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Closed Fracture of Midshaft Femur Fractures
Closed Fracture of Midshaft Femur Fractures
Disusun oleh :
Faris Nagib
01.211.6389
Pembimbing :
dr. Wisnu Murti Sp.OT
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2016HALAMAN PENGESAHAN
Nama
Faris Nagib
NIM
012116389
Fakultas
Kedokteran
Universitas
Tingkat
Bagian
Ilmu Bedah
Judul
Pembimbing,
CHAPTER I
INTRODUCTION
Orthopedic fractures are a common daily acute health issue. Improper initial
management of fractures can lead to significant long-term morbidity and,
potentially mortality. Traumatic femur fractures in the young individual are
generally caused by high-energy forces and are often associated with
multisystem trauma.
Traumatic femur fractures in the young individual are generally caused by
high-energy forces and are often associated with multisystem trauma. In the elderly
population, femur fractures are typically caused by a low energy mechanism such
as a fall from standing height. Isolated injuries can occur with repetitive stress and
in the presence of metabolic bone diseases, metastatic disease or primary bone
tumors.
The incidence of diaphyseal femur fractures ranges from 9.9 to 12 for every
100,000 persons/year: 60% occur in men and 40% in women. The average age is
25, with a maximum incidence peak among 15 and 24 years of age (1-4).The cause
in the majority of cases is high-energy trauma, mainly traffic accidents (80-90%).
The fractures caused by minor trauma occur in patients above 60 (1, 2). The
considerable energy required to cause many of these fractures often also provoke
injuries in other structures, above all in the ipsilateral hip and knee and they often
go undiagnosed (1-4).
The femur is very vascular, and fractures can result in significant blood loss
into the thigh. Up to 40% of isolated fractures may require transfusion as such
injuries can result in loss of up to three units of blood. This factor is significant,
especially in elderly patients who have less cardiac reserve.
Femur fracture patterns vary according to the direction of the force applied
and the quantity of force absorbed. A perpendicular force results in a transverse
fracture pattern, an axial force may injure the hip or knee, and rotational forces may
cause spiral or oblique fracture patterns. The amount of comminution present
increases with increasing amounts of force.
Most femur fractures are treated surgically. The goal of early surgical
treatment is stable, anatomic fixation, allowing mobilization as soon as possible.
Surgical stabilization is also important for early extremity function, allowing both
hip and knee motion and strengthening. Injuries and fractures of the femur may
have significant short and long-term effects on gait kinematics and function if
alignment is not restored
CHAPTER II
PATIENTS STATUS
I.
II.
IDENTITY
a. Name
b. Age
c. Sex
d. Religion
e. Address
f. Room
g. Register number
h. Date of in patient
: Ms. N
: 26 years old
: Female
: Islam
: Cening-juku, Kendal
: Kenanga 2
: 512-770
: October 28, 2016
ANAMNESA
Autoanamnesa with the patient held on October 29, 2016 in kenanga
room and also supported by medical records.
Primary Survey :
A (Airway) : Airway and cervical spine stabilisation (Cleared)
B (Breathing) : Adequate breathing (respiration rate :
didnt do the activity, she just sit and lay down. She drank pain reliever
medication to heal the pain, but the symptoms are not reduced.
A patient came to emergency room with chief complaining cant
walked, after she fell down when she was following rounders match on
the occasion of Independence Day 2 months ago. When that accident
happened, she cant move her right leg and felt pain. Patient brought to a
masseuse and her leg in a splint with cardboard. After that, she didnt do
the activity, she just sit and lay down. She drank pain reliever
medication to heal the pain, but the symptoms are not reduced.
Medical condition history:
- History of asthma and allergies
- History of heart disease
- History of hypertension
- History of diabetes
: denied
: denied
: denied
: denied
Family history:
- History of asthma and allergies
- History of heart disease
- History of hypertension
- History of diabetes
: denied
: denied
: denied
: denied
Socioeconomic status :
The cost of treatment using SKTM.
Impression: enough in socioeconomic.
III.
Physical Examination
Held on October 29, 2016 at 14:00 pm in Kenanga room of Kendal
Hospital
Physical Assessment
fall)
Skin : brown, skin turgor normal
Head : mesocephal form, injuries (-)
Eyes : isokor pupil (d : 3mm/3mm), light reflex (+/+), palpebral
N
N
: (-)
: (-)
: (-)
Pasif :
o Flexion
: (-)
o Endorotation
: (-)
o Exorotation
: (-)
Neurovascular Distal (NVD) :
Neurological :
o Physiological reflex : difficult to evaluate
o Pathological reflexes: (-)
o Motor
: 1/5
o Sensory
: touch (+), tenderness
(+), temperature (+)
Vaskular : CRT : >1 seconds
IV.
Laboratory Results
1. Blood laboratory
Examines
Hb
Leucosite
Trombosite
Ht
PT
APTT
Results
15.5 gr%
8.000 cell/mm3
301.000 cell/mm3
45.2 %
12.4 seconds
34.2 seconds
Normal Results
13 18 gr%
4.000 10.000 cell/mm3
150.000 500.000 cell/mm3
39 54 %
11,3-14,7 seconds
27,4 39,3 seconds
3. Radiology
V.
BAB III
CONTENTS REVIEW
3.1 Anatomy
The femur is the strongest, longest, and heaviest bone in the body and is
essential for normal ambulation. The femoral shaft is tubular with a slight anterior
bow, extending from the lesser trochanter to the flare of the femoral condyles. The
femur is subject to many forces during ambulation including axial loading, bending,
and torsional forces. During weight bearing, the medial cortex is subject to
compressive forces while tensile forces are placed on the lateral cortex during
contraction, the large muscles surrounding the femur account for a large portion of
the applied forces.
Several large muscles attach to the femur which can affect displacement of
certain fracture patterns. Proximally, the gluteus medius and minimus attach to the
greater trochanter. The forces from these muscles may result in an abduction
deformity to the proximal fragment of proximal femoral shaft and subtrochanteric
femur fractures. The iliopsoas attaches to the lesser trochanter, resulting in a flexion
deformity of this same fragment, in fractures occurring below the level of the lesser
trochanter. The linea aspera (rough line on the posterior shaft of the femur)
reinforces the strength of the femur and is an attachment for the gluteus maximus,
adductor magnus, adductor brevis, vastus lateralis, vastus medialis, vastus
intermedius, and short head of the biceps. Distally, the large adductor muscle mass
attaches medially, resulting in an apex lateral deformity seen in certain distal femur
fractures. The medial and lateral heads of the gastrocnemius attach over the
posterior femoral condyles, resulting inflexion deformity in distal-third fractures.
The blood supply enters the femur through metaphyseal arteries and branches
of the profunda femoris artery, penetrating the diaphysis and forming medullary
arteries extending proximally and distally. Healing of femur fracture is enhanced by
the surrounding muscles and soft tissues contributing to local recruitment of blood
supply around the callus. The femoral artery courses down the medial aspect of the
thigh to the adductor hiatus, at which time it becomes the popliteal artery. Injuries
to the artery occur at the level of the adductor hiatus, where soft-tissue attachments
may cause tethering.
high-energy
o most common in younger population
o often a result of high-speed motor vehicle accidents
low-energy
o more common in elderly
Grade 0
Deep abrasion
compartment syndrome
subcutaneous avulsion
Grade 1
Grade 2
Grade 3
Tscherne, 2003
Grade
Description
Grade I
Grade II
Grade II
I
Grade I
V
Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A
report of five hundred and twenty cases. J Bone Joint Surg Am. 1984 Apr;66(4):52939.
OTA Classification
32A - Simple
A1 - Spiral
A2 - Oblique, angle > 30 degrees
A3 - Transverse, angle < 30 degrees
32B - Wedge
B1 - Spiral wedge
B2 - Bending wedge
B3 - Fragmented wedge
32C - Complex
C1 - Spiral
C2 - Segmental
C3 - Irregular
Palpate the pelvis as well as bilateral lower and upper extremities observing
for any deformity, instability, crepitation or pain generation.
Palpate the lumbar spine and heels if the injury involved a fall from a height
to rule out vertebral compression fractures and/or calcaneal fractures.
Assess the patients skin for any abrasions, lacerations or other disruptions;
it is imperative that open fracture is ruled out.
Assess all joints for deformity and any blocks to motion or pain with
motion.
External fixation is often used to hold the bones together temporarily when the skin
and muscles have been injured.
Intramedullary nailing. Currently, the method most surgeons use for treating
femoral shaft fractures is intramedullary nailing. During this procedure, a specially
designed metal rod is inserted into the marrow canal of the femur. The rod passes
across the fracture to keep it in position.
An intramedullary nail can be inserted into the canal either at the hip or the knee
through a small incision. It is screwed to the bone at both ends. This keeps the nail
and the bone in proper position during healing.
Intramedullary nails are usually made of titanium. They come in various lengths
and diameters to fit most femur bones.
(Left) This x-ray shows a healed femur fracture treated with intramedullary
nailing. (Right) In this x-ray, the femur fracture has been treated with plates and
screws.
Recovery
Most femoral shaft fractures take 4 to 6 months to completely heal. Some take even
longer, especially if the fracture was open or broken into several pieces.
3.8 Complication
Complications from Femoral Shaft Fractures
The ends of broken bones are often sharp and can cut or tear surrounding
blood vessels or nerves.
Open fractures expose the bone to the outside environment. Even with good
surgical cleaning of the bone and muscle, the bone can become infected.
Bone infection is difficult to treat and often requires multiple surgeries and
long-term antibiotics.
In addition to the risks of surgery in general, such as blood loss or problems related
to anesthesia, complications of surgery may include:
Infection
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)
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)
CHAPTER IV
DISCUSSION
Diagnose for the closed fracture of Midshaft Femur of the right in this patient
enforced from the history that the patient complains of pain in the right leg after
had traffic accident. Patients jumped from the bathroom and his leg hit the wall.
Patient complaining a pain on his right leg, swollen and hard to move it Patient felt
pain like punctured. Patient brought to a masseuse, symptoms are not reduced.
From the results of physical examination, we found abnormalities in the
right femur. Localist status check on legs below the visible presence of edema,
deformity and the wound has been bandaged with unclean. There is tenderness on
palpation, the dorsalis pedis arterial pulsation is weakened, the difference true right
and left leg length 80 cm / 83 cm, the differences apparent right and left leg length
91 cm / 94 cm and the difference anatomical right and left leg length 34 cm/37 cm.
In the active movement of patients were not
able to
minimal endorotation,
minimal exorotation, and flexion. While in the passive movement, the patient were
not able to perform the minimal flexion, minimal endorotation, minimal
exorotation. At the neurovascular distal examination (NVD) it was not obtained for
pathological reflexes, motor examination by 2/5 (because of right leg pain), there is
no sensory disturbances, and CRT> 2 seconds.
Definitive diagnosis of fracture on the right regio femoral established based
on the results of the x-ray region of the left AP and lateral femoral indicating simple
fracture of 1/3 middle Os. Femur dextra.
From the results of abdominal ultrasonography, in this patient obtained
hepatomegaly and Appear fluid at morison pouch still intra abdominal bleeding.
There are blunt abdominal trauma in this patient.
AP chest X-ray examination, laboratory tests Hb, leucosite, trombosite, Ht,
PT, APTT, GDS, ureum, creatinin intended as preparation if conducted operative
intervention in these patients.
Medical management of the case are: IVFD RL 20 drops per minute, antiinflammatory analgesics: ketorolac 3 x 30 mg IV, antibiotics: cefotaxim 2 x 1 g IV,
anti fibrinolitic : asam traneksamat 3 x 50gr IV. Ketorolac is used as an analgesic to
CHAPTER V
CONCLUSION
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. There are classification of classification
of soft tissue injury in closed fractures by Oestern and Tscherne consist by
grade 0, grade 1, grade 2 and grade 3. And then classification shaft fracture
by Winquist and Hansen consist by grade 0, grade 1, grade 2 grade 3 and
grade 4. Morbidity and mortality rates have been reduced in femoral shaft
fractures, mainly as the result of changes in methods of fracture
immobilization. Current therapies allow for early mobilization, thus
reducing the risk of complications associated with prolonged bed rest.
classification,
clinical
classification,
and
radiological
examination,
vascular
examination
and
radiological
REFERENCES
1. 1. Browner BD, Jupiter JB, Levine AM, Trafton PG. Skeletal Trauma:
Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, PA:
WB Saunders; 1998.
2. Delee JC Jr, Drez D. Orthopaedic Sports Medicine: Principles and Practice.
Philadelphia, PA: WB Saunders; 1993.
3. Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in
patients with isolated femur fractures. J Orthop Trauma. 1992. 6(2):1759. [Medline].
4. Evans FG, Pedersen HE, Lissnwe HR. The role of tensile stress in the
mechanism of femoral fractures. J Bone Joint Surg Am. 1951 Apr. 33A(2):485-501. [Medline].
5. Goodfellow J, O'Connor J. The mechanics of the knee and prosthesis
design. J Bone Joint Surg Br. 1978 Aug. 60-B(3):358-69. [Medline].
6. Brasel KJ, Olson CJ, Stafford RE, Johnson TJ. Incidence and significance of
free fluid on abdominal computed tomographic scan in blunt trauma. J
Trauma. 1998 May. 44(5):889-92. [Medline].
7. Apley, A Grahm dan Solomon, Louis. 1995. Buku Ajar Ortopedi dan
Fraktur Sistem Apley. Edisi ketujuh. Jakarta : Widya Medika.
8. Ruedi, Thomas P dan Murphy. William M, 2000. AO Principles of Fracture
Management. New York : Thieme Stuttgart
9. Hogan TM. Hip and femur. Hart RG, Rittenberry TJ, Uehara DT,
eds. Handbook of Orthopaedic Emergencies. Publishers: Lippincott
Williams & Wilkins; 1999. 307-8.
10. Braten M, Helland P, Myhre HO, Molster A, Terjesen T. 11 femoral
fractures with vascular injury: good outcome with early vascular repair and
internal fixation. Acta Orthop Scand. 1996 Apr. 67(2):161-4.[Medline].