CASE REPORT

CLOSED FRACTURE OF MIDSHAFT FEMUR FRACTURES

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian
Ilmu Bedah RSUD Kendal

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

Universitas Islam Sultan Agung ( UNISSULA )

Tingkat

Program Pendidikan Profesi Dokter

Bagian

Ilmu Bedah

Judul

Closed Fracture Of Midshaft Femur Fractures

Kendal, November 2016

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

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 :

22x/minutes ) nothing abnormality

Circulation (C) : Adequate circulation
Disability (D) : E4V5M6 , pupil refleks +/+ isokor
Exposure (E) : Abnormality on lower right extremity

Chief complaints: Cant walked

Present status:
Patient came to emergency room after had accident two months ago.
Patients fell two months ago when he was following the rounders match
on the occasion of Independence Day. Patient complaining a pain on her
right leg, hard to move it. Patient felt pain like punctured. Patient
brought to a masseuse and her leg in a splint with cardboard. Patient

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

General Condition : Looks weak

Awareness: Composmentis, GCS 15
Vital Signs
1. Blood pressure
: 110/70 mmHg
2. Heart rate
: 98 x / minute, regular
3. Temperature
: 36,8oC
4. Breathing
: 22 x / min

Physical Assessment

General Appearance : slightly untidy with discomfort ( due to previous

fall)
Skin : brown, skin turgor normal
Head : mesocephal form, injuries (-)
Eyes : isokor pupil (d : 3mm/3mm), light reflex (+/+), palpebral

conjungtival pallor (-/-), sclera jaundice (-/-) arcus senilis (-/-)

Ears : Discharge (-/-)
Nose : septal deviation (-), discharge (-/-),
Mouth : Normal , cyanosis (-)
Neck : symmetrical, deviation of the trachea (-), enlarged lymph nodes

clear (-), an enlarged thyroid gland (-)

Chest : normochest, symmetrical
Abdomen : lesion (-), tenderness (-)
Extremities : Right leg : edema and covered by unsterile bandage, warm
and the skin wasnt wrinkeled and paled
Motor
5
5
1
5
Sensorik
N
N

N
N

Localized Status of lower extremities in right femoral region:

Look :
o Skin color
: normal
o Edema
: (+)
o Pale and wrinkled
: (-)
o Vulnus
: (-)
o Deformity
: (-)
Feel :
o skin temperature
: warm
o Tenderness
: (+)
o Krepitation
: difficult to evaluate
o Dorsalis pedis artery pulsation
: (+)
o True leg length right / left
: 74 cm / 76 cm
o Apparent leg length right / left
: 84 cm / 86 cm
o Anatomical leg length right/left
: 44 cm/ 47 cm

 Move of femoral dextra :

Aktif :
o Flexion
o Endorotation
o Exorotation

: (-)
: (-)
: (-)

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

X- ray Femoral region dextra AP-lateral

Interpretation : simple fracture of 1/3 middle Os. Femur dextra

V. DIAGNOSE
Close fracture of Midshaft Femur dextra
VI. PLANNING THERAPY
Medical
IVFD RL 20 drops per minute
Analgetic anti inflammation : Ketorolac 3 x 30 mg IV
Antibiotic
: Cefotaxim 2 x 1 gr IV
Anti fibrinolytic
: Asam traneksamat 3x500 gr IV
Non-Medical :
Conservative :

V.

Close reduction long leg casting

NVD evaluation
Vital Sign evaluation
Operative :
Consul to orthopedic
Can be performed ORIF
Post Operative (ORIF)

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.

3.2 Bone healing

Bone healing process (cortical bone on bone length) consists of five phases,
there are :
1. Hematoma phase (within 24 hours arising bleeding)
If a fracture occurs, the small blood vessels that pass through the
canaliculi in system suffered a tear in the area of the fracture and hematoma
will form between the two sides of the fracture. Large hematoma covered by
the periosteum. Periosteum will be motivated and able to experience tears
hematoma that occurred as a result of pressure that can occur extravasation
of blood into soft tissue. Osteocytes with the lacuna, located one millimeter
from that area of blood loss and fractures will die, which would lead to an
avascular area dead bone on the sides of the fracture immediately after the
trauma.

2. Proliferation / inflammation Phase (Occurs 1-5 days after trauma)

Soft tissue reaction occurs around the fracture as a healing reaction.
Healing occurs because of osteogenic cells which proliferate from
perosteum to form callus on the external and internal callus in endosteum
areas as cellular activity in the canal medullaris. In the event of severe
laceration in the periosteum of the healing cells derived from mesenchymal
cells that are not differentiated into soft tissue. In the early stages of fracture
healing by an additional amount of osteogenic cells which provides rapid
growth of malignant tumors.
Soft tissue are not formed from freezing hematoma organization of
a region of the fracture. After a few weeks of the fracture callus will form as
a mass of tissue covering the osteogenic. On radiological examination
contains bone callus yet so it is still a radiolucent area.
3. Callus formation Phase (occurring 6-10 days after trauma)
After the formation of the cellular tissue that grew from each
fragment based on derived from osteoblasts and then on chondroblasts form
the cartilage. Osteoblasts place occupied by the intercellular matrix of
collagen and attachment of polysaccharide by calcium salts formed
immature bones. This bone forms called "woven bone" (an indication of the
first radiological fracture healing).
4. Consolidation phase (2-3 weeks after the fracture to heal)
Woven bone callus will form the primary and gradually transformed
into a more mature bone by the osteoblasts activity and excess callus
lamellar structure can be gradually resorbed.
5. The remodeling phase (time over 10 weeks)
Slowly happening in osteoclastic resorption and osteoblastic process
persists on external callus is slowly disappearing. Intermediates turned into
a bone callus is compact and contains haversian systems and callus inside
will experience to form a marrow space.

3.3 Definition of Fracture

A fracture is a break, usually in a bone. If the broken bone punctures the
skin, it is called an open or compound fracture. Fractures commonly happen
because of car accidents, falls or sports injuries. Other causes are low bone
density and osteoporosis, which cause weakening of the bones. Overuse can
cause stress fractures, which are very small cracks in the bone.
The femur is the largest and strongest bone and has a good blood supply.
Because of this and its protective surrounding muscle, the shaft requires a large
amount of force to fracture. Once a fracture does occur, this same protective
musculature usually is the cause of displacement, which commonly occurs with
femoral shaft fractures.[1]
As with many orthopedic injuries, neurovascular complications and pain
management are the most significant issues in patients who come to the ED.
The rich blood supply, when disrupted, can result in significant bleeding. Open
fractures have added potential for infection.[2]
The 3 types of femoral shaft fractures are as follows:
Type I - Spiral or transverse (most common)
Type II - Comminuted
Type III - Open
Associated injuries are common.

Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.

3.4 Mechanism of injury

Diaphyseal fractures result from significant force transmitted from a direct
blow or from indirect force transmitted at the knee.[3]
Pathologic fractures may occur with relatively little force.[4] These may be
the result of bone weakness from osteoporosis or lytic lesions
traumatic

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

o often a result of a fall from standing

o gunshot
3.5 Classification
Close Fracture

Oestern and Tscherne classification of soft tissue injury in closed fractures

Grade 0

Minimal soft tissue damage

indirect injury to limb (torsion)

simple fracture pattern

Superficial abrasion or contusion

mild fracture pattern

Deep abrasion

skin or muscle contusion

severe fracture pattern

direct trauma to limb

Extensive skin contusion or crush injury

severe damage to underlying muscle

compartment syndrome

subcutaneous avulsion

Grade 1

Grade 2

Grade 3

Tscherne, 2003

Grade

Description

Grade I

no comminution or minimal comminution with a small wedge

fragment < 25% of the circumference of the bone

Grade II

comminuted fracture with a wedge fragment <50% of the

circumference of the bone

Grade II
I

comminuted fracture with a large wedge fragment >50% but less

than 100% of the circumference of the bone

Grade I
V

segmental comminution with no abutment of main fragments

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

3.6 Physical Examination

Physical examination of traumatic femoral fractures
o

Associated injuries must be addressed, and ATLS guidelines must be

followed.

A head-to-toe examination is indicated.

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.

Correct any lower extremity deformity by applying inline longitudinal

traction.

A distal vascular assessment is necessary to rule out a vascular injury.

A distal neurologic assessment is indicated to rule out a nerve injury.

o True leg length - Greater Trochanter of the femur or Anterior Superior Iliac
Spine of pelvis to medial malleolus of ipsilateral leg.
o Apparent leg length - umbilicus or xiphisternum (noting which is used) to
the medial malleolus of ipsilateral leg.
o Anatomical leg length- trochanter major to epicondylus lateralis of
ipsilateral leg.
3.7 Theraphy
External fixation. In this type of operation, metal pins or screws are placed into the
bone above and below the fracture site. The pins and screws are attached to a bar
outside the skin. This device is a stabilizing frame that holds the bones in the proper
position so they can heal.
External fixation is usually a temporary treatment for femur fractures. Because they
are easily applied, external fixators are often put on when a patient has multiple
injuries and is not yet ready for a longer surgery to fix the fracture. An external
fixator provides good, temporary stability until the patient is healthy enough for the
final surgery. In some cases, an external fixator is left on until the femur is fully
healed, but this is not common.

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.

Intramedullary nailing provides strong, stable, full-length fixation.

Plates and screws. During this operation, the bone fragments are first repositioned
(reduced) into their normal alignment. They are held together with special screws
and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible,
such as for fractures that extend into either the hip or knee joints.

(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

Femoral shaft fractures can cause further injury and complications.

The ends of broken bones are often sharp and can cut or tear surrounding
blood vessels or nerves.

Acute compartment syndrome may develop. This is a painful condition that

occurs when pressure within the muscles builds to dangerous levels. This
pressure can decrease blood flow, which prevents nourishment and oxygen
from reaching nerve and muscle cells. Unless the pressure is relieved
quickly, permanent disability may result. This is a surgical emergency.
During the procedure, your surgeon makes incisions in your skin and the
muscle coverings to relieve the pressure.

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.

Complications from Surgery

In addition to the risks of surgery in general, such as blood loss or problems related
to anesthesia, complications of surgery may include:

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)

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

relieve pain experienced by the patient. Ceftriaxon given as an antibiotic to prevent

infection in these patients and given haemostatic to prevent stop bleeding.
Non medical therapy consists of conservative and operative therapy.
Conservative therapy: do immobilization as first aid with close reduction casting
long leg, leg elevation at chest level to prevent complications compartment
syndrome, NVD evaluation to monitor the presence of pain and fracture
complications, and also vital sign. In the operative therapy can do the open
reduction internal fixation (ORIF).

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.

Fracture is the loss of continuity of bone, joint cartilage, epiphyseal

cartilage is both total and partial. Fracture classification is divided into,
etiological

classification,

clinical

classification,

and

radiological

classification. Fracture diagnose is made by history, physical examination,

and local checks in the form of inspection, palpation, movement,
neurological

examination,

vascular

examination

and

radiological

examination. Fracture treatment principle is the recognition, reduction,

retention, and rehabilitation. This treatment will be divided based on closed
fractures and open fractures. In the closed fracture treatment is divided into
conservative and operative treatment. The fracture healing process consists
of five phases, there are hematoma phase, cellular proliferative

subperiosteal and endosteal phase, callus formation phase, the consolidation

phase and remodeling phase.

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