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case reportTRANSCRIPT
Open Fracture 1/3 Distal femur (S) grade IIIA Open Fracture 1/3 Distal femur (S) grade IIIA Closed Fracture 1/3 Distal tibia (S) Closed Fracture 1/3 Distal tibia (S) Closed Segmental Fracture Fibula (S) Closed Segmental Fracture Fibula (S)
Presented by :
Hasmia
Advisor
dr. Benny Murtaza
dr. Jecky Chandra
Supervisordr. M.Ruksal Saleh, Ph.D, Sp.OT
Patient IdentityPatient Identity
Name : Mr. EAge : 16 years oldSex : MaleAdmittance : 20 July 2012Address : Parigi, MarosOccupation : StudentRM number : 55 51 42
History TakingHistory TakingChief complaint : wound at the left
lightAnamnesis : suffered since + 4 hours
before admitted to Wahidin Sudirohosodo hospital due to traffic accident.
Injury mechanism : He was riding a motocycle, and then hit the tree.
History of unconsciousness (-), nausea (-), vomit (-).
A : Patent, clearB : RR = 18 x/min, simetris,
spontaneous, thoracoabdominal type.
C : BP: 90/60 mmHg, PR= 88 x/min regular, strong.
D : GCS 15 (E4V5M6), pupil isochors Ø 2,5mm/2,5 mm, light reflex +/+
E : T = 36,7 0 C (axillar)
Primary Survey
Secondary SurveySecondary SurveyFemur sinistra region :I : Lacerated wound at anterior aspect, size 10 cm x 5 cm, deformity (+), swelling
(+), hematoma (+), muscle exposed (+), bone exposed (+).
P : Tenderness (+)ROM : active and passive motion at knee
and ankle joint are limited due to painNVD : sensibility is good, the pulse of
dorsalis pedis artery is palpable, capillary refill time < 2”
Cruris sinistra region :I : Lacerated wound at anterior aspect, size 2 cm x 2 cm, deformity (-), swelling (-),
hematoma (-), muscle exposed (-), bone exposed (-).
P : Tenderness (+)ROM : active and passive motion at knee
and ankle joint are limited due to painNVD : sensibility is good, the pulse of
dorsalis pedis artery is palpable, capillary refill time < 2”
Cruris dextra region :I : Lacerated wound at anterior aspect,
size 2 cm x 1 cm, deformity (-),
swelling (-), hematoma (-), muscle exposed (-), bone exposed (-). abration wound at anterior aspect, size 2cm x 2cm, deformity (-), hematoma(+),
Leg Leg LLength ength DDiscrepancy iscrepancy
R L
ALL 72 cm 70 cm
TLL 67 cm 65 cm
LLD 2 cm
WBC 7,40 x 103 /uL RBC 4,11 x 106 /uL HGB 11,4 g/dL PLT 661 x 103 /uL GDS 67 mg/dl Ureum 28 mg/dl Creatinin 0,5 mg/dl SGOT 19 u/l SGPT 12 u/l
Radiological Radiological FindingsFindings
• Open Fracture 1/3 Distal femur (S) grade IIIA Open Fracture 1/3 Distal femur (S) grade IIIA • Closed Fracture 1/3 Distal tibia (S) Closed Fracture 1/3 Distal tibia (S) • Closed Segmental Fracture Fibula (S) Closed Segmental Fracture Fibula (S)
ManagementManagementIVFD RL AntibioticAnalgesicDebridement
Planning :Plan for ORIF
ResumeResumeA 13 years old with Deformity (+)
edema (+) and tenderness at the antebrachii region, limited active and passive motion of elbow and wrist joint due to pain. Deformity (+) edema (+) and tenderness at the femoral region and limited active and passive motion of hip joint and knee joint due to pain. Sensibility is good, dorsalis pedis artery palpable, Capillary refill time < 2”. Radiological finding with distal fracture of left radius and left ulna, distal fracture of right radius, and comminuted fracture of left femur shaft.
The diagnosis are Closed Fracture 1/3 distal of the Left Radius and Left Ulna, Closed Fracture 1/3 distal of the right Radius, and Closed comminuted fracture 1/3 middle of the Left Femur.
Fracture in Fracture in PediatricsPediatrics
Femur Shaft Femur Shaft Fracture in Fracture in
ChildrenChildren
Introduction Introduction Fracture of the femur are quite
common and are usually due to direct violence or a fall from high.
Between 1 and 4 years of age, 30 % of femoral shaft fracture are attributed to abuse.
In the adolescent age group, high velocity motor vehicle accidents are more often the mechanism of injury and account for up to 90% of all femoral shaft fractures.
ANATOMY ANATOMY OF OF FEMURFEMUR
Muscles Compartment of the Muscles Compartment of the FemurFemur
ANTERIOR COMPARTMENT
MUSCLE ORIGIN INSERTION NERVE
Sartorius ASIS Prox. med. tibia (pes anserius)
Femoral
Rectus femoralis
1.AIIS2.Sup. acetab. rim
Patella/tibia tubercle
Femoral
Vastus lateralis
Gtr. trochanter, lat. linea aspera
Lat. patella/tibia tubercle
Femoral
Vastus intermedius
Proximal femoral shaft
Patella/tibia tubercle
Femoral
Vastus medialis
Intertrochant. line, med. linea aspera
Medial patella/tibia tubercle
Femoral
Muscles Compartment of the Muscles Compartment of the FemurFemur
MEDIAL COMPARTMENT
MUSCLE ORIGIN INSERTION NERVE
Obturator externus
Ischiopubic rami, obturator memb
Piriformis fossa Obturator
Adductor longus
Body of pubis (inferior)
Linea aspera (mid 1/3)
Obturator
Adductor brevis
Body and inferior pubic ramus
Pectineal line, linea aspera
Obturator
Adductor magnus
1.Pubic ramus2. Isxhial tub.
Linea aspera, add. tubercle
1.Obturator
2.Sciastic
Gracilis Body and inferior pubic ramus
Prox. med. tibia (pes anserius)
Obturator
Pectineus
Pectineal line of pubis
Pectineal line of femur
Femoral
Muscles Compartment of Muscles Compartment of the Femurthe FemurPOSTERIOR COMPARTMENT
MUSCLE ORIGIN INSERTION NERVE
Semitendinosus
Ischial tubersity
Proximal medial tibia (pes anserius)
Sciastic (tibial)
Semimembranosus
Ischial tubersity
Posterior medial tibial condyle
Sciastic (tibial)
Biceps femoris : Long head
Ischial tubersity
Head of fibula Sciastic (tibial)
Biceps femoris :Short head
Linea aspera, supracondylar line
Fibula, lateral tibia
Sciastic (peroneal
)
Classification of FractureClassification of FractureDescriptive Open versus closed Level of fracture: proximal, middle,
distal third Fracture pattern: transverse, spiral, or
obliqueComminuted, segmental or butterfly fragment
Angulation or rotation deformity Displacement : shortening or translation
Winquist & Hansen Winquist & Hansen Classification Classification
Stable0 : No comminutionI : Minimal comminutionII : Comminuted > 50% of cortices intact
UnstableIII : Comminuted < 50% of cortices intactIV : Complete comminution, no intact cortex
Mechanism of Mechanism of InjuryInjury
Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse are causes.
Indirect trauma: Rotational injury.
Pathologic fractures: Causes include osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors.
Clinical EvaluationClinical EvaluationPatients with a history of high-energy
injury should undergo full trauma evaluation as indicated.
The presence of a femoral shaft fracture results in an inability to ambulate, with extreme pain, variable swelling, and variable gross deformity.
A careful neurovascular examination is essential.
Radiologic EvaluationRadiologic Evaluation
Anteroposterior (AP) and lateral views of the femur should be obtained.
Radiographs of the hip and knee should be obtained to rule out associated injuries
TreatmentTreatmentGuideline Age0 to 6 Months : Pavlik Harness7 Months to 5 Years : Closed Reduction
with Spica Cast Application, Skin or Skeletal Traction, Flexible Intramedullary Rods.
6 to 10 Years : Open Reduction with Flexible Rods.
11 Years to Skeletal Maturity : Flexible Intramedullary Rodding, Submuscular Plate Fixation, Rigid Intramedullary Rodding.
ComplicationComplicationCommonLimb Length InequalityUnacceptable AngulationRotational DeformitiesNon-union and Delayed UnionRareCompartment SyndromeInfectionInflamationVascular Injury
TIBIA FRACTURE IN TIBIA FRACTURE IN CHILDRENCHILDRENTibia fractures represent the third most
common pediatric long bone fracture, after femur and forearm fractures.
They represent 15% of pediatric fractures.
The average age of occurrence is 8 years of age.
Of these fractures, 30% are associated with ipsilateral fibular fractures.
Ratio of incidence in boys and girls is 2:1.