November 2012

CASE REPORT: OPEN FRACTURE 1/3 MIDDLE OF THE RIGHT FEMUR

Written By: Kaharuddin (C 111 06 147) Mentors: dr.Arnold dr. Rizqi Supervisor: dr. Zulfan Oktasatria Siregar, Sp.OT

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY MAKASSAR 2012

PATIENT IDENTITY

Name Age 17 years Sex Female

: Mrs. H : Right Left old :

Date of admittance : 20 November 2012 MR Number : 579658

HISTORY Chief Complaint History of illness : wound at right leg : Suffered since 5 hours before admitted to the hospital

because due to traffic accident. Mechanism of trauma : The patient was ride a motorcycles and then hit the car from the right and the patient fell to the right. History of unconsciousness (-), nausea (-) vomiting (+).

PHYSICAL EXAMINATION PRIMARY SURVEY Airway Breathing Circulation Disability : patent : RR=20x/min, symmetrical, spontaneous, thoracoabdominal type : BP=100/60 mmHg, P=82x/minute regular and strong : GCS 15 (E4M6V5), isochoric pupil 2.5 mm/2.5 mm

Environment : Axillary temperature of 36.5oC

SECONDARY SURVEY (LEFT FEMUR REGION) Inspection : deformity (-), hematoma (+), swelling (+), wound (+) Palpation ROM NVD : Tenderness (+) : Active and passive motion of hip joint and knee joint limited by pain : Sensibility is good, dorsalis pedis artery and tibialis posterior artery palpable, Capillary refill time <2

LEG

ALL TLL LLD

81 71 1 cm

82 72

DISCREPANCY

CLINICAL PICTURE

LABORATORY FINDINGS WBC : 9,59. 103/uL HGB : 12,9 g/dl RBC PLT CT BT : 4,34.106 : 182.103/uL : 530 : 230

RADIOLOGICAL FINDINGS Pelvic X-Ray AP Position

Right Femur AP/Lateral Position

DIAGNOSIS

Open fracture 1/3 middle of the right femur MANAGEMENT IVFD RL Analgetic Antibiotic and anti tetanus serum Wound toilet Immobilization -> Skin Traction load 2 kg Plan for ORIF

RESUME Women 17 years old come to the hospital with chief complaint wound at right leg. Suffered since 5 hours before admitted to Wahidin Hospital due to traffic accident The patient was ride a motorcycles and then hit the car from the right and the patient fell to the right. History of unconsciousness (-), nausea (-) vomiting (+). wound (+), deformity (+), hematoma (+), and edema (+), tenderness (+). Active and passive motion at hip and knee joints was limited by the pain. Sensibility is good, dorsalis pedis artery is palpable, capillary refill time <2

DISCUSSION:

FRACTURE OF THE FEMUR SHAFT

1. Introduction 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. The femoral shaft is circumferentially padded with large muscles. This provides advantages and disadvantages reduction can be difficult as muscle contraction displaces the fracture; however, healing potential is improved by having this well-vascularized sleeve containing a source of mesenchymal stem cells, and open fractures often need no more than split thickness skin grafts to obtain satisfactory cover. 2. Anatomy of the Femur The primary bone of the thigh is the femur, which is also the longest bone in the body. The femur has the following characteristic features: o The femoral head articulates with the acetabulum of the hip bone at the hip joint. It extends from the femoral neck and is rounded, smooth and covered with articular cartilage. This configuration permits a wide range of movement. The head faces medially, upwards and forwards into the acetabulum. The fovea is the central depression on the head to which the ligamentum teres is attached. o The femoral neck forms an angle of 125 with the femoral shaft.. o The femoral shaft constitutes the length of the bone. At its upper end it carries the greater trochanter and, posteromedially, the lesser trochanter. Anteriorly the rough trochanteric line, and posteriorly the smooth trochanteric crest, demarcate the junction between the shaft and neck. The linea aspera is the crest seen running longitudinally along the posterior surface of the femur splitting in the lower portion into the supracondylar lines. The medial supracondylar line terminates at the adductor tubercle. o The lower end of the femur comprises the medial and lateral femoral condyles. These bear the articular surfaces for articulation with the tibia at the knee joint. The lateral condyle is more prominent than the medial. This prevents lateral displacement of the patella. The condyles are separated posteriorly by a deep intercondylar notch. Anteriorly the lower femoral aspect is smooth for articulation with the posterior surface of the patella.

Picture 1. The Femur

The thigh is divided into three compartments, the anterior, medial and posterior compartment: o Anterior Compartment: the anterior compartment of the thigh is comprised of muscles that function as hip flexors and knee extensors such as sartorius, iliacus, psoas, pectineus and quadriceps femoris. The main artery in this compartment is the femoral artery, and the nerve found within this compartment is the femoral nerve.

Picture 2. The Anterior Compartment of the Thigh o Medial Compartment: comprises of muscles that function as hip adductors which are the gracilis, adductor longus, adductor brevis, adductor magnus and obturator externus muscle. The artery within this compartment is the deep femoral artery while the nerve found within this compartment is the obturator nerve. o Posterior Compartment: the posterior compartment contains the hamstring muscles which function for knee flexion and hip extension. They include: biceps femoris, semitendinosus, semimembranosus and the hamstring part of adductor magnus. The nerve found in this compartment is the sciatic nerve. 3. Types of Femur Shaft Fractures Fractures of the femur shaft can be classified based on the configuration of the fracture. As shown in the picture below, fractures of the femur shaft can be in the form of a transverse, spiral, comminuted, or segmental fracture.

Picture 3. Fracture of Shaft Femur

4. Etiology The mechanism of injury :

Femoral shaft fractures in adults are almost always the result of high-energy trauma. These fractures result from motor vehicle accident, gunshot injury, or fall from a height.

Pathologic fractures, especially in the elderly, commonly occur at the relatively weak metaphyseal-diaphyseal junction. Any fracture that is inconsistent with the degree of trauma should arouse suspicion for pathologic fracture.

Stress fractures occur mainly in military recruits or runners. Most patients report a recent increase in training intensity just before the onset of thigh pain.

5. Clinical Evaluation

Because these fractures tend to be the result of high-energy trauma, a full trauma survey is indicated.

The diagnosis of femoral shaft fracture is usually obvious, with the patient presenting nonambulatory with pain, variable gross deformity, swelling, and shortening of the affected extremity.

A careful neurovascular examination is essential, although neurovascular injury is uncommonly associated with femoral shaft fractures.

Thorough examination of the ipsilateral hip and knee should be performed, including systematic inspection and palpation. Range-of-motion or ligamentous testing is often not feasible in the setting of a femoral shaft fracture and may result in displacement. Knee ligament injuries are common, however, and need to be assessed after fracture fixation.

Major blood loss into the thigh may occur. The average blood loss in one series was greater than 1200 mL, and 40% of patients ultimately required transfusions. Therefore, a careful preoperative assessment of hemodynamic stability is essential, regardless of the presence or absence of associated injuries.

6. Radiologic Evaluation

During the radiological evaluation of a pediatric femur shaft fracture, there are several principles that should be kept in mind:
o o

Anteroposterior and lateral views of the femur should be obtained. Radiographs of the hip and knee should be obtained to rule out associated injuries; intertrochanteric fractures, femoral neck fractures, hip dislocation, physeal injuries to the distal femur, ligamentous disruptions, meniscal tears, and tibial fractures have all been described in association with femoral shaft fractures.

Magnetic resonance imaging and bone scans are generally unnecessary but may aid in the diagnosis of otherwise occult nondisplaced, buckle, or stress fractures.

7. Management
o o

These are typically the result of high-energy trauma. Patients frequently have multiple other orthopaedic injuries and involvement of several organ systems.

o o

Treatment is emergency debridement with skeletal stabilization. Stabilization can usually involve placement of a reamed IM nail.

8. Complications Nerve injury: This is uncommon because the femoral and sciatic nerves are encased in muscle throughout the length of the thigh. Most injuries occur as a result of traction or compression during surgery. Vascular injury: This may result from tethering of the femoral artery at the adductor hiatus. Compartment syndrome: This occurs only with significant bleeding. It presents as pain out of proportion, tense thigh swelling, numbness or paresthesias to medial thigh (saphenous nerve distribution), or painful passive quadriceps stretch. Infection (<1% incidence in closed fractures): The risk is greater with open versus closed IM nailing. Grades I, II, and IIIA open fractures carry a low risk of infection with IM nailing, whereas fractures with gross contamination, exposed bone, and extensive soft tissue injury (grades IIIB, IIIC) have a higher risk of infection regardless of treatment method.

 Refracture: Patients are vulnerable during early callus formation and after hardware removal. It is usually associated with plate or external fixation. Nonunion and delayed union: This is unusual. Delayed union is defined as healing taking longer than 6 months, usually related to insufficient blood supply (i.e., excessive periosteal stripping), uncontrolled repetitive stresses, infection, and heavy smoking. Nonunion is diagnosed once the fracture has no further potential to unite. Malunion: This is usually varus, internal rotation, and/or shortening owing to muscular deforming forces or surgical technique. Fixation device failure: This results from nonunion or cycling of device, especially with plate fixation. Heterotopic ossification may occur

DAFTAR PUSTAKA

1. 2.

Koval KJ, Zuckerman JD. In : Handbook of Fractures Third Edition. USA : Lippincott Williams & Wilkins. 2002 Solomon. L. et al. Apleys System of Orthopaedics and Fractures 9th Edition. New York : Arnold. 2010