open fracture femur

8/13/2019 Open Fracture Femur

1/31

By:

Nazirul Munir Bin Abu HassanC 111 08 795

Advisors:dr. Fadil

dr. Rico

Supervisor:dr. M. Ruksal Saleh, Ph.D, Sp.OT

OPEN FRACTURE 1/3 PROXIMAL

OF THE RIGHT FEMUR GRADE 1

Department of Orthopaedic dan Traumatology


2/31

Patient Identity

Name : AS

Age : 16 years old

Gender : Male RM : 63 33 14

Date of admission : October 20th 2013


3/31

Anamnesis

Chief Complaint : wound at the right thigh

History of illness : experienced since 3 hourbefore admitted to the Hospital. There are no

history of unconsciousness, severe headache,nausea and vomiting.

Mechanism of Trauma : Patient was ridingmotorcycle then crashed by a car from right side.The patient fall to the left side.

History of Treatment : There is no prior treatment.


4/31

Primary survey

A : Patent

B : RR : : RR=20x/min, symmetrical, spontaneous,thoracoabdominal type

C : pulse : 80x/minute, regular, BP: 120/90mmHg

D :GCS 15:E4M6V5), isochoric pupil 2.5 mm/2.5mm

E :Axillary temperature of 36.7oC


5/31

Secondary Survey

Right Femur region : Inspection: Pin point wound at anterolateral femur,

with size 0,5 x 0,5 cm, deformities (+), swelling (+),

hematom (+).

Palpation : tenderness (+)

ROM: Active and passive movement of hip and knee

joint are limited due to the pain

NVD : Sensibility is good, pulsation of dorsal pedis and

tibilalis posterior artery are palpable, Capillary refill time


6/31

Femur Length Discrepancy

Right Left

ALL 85 87TLL 88 90

LLD 2cm


7/31

Clinical picture


8/31


9/31

Laboratorium Result

Test Result

WBC 18,8 [10^3uL]

RBC 4,97 [10^6uL]

PLT 287 [10^3uL]GDS 116mg/l

CT 6

BT 2,3

Ur/Cr 20/0,7 mg /L

GOT/GPT 74/66 U/L

ElectrolitNaKCl

141 mmc3,4 mmc109 mmc


10/31

X ray of AP/Lateral of Right Femur


11/31

DiagnosisOpen fracture 1/3 Proximal of the Right Femur

grade I


12/31

Management Planning IVFD

Antibiotic

Analgesic

H2-Receptor Blocker Planning : ORIF + Debredement


13/31

ResumeA boy, 16 years old came with a complaint of

pain at the right femur which has been experiencedsince 3 hour due to traffic accident.

On the primary survey, the airway is clear andpatent with normal breathing rate. Pulse and bloodpressure within normal state. He was conscious withGCS 15 and afebris. On inspection, there is a 0,5 cm x0,5 cm pin point wound on anterolateral femur which

accompanied with deformities, swelling andhematom. Wound was tender, active and passivemovement at the knee and hip joint are difficult toevalute due to pain.


14/31

DISCUSSIONOpen Fractureof Femur


15/31

Introduction

Open fracture is a broken bone thatpenetrates the skin or a wound

penetrates down to the broken bone.

Femoral shaft fractures, includingsubtrochanteric and supracondylarfractures

Male : Female = 2,6 : 1

1. Cluett J., M.D.[Cited May 2012] Available at;http://orthopedics.about.com/cs/brokenbones/g/openfracture.htm

2. Beaty J.H, Kassar J.R. Fractures in Children. 7th edition. USA : Williams & Wilkins
http://orthopedics.about.com/cs/brokenbones/g/openfracture.htmhttp://orthopedics.about.com/cs/brokenbones/g/openfracture.htmhttp://orthopedics.about.com/cs/brokenbones/g/openfracture.htm


16/31

Thompson, J. NettersConcise Orthopaedic Anatomy 2ndEdition. Kansas : E lsevier.


17/31

Anterior Compartmen Muscle


Muscle Origin Insertion NerveAnterior

Articularis

genusDistal anterior

femoral shaftSynovial

capsuleFemoral

Sartorius ASIS Prox.med.tibia(pes

anserinusFemoral

QuadricepsRectus

Femoris

1.AIIS

2.Sup.acetab.rim

Patella/Tibial

tubercle

Femoral

Vastus

LateralisGtr.

Trochanter,lat.

Linea asperaLateral

Patella/Tibial

tubercleFemoral

Vastus

IntermediusProximal

femoral shaftPatella/Tibial

tubercleFemoral

Vastus

MedialisIntertrochant

line, med. Linea

asperaMedial

Patella/Tibial

tubercleFemoral


18/31

Medial Compartmen Muscle


Muscle Origin insertion Nerve

Medial

Obturator

externus

Ischiopubic rami, Piriformis fossa Obturator

Hip Adductors

Adductor longus Body of

pubis(inferior)

Linea aspera(

mid 1/3)

Obturator

Adductor brevis Body and inferior

pubic ramus

Pectineal line,l Obturator

Adductor

magnus

1.Pubic ramus

2.ischial tub.

linea aspera,

add. tubercle

1.obturat

or

2.Sciatic

Gracilis Body and inferior

pubic ramus

Prox. Med. Tibia Obturator

Hip Flexors

Pectinus Pectineal line of

pubis

Pevtineal line of

femur

Femoral


19/31

Posterior Compartment Muscle


Muscle Origin Insertion Nerve

Posterior : hamstrings

Semitendinosus Icshial tuberosity Prox. Medial

tibia

Sciatic

Semimembranosus Icshial tuberosity Posterior

medial tibial

condyle

Sciatic

(tibial)

Biceps femoris :

long head

Icshial tuberosity Head of

fibula

Sciatic

(tibial)

Biceps femoris :

short head

Linea

aspera,supracondylarline

Fibula,lateral

tibia

Sciatic

(peroneal)


20/31

Arteries



21/31

MECHANISM OF INJURY

Correlated with age

Before walking age

Child Abuse (70 80% cases) Adolescent

High-velocity MVA (+/- 90% cases)

Minor trauma

e.g osteogenesis imperfecta Stress Fracture

Adolescent athlete (rare)

Herring J.A. TachdjiansPediatric Orthopaedics. 4thEdition. Elsevier


22/31

Gustilosclassification of open fractures :


23/31

Acceptable Angulation


24/31

Clinical Features

Localized tenderness

Swelling

Deformity associated shortening

Open wound

w/o Neurovascular damage.



25/31

RADIOGRAPHIC FINDINGS

AP and Lateral radiographs of entirefemur (include hip and knee joint)



26/31

Management of open fracture

Antibiotics

Debridement

Stabilization

Solomon. L. et al. ApleysSystem of Orthopedics and Fractures 9th Edition.

New York : Arnold. 2010


27/31

NON-OPERATIVE TREATMENT12 y/o to maturity

1. Inapproriate.

2. Hip spica cast application is impossible andtraction often requires a skeletal pin andconsiderable time.

Femoral shaft fractures in children; James B. Hunter; Injury, Int. J. Care Injured

(2005) 36, S-A86S-A93 [Cited on April 2009] Available at :

http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/paediatric/p%20f

emur/p%20femur.htm


28/31

OPERATIVE TREATMENT

The indications for operative :

Definite:

Open fractures.

Major bone loss. Neurovascular injury.

Compartment syndrome.

Failure of conservative treatment.

Solomon. L. et al. ApleysSystem of Orthopedics and Fractures 9th Edition. New

York : Arnold. 2010


29/31

Treatment for 12 y/o tomaturity

Trochanteric-entry intramedullary rod

Flexible intramedullary nails

Open reduction Internal fixation

External fixation (rare)

Beaty J.H, Kassar J.R. Fractures in Children. 7th edition. USA : Williams &

Wilkins


30/31

COMPLICATION

Leg-Length Discrepancy

Physeal Injury

Compartment Syndrome

Infection

Beaty J.H, Kassar J.R. Fractures in Children. 7th edition. USA : Williams & Wilkins


31/31

THANK YOU

open fracture femur

Documents