CLOSED FRACTURE 1/3 MIDDLE OF THE LEFT FEMUR

Presented by: Juliet C G Umbas Advisor : dr. Salman Al Wahaby dr. Syarif Hidayatullah Supervisor: dr. Notinas Horas, M. Kes, Sp. OT

Orthopaedic and Traumatology Dept Medical Faculty of Hasanuddin University Makassar, 2013

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

History Taking
Chief Complaint: Pain at the left thigh
History of illness Suffered since 6 hours before admitted to hospital due to a traffic accident. the

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 Survey
A B
Patent
RR 20x/min regular, spontaneous thoracoabdominal type, symmetrical BP 120/80 mmHg HR = 88 x/min regular.

C
D

GCS 15 (E4V5M6), isochoric pupil, : 2.5 mm, light reflex +/+

T = 36,70 C (axilla)

Secondary Survey
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
Right ALL TLL LLD 98 93 2 cm Left 96 91

Clinical Picture

Laboratory Findings
WBC HGB RBC PLT Ur Cr : 10.000/mm3 : 13,5 mg/dl : 5.260.000/mm3 : 259.000/mm3 : 30 : 0,9 GOT : 61 GPT : 60 CT : 800 BT : 200 HbsAg : non reactive GDS : 72 Elektrolit Na : 136 K : 5,0 Cl : 102

X-ray : Femur (S) AP/Lateral view 24th June 2013 Fracture 1/3 middle (L) femur

Pelvic X-ray 24th June 2013 Within 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. Netters 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 : Apleys System of Orthopaedics and Fractures 9th Edition 2. 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 : Apleys System of Orthopaedics and Fractures 9th Edition

Mechanism of Injury

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

Diagnose
History and Mechanism of Trauma

Physical Examination

X-ray with Anteroposterior/ lateral view

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

NVD evaluation
Solomon Louis, Warwick David, Nayagam Selvadurai : Apleys System of Orthopaedics and Fractures 9th Edition Thompson, Jon C. Netters Concise Orthopaedics Anatomy 2nd Edition

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
Shock Vascular injury Nerve Injury Fat embolism Thromboembolism Infection

Late

Non union or delayed union Malunion Joint stiffness Refracture and implant failure

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

Thank You