CASE REPORT

CLOSED FRACTURE NECK FEMUR

Thathmainnul Qulub C111 10 817

Alif Zulfikar Supardi C111 12 895
Ditha P. Buntuan C111 11 381
Vivi Utami Mulia C111 12 332
Dian Nurani C111 10 338

Pembimbing:
dr. Anak Agung Gede Putra
dr. Marcell Wijaya

Supervisor:
dr. Michael John, M.Kes, SpOT
IDENTITY
Name : Mrs. DM
No. Medical Record : 816165
Birthday : 11 Juni 1935
Age : 82 years old
Gender : Female
Address : Jl. Anggrek No.23 Makassar
Ocupation : Housewife
Religion : Moeslem
Enter Date : 21 September 2017
Supervisor : dr. Henry Yurianto, M.Phil, Ph.D, SpOT(K)
AUTOANAMNESIS

Chief Complain : Right Hip Pain

Suferred since 5 days before admittance at Wahidin General
Hospital.
Patient was falling in the bathroom when she was doing
wudhu.
Patient slipped and fell down in a sitting position with her
right hip hitting the floor first.
Patient was not able to stand nor walk after she fell.
Patient was able to walk before she fell down.
AUTOANAMNESIS
Theres no history of loss of consciousness.
Theres no prior syncopal episode.
Medical history : no DM, no hypertension, no allergic of
medicine, no history of operation.
CLINICAL FINDING
LOCAL STATUS
Right Hip Region:
Look : Deformity (+), swelling (-), wound (-), hematome (-)
Feel : Tenderness at proximal thigh
Move : Active and passive movement of hip joint cannot be
evaluated due to pain.
Active and passive movement of knee joint cannot be
evaluated due to pain.
NVD : Good sensibility, pulsation tibialis posterior and dorsalis
pedis arteries are palpable, capillary refill less then 2
seconds
LOCAL STATUS
Right Left

ALL 85 cm 86 cm

TLL 82 cm 83 cm

LLD 1 cm
RADIOLOGY FINDING

Kesan :
Tampak fraktur pada bone cervical right femur.
 RADIOLOGY FINDING

Kesan :
Fraktur basicervical collum femur dextra
LABORATORY FINDING
Pemeriksaan Hasil Nilai Normal

HB 9,8 g/dL 11,5 - 16,0

RBC 3,11 x 106 / mm3 3,80 - 5,80

WBC 12,1 x 103 / mm3 4,0 - 10,0

PLT 360 x 103 / mm3 150 - 500

HCT 29,3 % 37,0 - 47,0

MCV 94 m3 80 - 100

MCH 31,5 pg 27,0 - 32,0

MCHC 33,4 g/dL 32,0 - 36,0

PT 9,1 detik 10 - 14

APTT 24,2 detik 22,0 - 30,0

INR 0,81 -
DIAGNOSIS
Closed fracture right neck femur Garden type II
Anemia
MANAGEMENT

IVFD Ringer Laktat

Analgesic
Apply skin traction of the right leg with a 3 kg load
Plan for hemiarthroplasty
DISCUSSION
OVERVIEW

The femoral neck is the most common site of fractures in the elderly.
The incidence in younger patients is very low and is associated
mainly with high-energy trauma.
Risk factors include female, white race, increasing age, poor health,
tobacco and alcohol use, previous fracture, fall history, and low
estrogen level.
FEMUR BONE
Muscle and Nerve
ANTERIOR COMPARTMENT
Muscle and Nerve
ANTERIOR COMPARTMENT
Muscle and Nerve
POSTERIOR COMPARTMENT
Arteries
The Mechanism of Fracture
Low-energy High- energy Cyclic loading- Insufficiency
trauma trauma stress fractures fractures
Direct: a fall This accounts These are seen Patients with
onto the greater for femoral in athletes, osteoporosis
trochanter neck fractures military recruits, and osteopenia
(valgus in both younger and ballet are at particular
imapction) or and older dancers risk
forced external patients, such
rotation of the as motor
lower extremity vehicle accident
impinges an or fall from a
osteoporotic significant
neck onto the height
posterior lip of
the acetabulum
Indirect: muscle
forces
overwhelm the
strength of the
femoral neck
Classification of Neck Femur Fractures

Anatomic Location
Subcapital
Transcervical
Basicervical

Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 3rd Ed. Lippincott Williams & Wilkins, 2002. Hal: 319-28
Muller Classification
Pauwel Classification
This is based on the angle of fracture from the horizontal:
Tipe I : >30 degrees
Tipe II : 31-70 degrees
Tipe III : > 70 degrees

Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 3rd Ed. Lippincott Williams & Wilkins, 2002. Hal: 319-28
Garden Classification
Garden Classification based on the amount of displacement apparent in the
pre-reduction x-rays
Stage I : incomplete / valgus impacted
Stage II : complete but undisplaced fracture.
Stage III : complete fracture with partial displacement
Stage IV : severely displaced fracture.

Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 3rd Ed. Lippincott Williams & Wilkins, 2002. Hal: 319-28
Solomon, L dkk. Fractures of the Femoral Neck; Apleys System of Orthopaedic and Fractures, 8th Ed. Arnold, 2001. Hal: 847-52.
Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010. Hal: 255
Solomon, L dkk. Fractures of the Femoral Neck; Apleys System of Orthopaedic and Fractures, 8th Ed. Arnold, 2001. Hal: 847-52.
Clinical Features
There is usually a history of trauma: road trafc accidents
or falls from heights and are often associated with multiple
injuries

Fracture with displacement: shortening and external

rotation of the lower extremity

Pain is evident on attempted range of hip motion, with pain

on axial compression, and with tenderness to palpation of
the groin.

Low-energy fracture usually occurs in older individuals

Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 3rd Ed. Lippincott Williams & Wilkins, 2002. Hal: 319-28
Solomon, L dkk. Fractures of the Femoral Neck; Apleys System of Orthopaedic and Fractures, 8th Ed. Arnold, 2001. Hal: 847-52.
Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010. Hal: 255
DIAGNOSIS
Pain on right groin
Simple, low-energy fall history of fall on right region
History
Taking position

Deformity
Tenderness at right groin
Physical
Examination Pain on movement

Xray shows fracture right neck of femur

Imaging
HISTORY TAKING

Obtaining a history of loss of consciousness, prior syncopal episode,

medical history, chest pain, prior hip pain (pathologic fracture),
mechanism of injury, and preinjury ambulatory status is essential in
determining optimal treatment.
PHYSICAL EXAMINATION
Look
Deformity
Examination of overlying skin and soft tissue
Feel
Local bony tenderness
Muscle spasm
Crepitus
Distal neurovascular examination
Move
Active movements of all four limbs are tested
in initial assessment. Patient with fracture
may find it difficult to move and fracture
must be suspected if there is painful
limitation. Adjacent joint movements should
be checked
PHYSICAL EXAMINATION
Apparent Leg Length
Discrepancy

True Length Discrepancy

PHYSICAL EXAMINATION
Bryants triangle Synonyms: Iliofemoral triangle
Position: The patient lies supine with the
pelvis square, and the limbs in identical
position.
Points of the Bryants triangle:
The Bryants triangle is a right angled
formed by:
Anterior Superior Iliac Spine (ASIS)
Tip of Greater trochanter
Junction of perpendiculars from the 2
points above (1st draw a perpendicular
from ASIS to bed and another
perpendicular from greater trochanter to
meet the 1st perpendicular)
IMAGING

AP View of the pelvis.

AP and a cross-table lateral view of the involved proximal.
MRI to diagnose occult femoral neck fractures in patients with
negative radiographs.
MANAGEMENT GOALS

Minimize patient discomfort

Rapid mobilization
Restore hip function
MANAGEMENT
Non Operative

Skin Traction
Sceletal Traction

Operative

Cannulated screw fixation

Sliding hip screw
Hemiarthroplasty
Total Hip Arthroplasty
OPERATIVE MANAGEMENT
Cannulated Screw Fixation
Garden I & II fracture in the elderly
Displaced transcervical fracture in young patient

Sliding Hip Screw

Basicervical fracture
Vertical fracture pattern in a young patient
Hemiarthroplasty
Elderly with poor bone quality

Total Hip Arthroplasty

Eldery with high functional demands and
good bone density
Garden III & IV fracture in patient > 85
years
COMPLICATIONS
Early Complication :

Pulmonary Embolism
Bed sores

Late Complication :

Osteonecrosis Avascular Necrosis of

femoral head
Non-Union
Secondary Osteoarthritis
BIBLIOGRAPHY
Egol, K dkk. Femoral Neck Fractures; Handbook of Fractures, 5th Ed. Lippincott Williams
& Wilkins, 2015. Hal: 349.
Solomon, L dkk. Fractures of the Femoral Neck; Apleys System of Orthopaedic and
Fractures, 9th Ed. Arnold, 2010. Hal: 847.
Muller, Maurice E. 2006. Muller AO Classification of fractures Long Bones. AO Publishing
Muller AO Classification of Fractures Long Bones. AOTRAUMA.
Thompson, J. Netters Concise Orthopaedic Anatomy, 2nd Ed. Elsevier Saunders, 2010.
Hal: 251-7.
Rex, C. Examination of Patient withBone and Joint Injuries; Clinical Assessment and
Examination in Orthopedics, 2nd Ed. Jaypee Brothers Medical, 2012. Hal: 17-21.
Frassica, F dkk. Femoral Neck Fractures. 5-Minute Orthopaedic Consult, 2nd
Ed.Lippincott Williams & Wilkins, 2007.Hal: 127.
Miller MD, Thompson SR, Hart JA. Review of Orthopaedics 6th Edition. Philadelphia;
Saunder Elsevier. 2012. p. 315-6.
Skinner, H. Femoral Neck Fractures. Current Essentials Orthopedics.McGraw-Hill, 2008.
Hal: 37.