendi lutut
N.ischiad
serta Arc.
icum
Coxae

2 Semi Tuber Condylus Flex dan Ramus

membranosus ischiadikum medialis rotasi, tibialis
tibia medial N.
sendi lutut Ischiadic
serta um
extensi
serta
extensi
Arc.
Coxae

3 Adduktormagnu Tuber Tiberculu Extensi Ramus

s ischiadicum madduktor Arc Coxae tibialis
femur
N.
Ischiadic
um
 Table 2.3 Regio gluteal muscles upper limbs (Richar, S. 1986)

No Otot Regio Insertio Fungsi Iner

vasi

1 Gluteus Permukaanluar ilium, Tractus Extensi N.

maximus sacrum, illiotibialis dan rotasi glute
ligamensacrotuberale dan laterale us
duterositas Arc. interi
gluteo femoris Coxae or

2 Gluteus Permukanaluar ilium Lateral Extensida N.

Medius throchantorma nrotasi glute
yor femoris us
super
ior

3 Gluteus Permukaanluar ilium Anterior Abduksi N.

minimus throchantor Arc. glute
mayor femoris Coxae us
super
ior

4 Piriformis Permukaan anterior Throchantor Rotasi N.

sacrum mayor femoris lateral Sacra
lis I
dan
II

5 Obturatoriusi Permukaandalammembra Tepianatasthr Rotasi Plexu

nternus naabturatoria ochantor lateral s
mayor femoris sacra
lis
 Table 2.4Otot Pour Medial Thigh

No Otot Regio Insertio Fungsi Inervasi

1 M. Gracilis Ramus interior Tuberositas tibia Adduktor Ramus

ossis pubis dibelakang flexor, hip anterior
danossisischi flexor dan N.
internal obturato
rotator ria L2-4
tungkaiba
wah

2 M. Dataran anterior M. sartorius Ramus Addukto

adduktorlangus ramus superior labium medial anterior N. r, flexor
ossis pubis linea aspera 1/3 Abtoratori hip
medial um L2-3

3 M. adduktor Lateral ramus Labium medial Adduktor Ramus

brevis interior ossis lineaaspera flexor, anterior
pubis internal dan
rotasi hip posterio
r N.
abturato
ria L2-4

4 M. Dataran anterior Labium medial Adduktord Ramus

adduktormagnus ramus lineaaspera an posterio
interfiorossiischi extensor r dan N.
idan tuber hip tibialis
ischiadicum dan L2-
5 dan S1

5 M. Datarna anterior Fossa External Ramus

Obturatoriusexte membrana throhantoricafe rotator hip muscula
rnus abturatoria, moris membantu ris
foramen extensor plexus
abturatroium hip sacralis
S1-3
Nerve supply system

The nervous system in the upper leg (thigh) is divided into four, namely:

1. The femoral nerve

Is the largest branch of the lumbar plexus. This nerve plexus contains three parts derived
from nerve anterior lumbar (L2, L3 and L4). This nerve emerges from the lateral edge of
the psoas within the abdomen and walk down past m. psoas and m.iliacus it is located
next to the fascia illiaca and enters the thigh lateral to the anterior femoral and femoral
sheath behind the inguinal ligament and broke into anterior and posterior division of the
femoral nerve mensyarafi all anterior thigh muscles.
2. obturator nerve
Derived from the lumbar plexus (L2, L3 and L4) and appear at the edges m. psoas within
the abdomen, it passes down and forward on the lateral pelvis to reach the top of the
foramen abturatorium, which place is broken into anterior and posterior divisions.
Division gave anterior muscular branches in m. gracilis, m. adductor brevis and longus.
While mensyarafiarticularis posterior division to provide muscular branches to
m.obturatoriusesternus, and adductor magnus.
3. The superior and inferior gluteal nerve
Sacralis nerve branches leaving the pelvis through the top and bottom of the wise above
the foramen ischiadicus m. piriformis and mensyarafim.gluteusmedius and minimus and
maximus.

Bloodstream system
The circulatory system of the upper leg (thigh) Here will be discussed throughout the
circulatory system of the upper leg or thigh ie arteries and veins.

Arteries
Arteries carry blood from the heart to the body cavity and arteries always bring fresh
blood containing oxygen, except pulmonale arteries that carry dirty blood oxygenation
require. The arteries in the legs, among others, namely:

Femoral Artery
Femoral artery enters the thigh through the rear of the inguinal ligament and is a
continuation of the external illiace artery, which is located mid between SIAS
(illiacaspina anterior superior) and femoral pubis.Arteriasympiphis the main blood
supplier part of the leg, walking downhill almost bump into the femoral adductor
tuberculum and ends Reviewed by magnus muscle hole enters the popliteal spatica as
popliteal artery.

The Deep Femoral Artery

A major artery arising from the lateral side of the femoral artery femorale triangle. He
came out of the anterior thigh through the back of the adductor muscle, he walked down
between the adductor brevis muscle and then sifting the adductor magnus muscle.

Obturator Artery
An internal illiaca arterial branches, he goes down and forward on the lateral wall of the
pelvis and accompanying obturator nerves through the obturator canal, which is the top of
the foramen obturatum.
Popliteal Artery
Popliteal artery running through the canal adduktorius entered into a branched fossa
posterior tibial artery is located in the popliteal fossa from lateral to medial fossa is the
tibial nerve, popliteal vein, the popliteal artery.

Veins

Veins of the legs, among others:

Femoral Vein

The femoral vein into the thigh through the hole in the adductor magnus muscle as a
continuation of the popliteal vein, he climbed the thigh early on the lateral side of the
artery. Then the posterior of it, and ended up on the side medialnya.Ia left thigh in the
space of the medial femoral sheath and walked behind the inguinal ligament into vena
iliacaexterna.

Deep venous femoral

Femoris accommodate deep venous branches that can be likened to the branches of the
artery, it flows into the femoral vein.vena obturator Accommodate the obturator vein
branches that can be likened to the branches of the artery, which pours its contents into
the vein internal illiaca.

Saphenous vein

Transporting the journey of blood from the medial end venosumarcusdorsalispedis and
runs up right in the medial malleolus, venosumdorsalin this vein runs behind the knees,
bent forward through the medial side of the thigh. He is shooting went through the
bottom n. saphensus the deep fascia and join the femoral vein.
 Etiology Collum Femur Fractures
a. Direct trauma: the impact on the resulting bone fracture in place, such as patient falls at
an angle where major trochanter area directly hit with a hard object.
b. . Trauma indirectly: the bone can fracture at a place away from the area of impact, for
example due to the sudden movement of the limbs eksorotasibawah.Karena femoral head
is firmly attached to the ligaments in the acetabulum by iliofemoral ligaments and joint
capsule, causing fractures in the femoral neck.
c. Pathologic fractures: fractures caused by trauma yamg minimal or no trauma. Examples
of pathologic fracture: Osteoporosis, bone infections and bone tumors. Fractures of the
neck of the femur often occurs in women caused by the fragility tulangakibat
combination of the aging process and post-menopausal osteoporosis. Fractures can be
subkapital fracture, transcervical and basalt, which is located inside the hoop
kesemuannya or intracapsular hip joint, fractures intertrochanter and sub trochanter is
extra capsular.
d. Pressure varus or valgus

Classification Collum Femur Fracture

Classification of femoral neck fracture by:
a. Anatomic location, divided into:
1. intracapsular fractures, these fractures occur in the hip joint capsule
a. Capital fracture: a fracture of the femoral head
b. Subkapital fracture: a fracture that is located below the femoral head
c. Transcervical fracture: a fracture of the neck of the femur
2. extracapsular fractures, fractures that occur outside the hip joint capsule
a. Fractures throughout the greater trochanter and minor
b. Fractures intertrokanter
c. Fractures subtrokanter
 Fractures of the neck of the femur including intracapsular fracture which occurs in the
proximal femur, which included the femoral neck is starting from the distal surface of the
femoral head to the proximal part of the intertrokanter.

On physical examination, fracture neck of femur with a shift would cause a deformity
that occurs shortening and external rotation while the fractures without deformity shift is not
clearly visible. Regardless of how many shifts occurring fracture, most patients will complain
of pain when it gets imposition, tenderness in the groin and hip pain when actuated.
Standard radiographs for femoral neck fractures are the hip and pelvic anteroposterior
radiograph and cross-table lateral. Classification of femoral neck fractures according to
Garden's are as follows:

a. Grade I: Fracture Incomplete (abduction and impacted)

b. Grade II: Fracture complete without shifting

c. Grade III: Fracture complete with partial shift (varusmalaligment)

d. Grade IV: Fracture to shift the entire fragment without passage segments that
intersect
Pauwel's classification for femoral neck fractures are often digunakan.Klasifikasi is based
on the angle formed by the fracture line and the horizontal plane in an upright position.
a. Type I: the fracture lines form an angle of 30 to the horizontal plane in an
upright position.
b. Type II: fracture lines form an angle of 30-50 to the horizontal plane in an
upright position.
c. Type III: fracture lines form an angle> 50 to the horizontal plane in an upright
position.

Another frequently used classification is Russel Taylor. This classification is based on the
involvement of piriformis fossa.

a. Type I: fracture does not reach the piriformis fossa

IA: comminution and fracture line extends from below the lesser trochanter to the
femoral isthmus
IB: comminution and fracture line involving the lesser trochanter to the isthmus area
b. Type II: fracture extends proximally to the greater trochanter and involve fossa
IIA: terapat no significant comminution of the fracture on the lesser trochanter
IIB: teradapat significant comminution of the medial femoral cortex and the loss of
continuity of the lesser trochanter

Pathophysiology Collum Femur Fractures

When a pressure on the bone and that power can not be absorbed by the bones,
tendons and muscles that occurs when bone fracture fraktur.Pada periosteum and blood
vessels in the cortex, the bone marrow and soft tissue around into rusak.Perdarahan
occurs from the end of the damaged and from the network soft around (muscle) .Then
hematoma formed in the medullary canal, between the end of the area of the fracture and
the bone immediately below periosteum.Jaringan closer to areas of dead bone. Necrotic
tissue is stimulated response imflamasiditandai with vaso dilation, plasma exudation,
leukocytosis and infiltration of white blood cells then lead to nerve compression and
muscle which can cause interference sense of discomfort, pain in a person and also the
occurrence of muscle spasm can cause contractures that will cause impaired mobility and
the physical integrity of the skin disorder.

Clinical Manifestations Collum Femur Fractures

a. Looks swelling in the femur
Swelling and discoloration of the skin caused by local trauma fracture danperdarahan
that follow. This sign only after several hours ataubeberapa days after the injury.
b. Tenderness and pain when it is moved
Ongoing pain and increase in severity until the bone fragments that accompanies
muscle diimobilisasi.Spasme fracture splint is a form of natural dirancanguntuk
minimize movement between the bone fragments.
c. deformity
Deformity can be caused by a shift in eksremitas.Deformitasdapatdi fragment
information by comparing the limb normal.Ekstremitas can not function properly due
to normal muscle function depends on the integrity of the bone where drug adhesion.
d. crepitations
Crepitations namely when the limb is checked by hand, a palpable presence of
rattlesnakes bones. Crepitus palpable friction between the fragments with one
another.
e. Fungsileosa (impaired function)
f. muscle spasm
g. Other signs and symptoms:
1. Loss of sensory
2. Mobility abnormal
3. Hypovolemik shock

Diagnosis Collum Femur Fractures

1. History
Biographical data, past medical history, current medical history, family medical
history, psychosocial history (interaction with family), pattern of daily hygiene,
activity, blood circulation, Neurosensori (numbness, kesemuran, tense), Pain /
comfort.
2. Physical Examinatio
inspection:
Swelling, bruising and deformity (abnormal protrusion, angulation, rotation,
shortening) may be obvious, but the important thing is whether the skin was intact;
ripped skin and wounds that have a relationship with the fracture, an injury
terbuka.Pemeriksaan motion of your joints are actively included in the routine
examination of fractures.
Palpation:
There is local tenderness, but it should also examine the distal part of the fracture to
feel the pulse and to test sensation. Vascular injury is an emergency that requires
surgery
Motion:
On or pasif.Krepitus and abnormal movement can be found, but it is more important
to ask whether the patient can move the distal section joints injury.
3. Investigations Collum Femur Fractures
Radiological (x-ray), the area suspected fractures, must follow the role of two,
consisting of:
1. Includes two images are anteroposterior (AP) and lateral.
2. Load the two joints between the fracture is proximal and distal parts.
 3. Load the two extremities (especially in children) both injured and not affected by
the injury(to compare with normal)
4. Do it twice, ie before the procedure and after the action.

X-rays
In the AP projection is sometimes not clearly found a fracture in the cases
impacted, for additional examination is necessary axial projection. Shifting assessed
through shadow form abnormal bone and trabecular level of mismatch line at the end of
the femoral head and the femoral neck. This assessment is important because an impacted
fracture or shift (stage I and II Garden) can be improved after internal fixation, while
fractures were shifted often have non union and avascular necrosis.
Plain radiographs have traditionally been used as the first step in the examination
of the hip bone fracture. The main purpose of the film x-ray to rule out any obvious
fractures and to determine the location and extent of the fracture. The presence of
periosteal bone formation, sclerosis, callus, or a fracture line may indicate a voltage
fraktur.Radiografi may indicate a fracture line on the neck of the femur, which is the
location for this type of fraktur.Fraktur be distinguished from compression fractures,
which according to the Devas and Fullerton and Snowdy, usually located in the inferior
part of the femoral neck. If the movie is not visible in the standard x-ray, bone scan or
Magnetic Resonance Imaging (MRI) should be performed.

Bone Scanning
Bone scanning can help determine the presence of a fracture, tumor, or
infeksi.Bone scan is the most sensitive indicator of bone trauma, but they have little
specificity. Shin et al. reported that bone scanning has a positive predictive value of 68%.
Bone scanning is limited by the relative spatial resolution of the anatomy of the hip. In
the past, bone scanning is considered unreliable before 48-72 hours after a fracture, but a
study conducted by Hold et al found sensitivity of 93%, regardless of the time of the
injury.
Magnetic Resonance Imaging (MRI)
MRI has proven accurate in the assessment of fracture and reliably performed
within 24 hours of injury, but this examination is expensive. With MRI, fractures usually
occur as fracture lines in the cortex is surrounded by a zone of intense edema in the
medullary cavity. In a study by Quinn and McCarthy, the findings on MRI 100%
sensitive in patients with the results of x-rays that are less terlihat.MRI can show results
that are 100% sensitive, specific and accurate in identifying femoral neck fractures.

Laboratory examination
Highlights include:
1. Blood routine,
2. The blood clotting factor,
3. Blood groups (especially if it will do the surgery),
4. urinalysis,
5. Creatinine (muscle trauma can increase the load creatinine for kidney clearance).

Differential Diagnosis Femur Fractures Collum

1. Osteitis Pubis
Inflammation of the pubic symphysis - joints of two large pelvic bone at the front of
thepelvis.
2. SlippedCapital Femoral epiphysis
Fractures were passing a physical (tembat plate grows in the bones), causing insertion
occurs above the epiphysis.
3. Snapping Hip Syndrome
Medical condition characterized by a snapping sensation felt when the hip is flexed
and diperpanjang.Hal can be accompanied by audible snapping or popping noise and
pain .Thats such as cracking sounds different coming from all over the pelvic region
when the joint passes from the unhinged longed. to be medically known as the
iliopsoas tendinitis, those commonly affected are the athletes, such as weightlifters,
gymnasts, runners and ballet dancers, who routinely apply excessive force or perform
difficult movements involving the hip joint.
 Collum Femur Fracture Management
Management fractures are as follows:
general management
1. Fractures usually accompanies trauma, it is important to the examination of
airway,
breathing and circulation
2. If there is no problem anymore, do diagnose and detailed examination
3. The time of the accident ditanyaakan important to know how long until the
hospital,
given the golden period (1-6 hours)
4. If> 6 hours, more infectious complications>, history and a brief physical
examination,complete.
5. Make a photo radiology, fitting splints to reduce pain and ease the process of
maked photos

Principles of Fracture Management

Principles of action / handling includes the reduction of the fracture,

immobilization, and return to normal function and strength with rehabilitation

Reduction, namely: restoration of fracture fragments in order to get an acceptable

position.
Reduction of fractures (bone setting) means return the bone fragments in a parallel and
normal anatomical position.
The goal is to repair the fracture fragments in its normal anatomic position.
Methods for the reduction is with closed reduction, traction, and open reduction. The
particular method chosen depends the nature of the fracture, but the underlying principle
remains the same. Usually doctors perform fracture reduction as soon as possible to
prevent soft tissue loses its elasticity due to infiltration due to edema and hemorrhage. In
most cases, the reduction of the fracture becomes increasingly difficult when the injury
already experienced healing.
Reduction method:
1. Reduction covered, in most cases, closed reduction is done by returning the bone
fragments into position (edges are interconnected) with "Manipulation and Traction
manual". Before the reduction and immobilization, the patient's consent must be
requested, in accordance with the analgesic and anesthetic given if necessary.
Ektremitas maintained in the desired position while the cast, splint or other device
fitted by a doctor. Tools will maintain the reduction and immobilization of extremity
to stabilize the bone healing. X-rays should be performed to determine whether the
bone fragments have been in correct alignment.
2. Traction
Traction can be used to obtain the effect of reduction and immobilization. Weighing
traction adapted to muscle spasms that occur. Generally traction is done by placing
the burden to strap on ekstermitas patients. Area attractions also adjusted such that the
direction of the long axis aligned with the pull of a broken bone.
3. Reduction open
In certain fractures require open reduction. With the surgical approach, reduced bone
fragments. The internal fixation devices in the form of pins, wires, screws, palt, nail
or metal rod can be used to retain the bone fragments in his position until a solid bone
healing occurs.
Immobilization

Once the fracture is reduced, bone fragments must be immobilized, or maintained in

the correct position and alignment to occur unification.
The goal is to maintain the reduction in its place until healing occurs.
Methods to maintain immobilization is by means of "external" (splint, brace, case,
pen in plaster, fiksatorexterna, traction, bandage) and tools "internal" (nails, plates,
screws, wire, rod, etc.)

Table Estimated Time It Takes To The unification of Bone FracturesImmobilization

Rehabilitation
The goal is improve back function and normal strength on the affected part.
To maintain and improve the function to maintain the reduction and immobilization is
the exaltation to minimize swelling, monitor the status of neurovascular, control
 anxiety and pain, isometric exercises and arrangement of muscles, participation in
activities of daily living, and engage a gradual return can improve the independence
of the function , Returns staged at its original activity sought appropriate therapeutic
boundaries.

Bone Healing Process

Stages consist of bone healing: inflammation, cell proliferation, callus formation,

callus ossification (ossification), and remodeling.

1. Inflammation.
Inflammatory phase lasts a few days and disappear with the reduced swelling and
bleeding nyeri.Terjadi in the injured tissue and hematoma formation at the fracture
tulang.Ujung devitalized bone fragments because the breakdown of the blood supply.
Points injury will then be invaded by magrofag (large white blood cells), which will
clear the area. Inflammation, swelling and pain.
2. Proliferation Sel.
After approximately 5 days hematoma will experience the organization, formed
threads of fibrin in the blood clot, forming a network for revascularization, and the
invasion of fibroblasts and osteoblasts. Fibroblasts and osteoblasts (the developing of
osteocytes, endothelial cells, and cell periosteum) will produce collagen and
proteoglycan matrix of collagen in bone fracture. Formed fibrous connective tissue
and cartilage (osteoid) .From the periosteum, cartilage looked melingkar.Kalus the
growth is stimulated by micro minimal movement on the site of fracture. But the
excessive movement will damage sruktur callus. Bones that are actively growing
shows electronegative potential.
3. Callus Formation Stage.
Continued network growth and cartilage growth cycle reaches the other side until the
gap is plugged. Fragments of bone fracture combined with fibrous tissue, cartilage,
and bone callus matur.Bentuk fiber and volume needed to connect the defect is
directly related to the amount of damage and the shift tulang.Perlu within three to
 four weeks to allow the bone fragments belonging to the cartilage or fibrous tissue .In
clinical fargmen bones can no longer be moved.
4. Phase Reinforcement callus (ossification).
Callus formation started having reinforcement in two to three weeks of fracture,
through the process of ossification endokondral. Long bone fracture normal adults,
ossification takes three to four bulan.Mineral continuously backfilled until the bone
actually has united with callus keras.Permukaan remain electronegative.
5. Phase Bones Become Adults (Remodeling).
The final stage involves taking bone fracture repair dead tissue and new bone
reorganization to previous structural arrangement. Remodeling may take months to
years - years depending on the severity of bone modification is required, the function
of bone, and in cases involving the compact and cancellous bone - functional stress
on the bone. Cancellous bone healing and remodeling experience faster than the
compact cortical bone, particularly at the point of direct contact.
During the growth of elongated bones, the metaphysical area experienced remodeling
(formation) and at the same time epiphyseal bone progressively away from the stem.
Bone remodeling occurs as a result of a process between deposition and resorption of
bone osteoblastic simultaneously. The process of bone remodeling takes place
throughout life, whereas in children in infancy occurs equilibrium (balance) is
positive, while in adults there is a balance that is negative. Remodeling also occur
after healing of a fracture.

Collum Femur Fracture Complications

Segerea complications occur at the time of the fracture; Early complications occur
within a few days after the event; and later complications occurred shortly after broken
tulang.Ketiganya each subdivided into local and general complications.

Complications soon: Occurs when the occurrence of bone fractures

Local
a. Skin and muscle: various vulnus (abrasions, lacerations, cuts, etc.), contusions,
avulse
b. Vascular: disconnected, contusions, hemorrhage
c. The internal organs: heart, lungs, liver, spleen (in fractured rib), bladder (the pelvic
fractures)
d. Neurological: the brain, spinal cord, peripheral nerve damage
e. General: multiple trauma, shock

Early complications

1. Local: skin necrosis of muscle, compartment syndrome, thrombosis, joint infection,

osteomyelitis
2. General: ARDS, pulmonary embolism, tetanus

Old complications:

- Local a. Gannguan the bone healing process:

1) Mal-union: Bone Grafting imperfect

2) Non-union: Absolutely not connect

3) Delayedunion: Slowing bone grafting

b. Joints: ankylosis, joint post-traumatic degenerative disease, myositis

osifikan, nerve damage

- Generala a. Kidney stones (due to prolonged immobilization in bed and

hypercalcemia)
b. Post-traumatic neurosis

General Compilation:

a. Shock: hypovolemic or traumatic shock due to bleeding (blood loss either external or
invisible) and external fluid loss kejaringan damaged.
b. Fat embolism syndrome: In the event of fracture of fat globules can get into the blood
vessel due to the pressure higher than the bone marrow or the capillary pressure due
to catecholamines released by a stress reaction patients will mobilize fatty acid and
eases the fat globules in the bloodstream
c. Compartment syndrome: a problem that occurs when muscle tissue perfusion in less
than that required for the life of the network. This could be due to a decrease in the
size of the muscle compartment due to fascia that wraps muscles are too tight, use a
cast or bandage which ensnare or browse increase muscle compartment for edema or
bleeding in connection with various problems (eg, ischemia, injury crushed).
d. Venous Thrombosis: Blood clots in the veins, especially in the lower limbs caused by
blood flow becomes slow or static the bloodstream, whereas vascular endothelial
abnormalities rarely a factor. Venous thrombus composed largely of fibrin and
erythrocytes and platelets contain only a little time. In general, the reaction resembles
a blood clot in the tube.
e. Pulmonary embolism: blockage of the pulmonary artery (pulmonary artery) by an
embolus, which occurs suddenly. An embolism can be a blood clot (thrombus), but
can also be fat, amniotic fluid, bone marrow, tumor fragments or air bubbles, which
will follow the blood flow until eventually clog arteries. Clogged arteries are usually
not able to provide adequate amounts of blood to the lung tissue exposed to tissue
death could have been avoided. But if the blocked vessel is very large or the person
has a previous lung disorder, then the amount of blood may be insufficient to prevent
the death of the lungs. Most cases are caused by a blood clot from a vein, especially
the veins in the legs or pelvis. Less common causes are air bubbles, fat, amniotic
fluid, or clumps of parasites or tumor cells.
f. Avascular necrosis: results in 30% of patients with fractures that accompanied the
shift and 10% in fracture without shifting. If the fracture is more to the proximal
localization, then it is likely to occur avascular necrosis becomes larger.