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PRESENTATION
CLOSED FRACTURE
MS
MIDSHAFT RT FEMUR
AND OPEN FRACTURE
OF RT PATELLA
NAME:NURDINA AFINI BT
IZAMUDIN
ANATOMY OF FEMUR
Femur is the only bone of the human thigh.
It is both the longest and the strongest bone in the
human body, extending from the hip to the knee.
Important features are head, medial and lateral
condyles, patellar surface, medial and lateral
epicondyles, and greater and lesser trochanters.
The head is where the bone forms the hip joint with
the innominate bone.
The condyles are the points of articulation with the
tibia, which is a lower leg bone.
The patellar surface is the groove where the bone
articulates with the patella, or knee cap.
The epicondyles and trochanters are all important
attachment sites for various muscles.
ANATOMY OF PATELLA
-The patella is a small bone located in front of knee
joint where the thighbone (femur) and shinbone
(tibia) meet.
- It protects knee and connects the muscles in the
front of thigh to tibia.
-The ends of the femur and the undersides of the
patella are covered with a slippery substance called
articular cartilage. This helps the bones glide smoothly
along each other when move leg.
-Tendons connect the knee bones to the leg muscles that move
the knee joint.
-Ligaments join the knee bones and provide stability to the
knee:
I. The anterior cruciate ligament prevents the femur from
sliding backward on the tibia (or the tibia sliding forward
on the femur).
II. The posterior cruciate ligament prevents the femur from
sliding forward on the tibia (or the tibia from sliding
backward on the femur).
III. The medial and lateral collateral ligaments prevent the
femur from sliding side to side.
- Two C-shaped pieces of cartilage called the medial and lateral
menisci act as shock absorbers between the femur and tibia.
-Numerous bursae, or fluid-filled sacs, help the knee move
smoothly.
AETIOLOGY
Femoral shaft fractures in young people are
frequently due to
-some type of high-energy collision.
-The most common cause of femoral shaft
fracture is a motor vehicle or motorcycle
crash.
-Being hit by a car as a pedestrian is another
common cause,
-as are falls from heights and gunshot
wounds.
A lower-force incident, such as a fall from
standing, may cause a femoral shaft fracture
in an older person who has weaker bones.
DR. MX
-Imaging Tests
TREATMENT
Nonsurgical Treatment
Most femoral shaft fractures require surgery to heal. It is unusual
for femoral shaft fractures to be treated without surgery. Very
young children are sometimes treated with a cast..
Surgical Treatment
Timing of surgery.If the skin around fracture has not been
broken, doctor will wait until stable before doing surgery. Open
fractures, however, expose the fracture site to the environment.
They urgently need to be cleansed and require immediate
surgery to prevent infection.
For the time between initial emergency care and surgery, doctor
will place leg either in a long-leg splint or in skeletal traction. This
is to keep broken bones as aligned as possible and to maintain
the length of leg.
Intramedullary nailing
provides strong, stable,
full-length fixation.
COMPLICATION
Infection
Injury to nerves and blood vessels
Blood clots
Fat embolism (bone marrow enters the blood
stream and can travel to the lungs; this can also
happen from the fracture itself without surgery)
Malalignment or the inability to correctly
position the broken bone fragments
Delayed union or nonunion (when the fracture
heals slower than usual or not at all)
Hardware irritation (sometimes the end of the
nail or the screw can irritate the overlying
muscles and tendons)
PATELLAR FRACTURE
Patellar fractures account for about 1% of all
fractures. They are most common in people who
are 20 to 50 years old. Men are twice as likely as
women to fracture the kneecap.
Patellar fractures vary. The kneecap can crack
just slightly, or can be broken into many
pieces.
A break in the kneecap can happen at the top,
center, or lower part of the bone. Sometimes,
fractures occur in more than one area of the
kneecap.
AETIOLOGY
Patellar fractures are most commonly caused by
a direct blow, such as from a fall or motor vehicle
collision.
The patella can also be fractured indirectly. For
example, thigh muscles can contract so violently
that it pulls the patella apart.
DR. MX.
Tests
X-rays are the most common and widely available
diagnostic imaging technique. They create images of
dense structures, like bone, so are particularly useful
in showing fractures. X-rays are important for showing
front and side views of the fracture.
Although rare, a person may be born with extra bones
in the patella that have not grown together. This is
called bipartite patella and may be mistaken for a
fracture. X-rays help to identify bipartite patella. Many
people have bipartite patella in both knees, so doctor
may take an x-ray of other knee, as well.
Treatment
Nonsurgical Treatment
If the pieces of broken bone have not been
displaced by the force of the injury, may not need
surgery.
Casts or splints may be used to keep knee
straight.
This will keep the broken ends in proper position
while they heal.
Not be able to put any weight on leg until the
bone is completely healed.
This may take 6 to 8 weeks, and perhaps longer.
Most people use crutches during this period.
Surgical Treatment
If the patella has been (displaced), most likely need
surgery. Fractured patellar bones that are not close
together often have difficulty healing or may not heal.
The thigh muscles that attach to the top of the patella
are very strong and can pull the broken pieces out of
place during healing.
Timing of surgery.If the skin around fracture has not
been broken, doctor may recommend waiting until
any abrasions have healed before having surgery.
Open fractures, however, expose the fracture site to
the environment. They urgently need to be cleansed
and require immediate surgery.
Procedure.The type of procedure performed often
depends on the type of fracture .
PTs MX.
Because pt. will most likely lose muscle
strength in the injured area, exercises during the
healing process are important. Physical therapy
will help to restore normal muscle strength, joint
motion, and flexibility.
A physical therapist will most likely begin
teaching specific exercises while pt are still in
the hospital. The therapist will also help pt learn
how to use crutches or a walker.
DEMOGRAPHIC DATA
NAME: Mr. XX
AGE: 31 Y/O
RACE: MALAY
GENDER: MALE
DATE OF AX: 23 NOVEMBER 2014
DATE OF REFERRED: 16 NOVEMBER 2014
DR. DIAGNOSIS: CLOSED FRACTURE
MIDSHAFT RT FEMUR AND OPEN FRACTURE
RT PATELLA
DR MX.: OPERATIVE AND REFER PHYSIO
SUBJECTIVE AX.
PROBLEM:
Pt. c/o unable to bend his Rt. kn.
Pt. c/o pain when move his Rt. LL
PAIN SCALE:
Current: 8/10
Agg: 8/10 ( when move Rt. LL, bend Rt. Kn, put
Rt. Kn without support)
Ease: 5/10 ( on painkiller)
Nature: Dull aching pain and needling pain
24 H: Pain all the time
Irritibility: High
SOCIAL Hx:
Occ: clerk at school
Nature of work: sitt and use a lot of hand movt.
Smoker: not smoking
Dominant hand: Rt.
Life style: maximally dependence to his wife
Type of house: Single storey house with 5 steps
Toilet: Sitting
FUNCTIONAL ACTIVITY:
1) pt still depends on wheelchair and need help from
his wife.
OBJECTIVE AX
GENERAL OBSERVATION: An endomorph body size of
Malay male come to department accompanied with his
wife by using wheelchair.
Alert and obey command
LOCAL OBSERVATION:
Swelling of Rt. LL
On gauze at Rt. Kn.
Scar at Rt. Kn.
Dry skin at Rt. Calf and foot
On bandage at Rt. Foot.
Rt. Hip external rotation position.
PALPATION:
No increase in warmth at Rt. Ankle and foot.
Tenderness at Rt. Kn.
ROM: KIV d/t pt. refuse to touch his rt. LL because of
untolerable with pain.
MS. POWER
Jt.
Muscle
Hip.
Flexor
Flexor
Rt.
Lt.
1/5
3/5
Extensor
Ank.
d/flexor
p/flexor
3/5
4/5
MS. GIRTH:
From suprapatella (cm)
Rt. (cm)
Lt. (cm)
Diff. (cm)
63
59
10
67
65
15
70
68
44
42
Swelling of Rt. LL
FIGURE OF 8
Rt (cm)
Lt (cm)
diff (cm)
61
60
ANALYSIS
PTS IMPRESSION
1) Pain at rt. Kn d/t pt. condition
2) Swelling at Rt. LL d/t prolong immobilised
3) Reduce functional activty d/t pain
STG
4) To reduce pain at. Rt. Kn. within 1/52 by doing exs.
5) To reduce swelling at Rt. LL within 1/52
6) To improve ms. Power of bil. LL. Within 1/52
LTG
7) To regain maximal functional activity
8) To improve quality of life
PLAN OF TX
Stretching exs.
Mobilising exs
Strenghtening exs.
Circulatory exs.
Positioning
Ambulation
Gait training exs.
HEP
Pt. edu.
INTERVENTION
1) Positioning
Pt. half ly., correct rt. hip from external rot. to
internal rot.
2) Strengthening exs.
-Pt. half ly., lt. hip SLR, hold 5 sec., 50 reps.
-Pt. half ly., rt. Kn SQE,hold 15 sec.,50 reps.
-Pt. sitt with rt. LL supported, Lt. kn. Ext. exs.,
sandbag(3 lb), hold 10 sec., 50 reps.
-Pt. sitt., hand push up exs., hold 5 sec., 20 reps.
-Sitt to stand exs. (NWB), walking frame, hold 5
sec., reps.
3) Circulatory exs., 10 reps.
4) HEP
Advice pt to do all exs. home regularly 3 times per day.
5)Pt. edu.
-Encourage pt. to elevate his rt. LL more than heart
level when lying on bed and sleeping.
-Encourage pt to slowly move his rt. LL.
-Educate pt. correct his rt. LL position to prevent hip
external rotation.
EVALUATION
-Pt. refuse to touch him because of pain.
-Pt. give cooperation to do all exs.
-Pt. able to sitt on wheelchair with rt. Kn. unsupported.
REVIEW
-To review ROM
Follow up
Date:
S:
Pt. claim slightly reduce pain on rt. Kn. VAS (6/10)a
and reduce the intake of painkiller from everyday to 3
days per once.
Pt. c/o same problem.
O:
GO: An endomorph body size of Malay male come to
department accompanied with his wife by using
wheelchair.
Alert and obey command
LO:
Swelling of Rt. LL
Unmatured scar at Rt. Kn.
Dry skin at Rt. Calf and foot
On bandage at Rt. Foot.
Rt. Hip external rotation position.
PALPATION
No increase in warmth at Rt. Ankle and foot.
Tenderness at Rt. Kn.
ROM
Jt.
Movement
Rt.
Lt.
Hip.
Flex.
AFROM
Flex.
A:0-40 degree
P:0-45 degree
AFROM
Ext.
LACK 40 degree
AFROM
d/flex.
A:30-45 degree
P:30-55 degree
A:30-60 degree
P:30-70 degree
p/flex.
A:30-20 degree
P:30-15 degree
A:30-10 degree
P:30-5 degree
Ank.
MS. POWER
Jt.
Muscle
Hip.
Flexor
Flexor
Rt.
Lt.
1/5
3/5
Extensor
Ank.
d/flexor
p/flexor
3/5
4/5
MS. GIRTH
From suprapatella (cm)
Rt. (cm)
Lt. (cm)
Diff. (cm)
60
59
10
68
64
15
71
69
44
42
Swelling of Rt. LL
FIGURE OF 8
Rt (cm)
Lt (cm)
diff (cm)
63.5
61
1.5
ANALYSIS
PTS IMPRESSION
1) Pain at Rt. Kn d/t condition.
2) Reduce ROM of Rt. kn. and ank. jt. d/t jt.
stiffness.
3) Reduce of ms. power of bil. LL d/t lack of ms.
activity.
4) Swelling at Rt. LL d/t prolong immobilised
5) Reduce functional activty d/t pain
PLAN OF TX.
1) Positioning
Pt. half ly., correct rt. hip from external rot. to
internal rot.
2) Passive stretching exs.
Pt. half ly.,stretch Rt hip internal rot.,hold 15
sec.,20 reps
3) Strengthening exs.
-Pt. half ly., lt. hip SLR, hold 8 sec., 50 reps.
-Pt. half ly., rt. Kn SQE,hold 20 sec.,50 reps.
-Pt. sitt with rt. LL supported, Lt. kn. Ext. exs.,
sandbag(3 lb), hold 10 sec., 50 reps.
-Pt. sitt., hand push up exs., hold 8 sec., 20 reps.
REFERENCES
http://orthoinfo.aaos.org/
http://www.webmd.com/