Case Report ortho nurul.pptx

7/27/2019 Case Report ortho nurul.pptx

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CASE REPORT

fracture 1/3 proxsimal of the right femur

Presented by:Nurul Fitrawati Ridwan

Supervisor :dr.

Zulfan O Siregar

Advisordr. Wira

dr. Ikhsan

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University

Makassar2013


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IDENTITY

Name : A F

Age : 14 years old / Male

Admission : October 20th, 2013 at 01.37

Registration : 63 31 15

Status : Jamkesda


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HISTORY TAKING

Chief complaint : pain at the right thigh

Suffered since 3 hours before admited to WahidinGeneral Hospital due to traffic accident. The patientriding a motorcycle and got a crash with a car fromthe left side. The patient fall to the right side.History of unconsciousness (-), vomit (-), nausea (-)


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PRIMARY SURVEY

A : patent

B : RR = 20 x/min, symmetric, spontaneous,

thoracoabdominal typeC : BP = 110/80 mmHg, HR = 88 x/min, regular,

strong

D : GCS 15 (E4M6V5), light reflex +/+, pupilisochors, d = 2,5 mm/ 2,5 mm

E : T = 36,9oC (Axillary)


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SECONDARY SURVEY

Right Thigh RegionI : Wound (-). Deformity (+), swelling (+), hematoma

(+).

P : Tenderness (+)ROM : Active and passive movement of knee joint are

limited due to painActive and passive movement of hip joint are

limited due to painNVD : Sensibility is good.

Pulsation of the dorsalis pedis artery palpable.Tibialis posterior palpable

Capillary refilling time < 2


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SECONDARY SURVEY

nkle sinistra RegionI : Wound (-). Deformity (+), swelling (+), hematoma

(+).

P : Tenderness (+)ROM : Active and passive movement of knee joint are

limited due to painActive and passive movement of hip joint are

limited due to painNVD : Sensibility is good.

Pulsation of the dorsalis pedis artery palpable.Tibialis posterior palpable

Capillary refilling time < 2


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CLINICAL PICTURE

Deforming muscle forces


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RIGHT LEFT

ALL 99 101

TLL 85 82

LLD 2


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RADIOLOGY FINDING

Imaging: fracture 1/3 proximale of the right femur


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RADIOLOGY FINDING

Imaging: closed fracture lateral malleolus medial


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LABORATORY FINDINGS

CBC

WBC: 5.62 (10*3/ul)

RBC: 4.72 (10*6/ul)

PLT: 208 (10*3/ul) HGB: 12.6 g/dl

HCT: 35.9%

Electrolytes:

Na: 136

K: 4.3

Cl: 106

Blood chemistri

Blood glucosa : 95 MG/DL

Ur: 11 mg/l

Cr: 0.5 mg/l GOT : 45

GPT : 24

BT : 800

CT : 230


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RESUME

14 years old man, admitted to Wahidin Hospital with chief complain

pain on the right thigh suffered since 3 hours before admited toWahidin General Hospital due to traffic accident. The patient riding a

motorcycle and suddenly got a crash with a car from the left side. Thepatient fall to there right side

Physical examination :

Wound (-). Deformity (+), swelling (+), hematoma (+).

ROM: Active and passive movement of knee joint are limited dueto pain, Active and passive movement of hip joint are limited dueto pain

NVD: Pulsation of the dorsalis pedis artery palpable. Tibialisposterior palpable. Capillary refilling time < 2, extend big toe (+)

Radiology finding: closed fracture 1/3 proximal at the right femur


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DIAGNOSIS

Closed fracture 1/3 proximal of the right femur


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MANAGEMENT

Analgetic

Splint and traction

Plan for ORIF


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DISCUSSIONFEMORAL SHAFT FRACTURE


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INTRODUCTION

The femoral is the largest tubular bone in the body

and is surrounded by the largest mass of muscle. Femoral shaft fracture occur most frequently in young

men after high-energy trauma and elderly women aftera low energy fall.

Diaphyseal fracture in elderly patients should beconsidered as pathologicaluntil proven otherwise.

Fracture patterns are clues to the type of force that

produced the break.

1. Solomon Louis, Warwick David, Nayagam Selvadurai : Apleys System of Orthopaedics and Fractures 9th Edition

2. Russell R.C.G, Williams Norman S, Bulstrode Christopher J.K Bailey and Love : Short Practice of Surgery3. Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd edition.


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ANATOMY OF FEMUR

Thompson, Jon C. Netters Concise Orthopaedics Anatomy 2nd Edition


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MuscleANTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE

Sartorius ASIS Prox. med. tibia

(pes anserius)

Femoral

Rectus femoralis 1.AIIS

2.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

tomphson, john C.netter' concise atlas of orthopedic anatomy. philadelpia : saunders, 2002.


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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 ramus

2. 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



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POSTERIOR COMPARTMENTMUSCLE 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,

supracon

dylar line

Fibula, lateral

tibia

Sciastic

(peroneal)



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DEFORMING MUSCLE FORCES

Fracture displacement often follows a predictable

pattern dictated by the pull of muscles attached toeach fragments.

In proximal shaft fracture the proximal fragment isflexed, abducted and externally rotated because of

gluteus medius and iliopsoas pull, the distal fragment isfrequently adducted.

In mid-shaft fracture the proximal fragment is againflexed and externally rotated but abduction is less

marked. In lower third fractures the proximal fragments is

adducted and the distal fragment is tilted bygastrocnemius pull.

Solomon Louis, Warwick David, Nayagam Selvadurai : Apleys System of Orthopaedics and Fractures 9th Edition


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Fracture is a break in structural continuity of bone.

It may be no more than a crack, a crumping or asplintering of the cortex ; more often the break

complete and the bone fragmen are displaced.

nayagam, selvadurai.principles of fracture. [book auth.] louis salomon, david warwick and selvadurai nayagam. apley's system of orthopedic and fracturre.

united kingdom : hodder arnold, 2010.

DEFINITION


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Fracture due to a traumatic incident

Direct forced : the bone break at the point of impact, the soft tissue also

must be damaged.

Indirect forced : the bone breaks at a distance from where the forced isapplied , soft tissue damaged at the fracture site is not inevitable.

Fatigue or stress fracture

crack can occur in bone, as in metal and other materials, due to repetitive

stress. This is most often seen in the tibia, fibula, or metatarsal.

Pathological fracture Fracture may occur even with normal stress is the bone has been

weakened by a change in its structure or the presence of the lytic lession.



MECHANISM OF FRACTURE


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MECHANISM OF INJURY


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ayagam, selvadurai.principles of fracture. [book auth.] louis salomon, david warwick and selvadurai nayagam. apley's system

of orthopedic and fracturre. united kingdom : hodder arnold, 2010.

Femoral shaft fractures-Winquistsclassifisation


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Tscherne Classification of Clossed Fracture

CLASSIFICATION of Closed Fracture

Grade 0 : A fracture with little or no soft tissue injury

Grade 1 : a fracture with superficial abrasion or bruisingof the skin and subcutanceous tissue

Grade 2 : more severe fracture with deep soft-tissue

contusion and swellingGrade 3 : severe injury with marked soft-tissue damage

and a threatened compartmeny syndrome.


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DIAGNOSE OF FRACTURE OF THE

FEMUR

History and Mechanism of

Trauma

Physical Examination

X-ray with Anteroposterior/lateral


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TREATMENT

Most fractures in adults, regardless of the age of thepatients, require immediate stabilisation usually withan interlocked intramedullary nail.

In children femoral fractures can be treated withtraction.

Traction with a splint is first aid for a patient with

femoral shaft fractures.

1. Solomon Louis, Warwick David, Nayagam Selvadurai : Apleys System of Orthopaedics and Fractures 9th Edition2. Russell R.C.G, Williams Norman S, Bulstrode Christopher J.K Bailey and Love : Short Practice of Surgery


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TREATMENT

1. Solomon Louis, Warwick David, Nayagam Selvadurai : Apleys System of Orthopaedics and Fractures 9th Edition

Reduce :

Closed reduction

Open reduction

Hold

continuous traction and cast splintage

internal fixtation

eksternal fixtation

Exercise


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COMPLICATION

Early Late

Nerve injury

Vascular injury

Compartment syndrome

Infection

Non union or delayed union

Malunion

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition


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THANK YOU

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Case Report ortho nurul.pptx