Referat Bedah Gari New

PREFACE

Thank to Almighty God who has given His bless to the writer for finishing this referat assignment entitled Fracture Femur in Children , as a series of tasks in the Registrar of Clinical Medical Surgical in RSUD Koja North Jakarta.

In this moment author would like say thankyou to dr.Arsanto.T,Sp.OT,Fics K-Spine,MH.Kes as the advisor that helping author making this referat. And doesnt forget also thank to all doctors counselors at RSUD Koja on the guidance that writers get during in clinical work.

The author realizes that this referat is not perfect, and there are still many shortcomings that must be corrected. Therefore, the expected aid of the doctor advisor and fellow students to provide advice and useful input for the author.

Jakarta, April 2015

Author

CHAPTER I

INTRODUCTION

Femoral fracture is the most common orthopedic injuries of children and required hospitalization. Epidemiological studies from Indiana in 2006 mentioned from almost 10.000 femoral fracture, 1076 (11%) occurred in children aged less than 2 years, 2119 (21%) in children aged 2 to 5 years, 3237 (33%) in children aged 6 up to 12 years, and 3528 (35%) in adolescents aged 13 to 18 years. 71% of incident femoral fracture occurred in males with two-thirds cause of the motorcycle accident. Incidence of fall drive greater occurred in young people and incidence of collision was more common in adults. 15% of femoral fractures occurred in children less than 2 years due to child abuse.1

Pediatric femoral fracture is one of the most prevalent kinds of fractures with an incident rate of 1.6% and about 4% of them are open fractures and most of these fractures (90%) are resulted from high energy trauma. Studies also show that these fractures are associated with more complications. Therefore, it is important to do special treatment as well as improved safety for children considering the complications due to a femoral fracture seriously can cause shock, a fat embolism and disruptions of growth if there is epiphysis plate injury. The following will discuss about the treatment of femoral fracture on children.1,2

CHAPTER II

REVIEW OF LITERATUREA. FEMUR ANATOMY

Thefemuris the longest and strongest bone in the skeleton, is almost perfectly cylindrical in the greater part of its extent. In the erect posture it is not vertical, being separated above from its fellow by a considerable interval, which corresponds to the breadth of the pelvis, but inclining gradually downward and medialward, so as to approach its fellow toward its lower part, for the purpose of bringing the knee-joint near the line of gravity of the body. The degree of this inclination varies in different persons, and is greater in the female than in the male,on account of the greater breadth of the pelvis. The femur, like other long bones, is divisible into a bodyandtwo extremities.1

Picture 1. Right femur. Anterior surface.

The upper extremity presents for examination ahead,aneck,agreaterand alesser trochanter.

The Head (caput femoris).The head which is globular and forms rather more than a hemisphere, is directed upward, medialward, and a little forward, the greater part of its convexity being above and in front. Its surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, thefovea capitis femoris,which is situated a little below and behind the center of the head, and gives attachment to the ligamentum teres.1,3

Picture 2 . Upper extremity of right femur viewed from behind and above.

The Neck (collum femoris).The neck is a flattened pyramidal process of bone, connecting the head with the body, and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the body of the bone. In the adult, the neck forms an angle of about 125 with the body, but this varies in inverse proportion to the development of the pelvis and the stature. In the female, in consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right angle with the body than it does in the male. The angle decreases during the period of growth, but after full growth has been attained it does not usually undergo any change, even in old age; it varies considerably in different persons of the same age. It is smaller in short than in long bones, and when the pelvis is wide. In addition to projecting upward and medialward from the body of the femur, the neck also projects somewhat forward; the amount of this forward projection is extremely variable, but on an average is from 12 to 14.3-4The Trochanters.The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. They are two in number, the greater and the lesser.

TheGreater Trochanter(trochanter major; great trochanter) is a large, irregular, quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It has two surfaces and four borders. Thelateral surface,quadrilateral in form, is broad, rough, convex, and marked by a diagonal impression, which extends from the postero-superior to the antero-inferior angle, and serves for the insertion of the tendon of the Glutus medius. Above the impression is a triangular surface, sometimes rough for part of the tendon of the same muscle, sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and behind the diagonal impression is a smooth, triangular surface, over which the tendon of the Glutus maximus plays, a bursa being interposed. Themedial surface,of much less extent than the lateral, presents at its base a deep depression, thetrochanteric fossa(digital fossa), for the insertion of the tendon of the Obturator externus, and above and in front of this an impression for the insertion of the Obsturatorinternus and Gemelli. Thesuperior borderis free; it is thick and irregular, and marked near the center by an impression for the insertion of the Piriformis. Theinferior bordercorresponds to the line of junction of the base of the trochanter with the lateral surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to the upper part of the Vastus lateralis. Theanterior borderis prominent and somewhat irregular; it affords insertion at its lateral part to the Glutus minimus. Theposterior borderis very prominent and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa.TheLesser Trochanter(trochanter minor; small trochanter) is a conical eminence, which varies in size in different subjects; it projects from the lower and back part of the base of the neck. From its apex three well-marked borders extend; two of these are aboveamedial continuous with the lower border of the neck, alateralwith the intertrochanteric crest; the inferior borderis continuous with the middle division of the linea aspera. Thesummitof the trochanter is rough, and gives insertion to the tendon of the Psoas major.The Body or Shaft (corpus femoris).The body, almost cylindrical in form, is a little broader above than in the center, broadest and somewhat flattened from before backward below. It is slightly arched, so as to be convex in front, and concave behind, where it is strengthened by a prominent longitudinal ridge, thelinea aspera.It presents for examination three borders, separating three surfaces. Of the borders, one, the linea aspera, is posterior, one is medial, and the other, lateral.Thelinea asperais a prominent longitudinal ridge or crest, on the middle third of the bone, presenting a medial and a lateral lip, and a narrow rough, intermediate line. Above, the linea aspera is prolonged by three ridges. The lateral ridge is very rough, and runs almost vertically upward to the base of the greater trochanter. It is termed thegluteal tuberosity,and gives attachment to part of the Glutus maximus: its upper part is often elongated into a roughened crest, on which a more or less well-marked, rounded tubercle, thethird trochanter,is occasionally developed. The intermediate ridge orpectineal lineis continued to the base of the lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea aspera is prolonged into two ridges, enclosing between them a triangular area, thepopliteal surface,upon which the popliteal artery rests. Of these two ridges, the lateral is the more prominent, and descends to the summit of the lateral condyle. The medial is less marked, especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit of the medial condyle, in a small tubercle, theadductor tubercle,which affords insertion to the tendon of the Adductor magnus.Theanterior surfaceincludes that portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex, broader above and below than in the center. From the upper three-fourths of this surface the Vastus intermedius arises; the lower fourth is separated from the muscle by the interventionof the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu takes origin. Thelateral surfaceincludes the portion between the lateral border and the linea aspera; it is continuous above with the corresponding surface of the greater trochanter, below with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin. Themedial surfaceincludes the portion between the medial border and the linea aspera; it is continuous above with the lower border of the neck, below with the medial side of the medial condyle: it is covered by the Vastus medialis.The Lower Extremity (distal extremity)

The lower extremity, larger than the upper, is somewhat cuboid in form, but its transverse diameter is greater than its antero-posterior; it consists of two oblong eminences known as thecondyles.In front, the condyles are but slightly prominent, and are separated from one another by a smooth shallow articular depression called thepatellar surface;behind, they project considerably, and the interval between them forms a deep notch, theintercondyloid fossa.Thelateral condyleis the more prominent and is the broader both in its antero-posterior and transverse diameters, themedial condyleis the longer and, when the femur is held with its body perpendicular, projects to a lower level. When, however, the femur is in its natural oblique position the lower surfaces of the two condyles lie practically in the same horizontal plane. The condyles are not quite parallel with one another; the long axis of the lateral is almost directly antero-posterior, but that of the medial runs backward and medialward. Their opposed surfaces are small, rough, and concave, and form the walls of the intercondyloid fossa. This fossa is limited above by a ridge, theintercondyloid line,and below by the central part of the posterior margin of the patellar surface. The posterior cruciate ligament of the knee-joint is attached to the lower and front part of the medial wall of the fossa and the anterior cruciate ligament to an impression on the upper and back part of its lateral wall. Each condyle is surmounted by an elevation, the epicondyle. Themedial epicondyleis a large convex eminence to which the tibial collateral ligament of the knee-joint is attached. At its upper part is the adductor tubercle, already referred to, and behind it is a rough impression which gives origin to the medial head of the Gastrocnemius. Thelateral epicondyle,smaller and less prominent than the medial, gives attachment to the fibular collateral ligament of the knee-joint. Directly below it is a small depression from which a smooth well-marked groove curves obliquely upward and backward to the posterior extremity of the condyle. This groove is separated from the articular surface of the condyle by a prominent lip across which a second, shallower groove runs vertically downward from the depression. In the fresh state these grooves are covered with cartilage. The Popliteus arises from the depression; its tendon lies in the oblique groove when the knee is flexed and in the verticalgroove when the knee is extended. Above and behind the lateral epicondyle is an area for the origin of the lateral head of the Gastrocnemius, above and to the medial side of which the Plantaris arises.

Picture 2a. Lower extremity of right femur viewed from below.

There is a fundamental difference between fractures in children with fractures in adults, such differences in anatomy, biomechanics, and bone physiology. In children between the epiphysis and metaphysis are epiphyseal plate as congenital growth area. Epiphyseal plate will disappear in adults, so epiphyseal and metaphysical will converge at that moment will stop the growth of bone lengthening.Long bones consist of: epiphyseal, metaphysical and diaphysis. Epiphysis is the very top of the long bones, metaphysical is the part that is wider than the ends of long bones, which is adjacent to the discus epifisialis, while the diaphysis is part of the long bones in the form of primary ossification centers.The whole bone covered by a fibrous layer called the periosteum, which contains cells that can proliferate and play a role in the growth process transversal long bones. Most of the long bones have nutritional artery. The location and the integrity of the blood vessels that determine the success or failure of the process of healing a broken bone.In children, there is an epiphyseal plate cartilage growth. Periosteum is very thick and strong which in the process of bone callus helding will produce rapid and greater than adults.

B. DEFINITION OF FRACTUREFracture is the breaking continuity of the bones tissues determined according to the type and extent usually caused by the forced movement or external pressure which comes greater than what is acceptable by bone.1,3,5To find out why and how the bone fractures occur, physical condition of bone and traumatic circumstances that can lead to bone fractures must be known in advance. Cortical bone has a structure that can withstand the compression and the pressure of shearing.

Most of fracture occurs due to failure of the bone hold the bending, twisting, and pulling of trauma that is directly or indirectly. Immediate trauma causing pressure directly on bone and fracture occurs in the area of pressure. A fracture that occurs usually tends to be comunitive and soft tissue are also damaged while the indirect trauma occurs when the trauma delivered to areas further away from the fractures, for example fell by hand extensions can cause fracture of clavicle. In these circumstances typically soft tissue remains intact.Pressure on the bones can be in form of : (1) rotating pressure that can causes oblique or spiral fracture, (2) bending pressure causing transversal fracture, (3) the pressure along the length of the bone that can lead to impaction fracture or dislocation, (4) vertical compression fracture can cause comunitive or split fracture, for example on the vertebrae, (5) direct trauma accompanied with resistance at a certain distance will cause an oblique fracture or Z fracture, (6) trauma due to the pull of the ligaments or tendons will draw some bones.6C. CLSSIFICATION OF FRACTUREFracture can be distinguished based on the connection with the surrounding bone tissue, bone fracture shape, and location of the physical bones.5Based on the connection of bone with surrounding bone tissue:1. Closed fracture : there is no connection between the bone fragments with the outside bone.

2. Open fracture : when there is a connection between the bone fragments with outside bone due to an injury of the skin.

D. FEMORAL FRACTUREFemoral fracture is the break of bone continuity groin can be caused by direct trauma (traffic accidents, falls from high place), muscle fatigue and certain conditions such as osteoporosis /degeneration of bone. There are 2 types of femur fracture : 31. Intracapsuler fracture : fracture that occurs in the joints, the pelvic and the capsule.

a. through the head of the femur (capital fracture)

b. Only below of the head femur

c. Through the neck of the femur2. Extracapsuler Fracture;a. Occur outside of the joint and capsule, through the larger trochanter femur / smaller/ on intertrochanter area.b. Occurs in the distal part of the femur to the neck but not more than 2 inches below the small trochanter.

E. ETIOLOGY OF FEMORAL FRACTURES Based on the causes of femoral fractures, can be divided into three based on major of trauma causes:1. High energy trauma or trauma due to considerable energy, the type of accidents that cause this type of fracture including vehicle accident trauma (accident motorcycle, car accidents, plane crashes, etc.); sports-especially those related to speed such as: skiing, bike racing, mountain climbing; falling, falling from a high place; and gunshot wounds.

2. Low energy trauma or trauma due to weak energy, because the structure of the femur is strong enough structures, there is a tendency trauma due to weak energy is mainly due to loss of bone strength, especially in people who experience a decrease in bone density due to osteoporosis; bone metastasis of cancer patients and people taking long-term corticosteroids are also at high risk of femur fractures for bone strength will be reduced.

3. Stress fracture or fracture due to pressure, the third cause of femur fractures is repeated stress or trauma. This kind of trauma resulting in different types of fractures as usually happens gradually. Repetitive stress trauma resulting in internal damage of the structure of bone architecture. This type of fracture often occurs on athletes or on the military people who undergo weight training. This type of fracture typically affects the area of the corpus femoris.F. PATHOPHYSIOLOGY OF FRACTUREChildren fracture is usually as a result of trauma from motor vehicle accidents, falls, or soft on child maltreatment. Soft tissue is usually still flexible, so that fractures occur more frequently than tissue injury (Muscari, 2001). Fractures can be also caused by the impulse directly on bone, underlying pathological condition such as rickets which lead to spontaneous fractures, strong and sudden muscle contraction, and another indirect encouragement (Betz and Sowden, 2004). Another causes are metastatic of neuroblastoma, embryo deficiency, osteomyelitis, an injury due to overdose and immobilization which leads to osteoporosis.These fractures occur when bone resistance against pressure transported by the pressure force. The most common fractures seen in children are:71. Bend Fracture

Characterized by bending at the point of the broken bones and cannot be corrected without intervention.

2. Buckle Fracture

Caused by compression of the bone failure characterized by bones that break through himself

3. Greenstick Fracture

An incomplete fractureFractures usually causes bone cells will be damaged and causes bleeding in the area of the fracture that cause multiple fractures of the soft tissue in the area are damaged. When a fracture occurs, it will activate the inflammatory response and causes the release of leukocytes agent, white blood cells, and mast cells to repair the fracture condition. The release of the inflammatory agent causes an increase in blood flow to the area of the fracture and causes vasodilatation of blood vessels in the area that causes the heat, redness and swelling. As the inflammatory response, fibrin will form a mesh for new cells and cause stimulated ostevlas and will form callus and later they will form true bone.G. CLASSIFICATION OF FEMORAL FRACTURES ON CHILDREN

1. Femoral Subtrochanter Fractures When there is a femur fracture in the area of subtrochanter, muscles come into the proximal fragment, especially partially illiopsoas and gluteus muscles that form the position of flexion, external rotation, and abduction.8-9

Picture 3. Photo of anteroposterior, proximal fragment flexion 90 degrees so it looks medullary cavity with a circular radiolucent picture

To correct the alignment of the fracture, skeletal traction should be given continuously to pull the distal part into skeletal traction in line posititon. Position of skeletal traxy come into the distal metaphysis of the femur bone with a thigh flexion, external rotation, and abduction. Mostly subtrocanter femoral fractures occur on children who aged more than 10 years. At this age, they can use the locked intramedullary rod or ORIF with the nail plate.

Picture 4. Skeletal traction with pins inserted into

the distal femoral metaphysic.

Picture 5. subtrochanter femur fractures corrected with ORIF with screw and plate nail.2. Femur Neck Fractures

a. Frequency and Mechanism of InjuryThe femur neck on children is very strong unlike adults, just great trauma that can cause fracture. Femoral neck Fracture is a rare type of fracture but requires serious handling. Fracture around the hip joint due to a force such as high-energy trauma, or in rare circumstances often associated with pathological condition. Femoral neck fracture is also often associated with violence against children (child abuse). The incidence of femoral neck fractures on children is less than 1%. These fractures can occur on children of all ages, but the highest incidence at the age of 11 years and 12 years, with 60-70% occur in. In developing countries the most common cause is a traffic accident while in developed countries generally cause is falling from height such as trees and house roof. 30% of patients had injuries associated with chest, head, and abdomen. Injury on extremities such as femur fractures, tibia - fibula, and often pelvic. Another thing that often lead to fracture of the femur on children is child abuse.1,2,4b. classification

Fractures of the hip on children are classified by location and first morphology. Cromwell is the first who explained fractures of the femoral neck on children. Delbet publish standard classification of fractures of the proximal femur in 1907. This classification is not well known until Collona (1929) reported 12 cases using Delbet classification.Table 1. Classification of pelvic fractures on children (Delbet)Type ITrans epiphyseal separation (with or without dislocation of the femoral head from acetabulum)

Type IITranservical

Type IIICervikotrochantrik

Type IVIntertrokanter

Table 2. pediatric femoral neck fractures - the type and the importance characteristics Delbet type IncidenceCausesimportant characteristics

Type I8% High energy trauma

Child abuse The difficult Breech childbirth

50% of cases occur in the epiphyseal head dislocation

High risk of AVN (20-100%) when associating with epiphyseal dislocation

Differential diagnosis of septic arthritis, hip dislocation, loss of femoral head epiphysis.

Type II45%severe trauma Variation of the most widely 70-80% are displaced High risk of AVN (up to 50%). In displaced fractures, loss of reduction, malunion, non-union, varus deformity.

Type III35%Severe traumaAVN 20-25% depending on the placement at the time of injury.

Type IV12%TraumaNon-Union and rarely AVN

Picture 6. Classification of proximal femur fractures on children, based on the classification of Colonna and Delbet.c. Assessment and Diagnosis

In addition, clinically diagnosis is often confusing. Usually children who are traumatized often get pain in the pelvic region and shortening, extremity rotated outwards. Children are usually fear of passive limb movement and cannot move actively. Diagnose is enforced using radiography, which is generally used on two planets photograph, if it is not painful. Sonography is also often used on condition that raises doubts e.g. pelvic pain on children. Fracture line or hematoma intracapsular can be detected using fracture ultrasound. With unknown fractures on the femur, the radiography cannot be used as supporting diagnostic. Computed tomography (CT) can be used to assess the degree of fracture and other intracapsular hematoma. A bone scan at 3 months post-injury also helps in detecting necrosis of the femoral head, which is a possible complication. Magnetic resonance imaging (MRI) detects previously avascular.In the state of femoral fractures, dorsalis pedis arterial pulsation are palpated. In femoral fracture should also be a secondary inspection because most patients only complain of pain so things that can danger life such as internal bleeding in the spleen rupture is often overlooked. Hence, the blood pressure is also important to be supervised.10d. ManagementFractures of the femoral neck on children are very unstable as like adults and cannot be done adequately handling both with closed reduction, external immobilization, or traction continuously.1 principles of management including: 11-12 Minimize the potential complications in avascular necrosis (AVN).

Avoid injury to the physical plate.

Reduction of fragments anatomically

Stabilization with pins or screws leads early protection to withstand the weight.Decompression of the hemarthrosis and stable internal fixation is an important aspect of the treatment for all fractures with the shift. Fractures were not shifting can be managed conservatively by using hip spica cast immobilization.

Based on studies conducted in 71 cases of the British Orthopedic Association reported in 1962, Ratliff said that the high incidence of non-union fractures occured in type II or type III treated conservatively. Canale and Bourland in 1974, reported that the observed fixation surgery showed better results.

According to Anil Arora (2006) treatment of traumatic fractures of the femoral neck on children is based on the type and number of shifts due to fractures, and skeletal maturity of children. Internal fixation for femoral neck fracture type I, type II, and type III, a smooth pin can be used on infants, screw cannula 4.0 mm on children; screw cannula 6.5 mm on adolescents. For type IV fracture fixation, in theory pediatric pelvic screws (pediatric hip screw) is better on children and adults pelvic screws for teenagers. Hip spica cast used a lot for postoperative immobilization, especially on children 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

a. Frequency and Mechanism of Injury

Femoral shaft fracture including subtrokanter and suprakondilar ranging 1.6% of all fractures on children and most commonly is fractures in the middle third. The ratio of boys and girls is 2: 1. The annual incidence of femoral shaft fracture was 19 per 100,000 children.

Etiology of femoral shaft fractures depends on the age. In infants, the diaphysis of the femur bone is relatively weak and may be broken due to the load of tumble. At the age of kindergarten and school age, about half of femoral shaft fractures caused by low-speed accidents such as falls from heights, for example bikes, trees, stairs or after tripping and falling on the same level with or without collision. Along with the increasing strength of the femur, with subsequent maturity in childhood and adolescents, high-speed trauma often results in fractures of the femur.

Fracture of the femoral shaft is rare due to birth trauma, with such exceptions, then this fracture may also be caused by arthrogryposis multiplex congenita, myelomeningocele, and osteogenesis imperfect. Rigid contracture of the hip and knee in children with arthtogrypotic can cause femoral shaft fracture during childbirth or during subsequent handling. Other risk groups are newborns with neuromuscular diseases such as myelomeningocele, osteopenia and osteogenesis imperfect that caused multiple fractures.Femoral shaft fracture is rarely occurred during the first 12 months of life. Mostly 30-50% is non - accidental of child abuse.6,8b. Clinical findings

Common sign of the femoral shaft fractures includes pain, shortening, angulation, swelling, and crepitation. A child with a fledgling femur fracture usually cannot stand or walk. All children should be examined including the lower limbs and pelvic and abdominal circumference, so do not ignore the tibia, pelvic, abdominal, or renal trauma. Neuromuscular examination should be examined carefully although neuromuscular injury rarely occurs as a result of femoral shaft fracture. Bleeding is a major problem in femoral shaft fracture, the average blood loss can be more than 1200 ml and 40% require transfusion. Assessment of hemodynamic conditions pre-surgery absolutely must be done.c. Radiological findings

Radiographic examination should be conducted along the femur in two plane images and adjacent to the circumference of the pelvic and knee joints. If there is any doubt, the lower leg should be checked .Computed tomography (CT) or magnetic resonance imaging (MRI) scans are usually not needed. Indications for MRI will be used if it is suspected of hidden fractures or ligament injuries in the knee.d. Diagnosis

Diagnosis can be established based on a single physical examination because the typical deformity typical of angulation, external rotation and shortening. Because the fracture is unstable, it is important to conduct initial splint before radiological examination to avoid pain and injury of the femoral artery.8e. Management

Femoral shaft fracture treated by age and the size of the child. Adjustments to the treatment and socioeconomic factors should be considered. Femoral shaft fracture fromearly ages lifeup to age 5 yearsInitial skin traction for several days is followed by a hip spica cast with the position of the hip and knee slightly flexion.

Picture 9. The position of the hip and knee slightly flexion at the spica castFor the initial skin traction for children up to 2 years old can use Bryant's traction. For children aged 2-5 years, skin traction using the Thomas splint

Picture 10. Bryant skin traction. Both of leg is enforced to top, pulled by a rope under load 1-2 kg, until the child buttocks lifted from the bed.

Complications of Bryan traction is ischemic paralysis. This is due to the disruption of blood flow in the legs elevated. 10,11

Picture 11. Skin traction combined with a Thomas splint, slightly bent at the knee used in unstable fractures of the femoral shaft.

Children are then allowed to go home with a hip spica cast. Early contraindications of the use of hip spica is bone shortening of more than 3 cm from the fracture, multiple injury, and the presence of head injury. Spica cast after reduction, is the majority treatment of pediatric orthopedic surgeons. Position of the leg fracture is set at 90 flexion to hip and knee, to preventing secondary varus deformity, leg fracture should be kept in neutral abduction. Routine radiography on two planes is recommended after mounting the cast. If parents or families get good information about treatments using spica cast, children does not need to be hospitalized.During back control for 1 week in the clinic, routine radiographs will be easy to detect angular deviation. Because to the rapid consolidation of callus formation within 2-3 weeks, after the release of cast repair function occurs rapidly.

Pavlik harness is used over the period of 3-5 weeks. It is an alternative treatment for very small babies. Mounting of this equipment does not require anesthesia and hospitalization time can be minimized.

Overhead skin traction has a risk in the form of a detrimental effect on the circulation of the extremities. Skin traction hypoallergenic material should be selected for patients who are allergic with the usual ingredients or in the older people which the skin has been fragile.

Contraindication of skin traction is found if any injury or damage skin and traction that require loads > 5 kg. As a result of overload skin traction include skin necrosis, vascular obstruction, distal edema, and peroneal nerve palsy in the leg traction. Femoral shaft fractures in age 5 to 10 years

After a few days of skin traction, closed reduction is done either with a hip spica or flexible intramedullary nail or another alternatives with external skeletal fixation.

Flexible intramedullary nail or intramedullary Kirschner Wayer sometimes used for femur fractures in the group of pre-school children. The main indication is failure treatment using a spica cast. Two millimeters diameter of titanium nail is inserted from the medial and lateral metaphysic of the distal femur to stabilize intramedular of the fracture. Consolidation time is relatively short, requiring a span about 2-5 months depending on the age of the patient. Implants will be revoked at 3-6 months after mounting.12

Picture 12. Flexible intramedullary nail nancy type, alternative therapy after closed reduction.

Based on a descriptive-analytical study of treatment external fixation and flexible intramedullary nails in 27 children patients with open femur fractures at the Trauma Center of Northwestern Iran from 2006 to 2011, Razak stated that children with open fractures of the shaft femoral Gustilo grade II were treated with flexible intramedullary nails technique experiencing a faster recovery time with a normal range of motion in the hospitalization time is 6-24 weeks compared to using external fixators. Therefore, this technique has been recommended as an alternative way to treat open fractures of the shaft femoral in children. Femoral Fractures Shaft on Age > 10 yearsRussel traction is requires mounting of frames, pulleys, ropes, and plaster. The patient in supine position then fitted plaster from knee boundary, mounted sling in the poplitea region, sling is connected by a rope, where the rope is connected to the towing load. To reduce the time of hospitalization after 4 weeks in traction, callus has formed, but not strong right. Traction is released, then mounting gip hemispika.

Picture 13. Russel traction.After traction, then mounting the rigid and locked intramedullary nails. Nail fixed to the proximal and distal area of fracture by a screw which passes through both sides of the bone so it can control if there is rotation in the area of bone fracture. The advantage of this method is can be used for adults patient and it can withstand the weight full.

External fixation is an option in case of open fractures in patients with poly trauma or for segmental fractures, which are also in this group. If fixator removed earlier with callus formation is still lacking, it will make the risk of fracture back. In all patients which use fixator, pen mounting infections are common and can be healed with antibiotics. But the handling of closed femoral shaft fracture is not recommended to mount external fixator in preschoolers children.

Picture 14 A. External skeletal fixation. B. Locked intramedullary nails Temporary Overgrowth after Femoral Shaft Fractures Overgrowth can occur after a displaced of fracture shaft femur. This excessive growth is in average of 1 cm and imbalance length occurs one year after fracture. Ideal position to fragment fused properly without non-operative treatment is using side-to-side (bayonet apposition) with mutual inter-bone overriding approximately 1cm each other for compensation when there is an overgrowth for 1 year. 12g. complication

Serious complications of femoral shaft fractures in children are compartment syndrome, nerve and muscle spasm as result of the femoral artery or bleeding and edema accompanied by soft tissue compartment. Clinical manifestations which appear are in the form of pain, pale, swollen, pulselessness, paresthesia, and paralysis. The patients should not receive analgesics. A good controlling of fracture will not cause pain, but if children feels severe pain and constant in the calf it could be caused of impending ischemia (compartement syndrome). Analgesics will overcome this important sign and contraindication.If there is suspicion of compartment syndrome, all attached bandage should be removed. Skin traction replaced with skeletal traction through the distal femur metaphysis with hip and knee flexed. If the peripheral circulation is inadequate for half an hour, artery exploration and faciotomy should be done soon.H. PARTICULAR ATTENTION TO FEMUR FRACTURES IN CHILDREN The bones of children and adults share many of the same risks for injury. But because they are still growing, a child's bones are also subject to a unique injury called a growth plate fracture. Growth plates are areas of cartilage located near the ends of bones. Because they are the last portion of a child's bones to harden (ossify), growth plates are particularly vulnerable to fracture.3,10Several classification systems have been developed that categorize the different types of growth plate fractures. Perhaps the most widely used by doctors is the Salter-Harris system, described below.3,10Type I Injuries

Type I InjuriesDue to a separation through the growth plate of the metaphysis and diaphysis.

Type II Injuries

An incomplete type I with a metaphyseal bone fragment still attached to the epipyhseal end. Type I and II have a good prognosis as the blood supply to the germinal layer ( ephyseal side) is still intact and angulation and growth arrest are uncommon.

Type III Injury

This fracture occurs only rarely,and is seen in the pre pubescent child. It is seen in the femur or tibia. THe mechanism is a fracture that runs completely through the epiphysis and separates part of the epiphysis and growth plate from the metaphysis. Surgery is sometimes necessary to restore the joint surface to normal. The outlook or prognosis for growth is good if the blood supply to the separated portion of the epiphysis is still intact, if the fracture is not displaced, and if a bridge of new bone has not formed at the site of the fracture.

Type IVInjury

Here the fracture is through the metaphysis and epiphysis. As in the type III it is intra-articular and will need open reduction and internal fixation. The prognosis for future growth disturbances and angulation is poor.

Type V InjuryType V InjuryIs due to a compression force destroying all or part of the growth plate. This is difficult to diagnose and in most cases is a retrospective diagnosis where angulation developed without radiological evidence of a growth plate injury.The diagnosis can be established with MR imaging if hemorrhage or a haematoma is identified within the growth plate immediately after injury.

Remodeling fractures in children have greater power than adults, especially in areas close to the appropriate physical and angulasinya with the direction of movement of the joints.You need to know the physical trauma can damage the growth centers in the growth of the child so that it will stop causing progressive shortening of the limb bones, and this depends on the age and involvement efisis part as well.When the physical property which is damaged only partially, then that is not broken still growing, causing distortion of normal growth.Therefore you have to explain to parents that the patient will require a follow-up that long. In the event of the upper limbs will occur cosmetic nuisance, but at the bottom will cause osteartritis members.CHAPTHER III

CONCLUSION

Femur is the longest bone in the human body. This requires the development of appropriate in the proximal and distal allowing musculoskeletal coordination activities in hip and knee. The development of the proximal femur epiphysis and physis particularly is very complex in the region of appendicular skeletal growth.Femoral shaft fracture (femoral shaft fracture) including subtrochanter region and supracondilar range 1.6% of all fractures in children. The ratio between boys and girls is in 2: 1.

Diagnoses are done by clinical symptoms, radiology, sonography, CT scan, and MRI. However, the clinical symptoms and radiology are usually sufficient to diagnose a fracture of the femur in children.

Management is based on the a ge of the child. Therapy with fixation is recommended operation and will be greater success only by conservative management.

REFERENCE1. Salter RB. Textbook of Disorder and Injuries of The Musculoskeletal system, Third Editon. Maryland: Lippincott William & Wilkins, 1999.2. Loder RT, ODonnell PW, Feinberg JR. Epidemiology and mechanisms of femur fracture in children. J Pediatr Orthop 2006; 26(5):561-6.

3. Ogden. JA, 2000. Skeletal Injury In The Child Second Edition. New York : W. B Saunders Company. p.857 872

4. Engelhardt PW. 2010. Femoral Neck Fracture In : Benson M, Fixsen J, Macnicol M, Parsch Klaus (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer. p. 759 764

5. Gottlieb JR. 2006. SOAP for orthopedics. Philadelphia : Williams and Wilkins Publisher. p. 82 83

6. Arora A. 2006. Pediatrics Femoral Neck Fracture In : Kulkarni GS (eds) Textbook of Orthopedics and Trauma 2nd Edition. New Delhi : Jaypee Brothers Medical Publisher p. 3314 3333

7. Hbner .U, Schlicht .W, Outzen .S, Barthel .M, Halsband. H. 2000. Ultrasound in the diagnosis of fractures in children. The Journal of Bone and Joint Surgery 82-B:1170-3.

8. Benson M, Fixsen J, Macnicol M, Parsch K. 2010. Femoral Shaft Fracture In : Parsch K (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer. p. 765 771

9. Pring M, Newton P, Rang M. 2005. Femoral Shaft In : Wenger D.R, Pring M.E (eds) Rangs Childrens Fractures. Philadelphia : Lippincot Williams and Wilkins. p. 181 199

10. Egol KA, Koval KJ, Zuckerman JD.2010. Hand Book of Fracture. Philadelphia : Lippincot Williams and Wilkins. p. 400 418

11. Cui F. Z , Wen H. B,and Su X. W. 1996. Microstructures of External Periosteal Callus of Repaired Femoral Fracture in Children. Journal of Structural Biology 117, 204208

12. Aslani H, Tabrizi A, Sadighi A, Mirbolook A. 2013.Treatment Of Pediatric Open Femoral Fractures With external Fixator Versus Flexible Intramedullary Nails. Journal of Bone and Joint Surgery. 64-67

Salter RB. Textbook of Disorder and Injuries of The Musculoskeletal system, Third Editon. Maryland: Lippincott William & Wilkins, 1999.

Loder RT, ODonnell PW, Feinberg JR. Epidemiology and mechanisms of femur fracture in children. J Pediatr Orthop 2006; 26(5):561-6.



Ogden. JA, 2000. Skeletal Injury In The Child Second Edition. New York : W. B Saunders Company. p.857 872


Engelhardt PW. 2010. Femoral Neck Fracture In : Benson M, Fixsen J, Macnicol M, Parsch Klaus (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer. p. 759 764



Gottlieb JR. 2006. SOAP for orthopedics. Philadelphia : Williams and Wilkins Publisher. p. 82 83


Arora A. 2006. Pediatrics Femoral Neck Fracture In : Kulkarni GS (eds) Textbook of Orthopedics and Trauma 2nd Edition. New Delhi : Jaypee Brothers Medical Publisher p. 3314 3333


Hbner .U, Schlicht .W, Outzen .S, Barthel .M, Halsband. H. 2000. Ultrasound in the diagnosis of fractures in children. The Journal of Bone and Joint Surgery 82-B:1170-3.

Benson M, Fixsen J, Macnicol M, Parsch K. 2010. Femoral Shaft Fracture In : Parsch K (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer. p. 765 771

Pring M, Newton P, Rang M. 2005. Femoral Shaft In : Wenger D.R, Pring M.E (eds) Rangs Childrens Fractures. Philadelphia : Lippincot Williams and Wilkins. p. 181 199


Loder RT, ODonnell PW, Feinberg JR. Epidemiology and mechanisms of femur fracture in children. J Pediatr Orthop 2006; 26(5):561-6.

Engelhardt PW. 2010. Femoral Neck Fracture In : Benson M, Fixsen J, Macnicol M, Parsch Klaus (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer. p. 759 764

Egol KA, Koval KJ, Zuckerman JD.2010. Hand Book of Fracture. Philadelphia : Lippincot Williams and Wilkins. p. 400 418

Cui F. Z , Wen H. B,and Su X. W. 1996. Microstructures of External Periosteal Callus of Repaired Femoral Fracture in Children. Journal of Structural Biology 117, 204208

Aslani H, Tabrizi A, Sadighi A, Mirbolook A. 2013.Treatment Of Pediatric Open Femoral Fractures With external Fixator Versus Flexible Intramedullary Nails. Journal of Bone and Joint Surgery. 64-67





Benson M, Fixsen J, Macnicol M, Parsch K. 2010. Femoral Shaft Fracture In : Parsch K (eds) Childrens Orthopaedics and Fractures Third Edition. London : Springer



Cui F. Z , Wen H. B,and Su X. W. 1996. Microstructures of External Periosteal Callus of Repaired Femoral Fracture in Children. Journal of Structural Biology 117, 204208

Aslani H, Tabrizi A, Sadighi A, Mirbolook A. 2013.Treatment Of Pediatric Open Femoral Fractures With external Fixator Versus Flexible Intramedullary Nails. Journal of Bone and Joint Surgery. 64-67



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