Orthopaedic and Traumatlogy Department

1. CASE REPORT
Patient Identity
• Name : Mr. M
• Age : 16 years old
• Sex : Male
• Date of admittance : 23th
June 2013
• No. MR : 615468
History Taking :
• Chief complain : Pain at the left thigh
• History of illness : Suffered since 3 hours before admitted to the hospital due
to a traffic accident. History of unconsciousness (-), nausea (-) vomiting (-).
History of previous illnesses (-)
• Mechanism of trauma : Patient was a passenger of a bike when he fell down and
rolled on the road as the rider was trying to avoid car from opposite direction.
History of unconscious (-), nausea (-), vomiting (-)
Prior treatment at Pangkep hospital.
Physical Examination
General Status : Moderate illness / Well nourished / Compos mentis
Vital Sign:
T: 120/80 mmHg
N: 88 x/minutes, regular
P: RR 20x/min regular, spontaneous thoracoabdominal type, symmetrical
S: 36,7º C
Local Status
Left femur region
– Inspection: deformity (+), hematoma (+), swelling (+), wound (-)
– Palpation: Tenderness (+)
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2. – ROM: Active and passive motion of hip joint and knee joint cant be
evaluated due to pain.
– NVD: Sensibility is good, dorsalis pedis artery and tibialis posterior artery
palpable, Capillary refill time <2”
Right Left
ALL 98 96
TLL 93 91
LLD 2 cm
Clinical Findings
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3. Laboratory Findings
 WBC : 10.000/mm3
 HGB : 13,5 mg/dl
 RBC : 5.260.000/mm3
 PLT : 259.000/mm3
 Ur : 30
 Cr : 0,9
 GOT : 61
 GPT : 60
 CT : 8’00”
 BT : 2’00”
 HbsAg : non reactive
 GDS : 72
 Elektrolit
 Na : 136
 K : 5,0
 Cl : 102
Radiological Findings
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4. Femur (S) AP/Lateral view X-ray
Pelvic X-ray
Summary
A 16 years old boy was admitted to the hospital with pain at the left femur, which was
suffered since 3 hours ago due to a traffic accident. The patient was a passenger of a
motorcycle an then suddenly got hit by a car from behind, fell down, and then rolled on
the road. At the anterior aspect of the femur, deformity (+), hematoma (+), and edema
(+). The region was tender on palpation, with limited active and passive motion of hip
joint and knee joint due to pain. Sensibility is good, dorsalis pedis artery is palpable,
Capillary refill time <2”
Diagnosis
Closed fracture 1/3 middle of the left femur
Management
• Non – operative : - Skin traction
- Analgetik
• Operative : ORIF (Open Reduction Internal Fixation)
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5. DISCUSSION
1. Femoral Shaft Fracture
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
The femur is the largest tubular bone in the body and is surrounded by the largest
mass of muscle. An important feature of the femoral shaft is its anterior bow. The medial
cortex is under compression, whereas the lateral cortex is under tension. The isthmus of
the femur is the region with the smallest intramedullary (IM) diameter; the diameter of the
isthmus affects the size of the IM nail that can be inserted into the femoral shaft.
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6. The femoral shaft is subjected to major muscular deforming forces : Abductors
(gluteus medius and minimus): They insert on the greater trochanter and abduct the
proximal femur following subtrochanteric and proximal shaft fractures. Iliopsoas: It flexes
and externally rotates the proximal fragment by its attachment to the lesser trochanter.
Adductors: They span most shaft fractures and exert a strong axial and varus load to the
bone by traction on the distal fragment. Gastrocnemius: It acts on distal shaft fractures and
supracondylar fractures by flexing the distal fragment. Fascia lata: It acts as a tension band
by resisting the medial angulating forces of the adductors.
The thigh musculature is divided into three distinct fascial compartments :
Anterior compartment: This is composed of the quadriceps femoris, iliopsoas, sartorius,
and pectineus, as well as the femoral artery, vein, and nerve, and the lateral femoral
cutaneous nerve. Medial compartment: This contains the gracilis, adductor longus, brevis,
magnus, and obturator externus muscles along with the obturator artery, vein, and nerve,
and the profunda femoris artery. Posterior compartment: This includes the biceps femoris,
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7. semitendinosus, and semimembranosus, a portion of the adductor magnus muscle,
branches of the profunda femoris artery, the sciatic nerve, and the posterior femoral
cutaneous nerve.
Because of the large volume of the three fascial compartments of the thigh,
compartment syndromes are much less common than in the lower leg.
The vascular supply to the femoral shaft is derived mainly from the profunda
femoral artery. The one to two nutrient vessels usually enter the bone proximally and
posteriorly along the linea aspera. This artery then arborizes proximally and distally to
provide the endosteal circulation to the shaft. The periosteal vessels also enter the bone
along the linea aspera and supply blood to the outer one-third of the cortex. The endosteal
vessels supply the inner two-thirds of the cortex.
Following most femoral shaft fractures, the endosteal blood supply is disrupted,
and the periosteal vessels proliferate to act as the primary source of blood for healing. The
medullary supply is eventually restored late in the healing process. Reaming may further
obliterate the endosteal circulation, but it returns fairly rapidly, in 3 to 4 weeks. Femoral
shaft fractures heal readily if the blood supply is not excessively compromised. Therefore,
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8. it is important to avoid excessive periosteal stripping, especially posteriorly, where the
arteries enter the bone at the linea aspera.
3. Mechanism of Injury
This is usually a fracture of young adults and results from a high energy injury.
Diaphyseal fractures in elderly patients should be considered ‘pathological’ until proved
otherwise. In children under 4 years the possibility of physical abuse must be kept in mind.
Fracture patterns are clues to the type of force that produced the break. A spiral
fracture is usually caused by a fall in which the foot is anchored while a twisting force is
transmitted to the femur. Transverse and oblique fractures are more often due to
angulation or direct violence and are therefore particularly common in road accidents.
With severe violence (often a combination of direct and indirect forces) the fracture may
be comminuted, or the bone may be broken in more than one place (a segmental fracture).
4. Femoral Shaft Fractures Classification
Winquist’s classification reflects the observation that the degrees of soft-tissue
damage and fracture instability increase with increasing grades of comminution. In Type 1
there is only a tiny cortical fragment. In Type 2 the ‘butterfly fragment’ is larger but there
is still at least 50 per cent cortical contact between the main fragments. In Type 3 the
butterfly fragment involves more than 50 per cent of the bone width. Type 4 is essentially
a segmental fracture.
5. Diagnose
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9. There is swelling and deformity of the limb, and any attempt to move the limb is
painful. With the exception of a fracture through pathological bone, the large forces
needed to break the femur usually produce accompanying injuries nearby and sometimes
further afield. Careful clinical scrutiny is necessary to exclude neurovascular problems and
other lower limb or pelvic fractures. An ipsilateral femoral neck fracture occurs in about
10 per cent of cases and, if present, there is a one in three chance of a significant knee
injury as well. The combination of femoral shaft and tibial shaft fractures on the same
side, producing a ‘floating knee’, signals a high risk of multi-system injury in the patient.
The effects of blood loss and other injuries, some of which can be life-threatening, may
dominate the clinical picture.
It may be difficult to obtain adequate views in the Accident and Emergency
Room setting, especially views that provide reliable information on proximal or distal
fracture extensions or joint involvement; these can be postponed until better facilities and
easier patient positioning are possible. But never forget to xray the hip and knee as well
(Figure 29.21). A baseline chest x-ray is useful as there is a risk of adult respiratory
distress syndrome (ARDS) in those with multiple injuries. The fracture pattern should be
noted; it will form a guide to treatment.
6. Treatment
• Nonoperative
Skeletal Traction
Currently, closed management as definitive treatment for femoral shaft
fractures is largely limited to adult patients with such significant medical
comorbidities that operative management is contraindicated. The goal of skeletal
traction is to restore femoral length, limit rotational and angular deformities, reduce
painful spasms, and minimize blood loss into the thigh.
Skeletal traction is usually used as a temporizing measure before surgery to
stabilize the fracture and prevent fracture shortening. Twenty to 40 lb of traction is
usually applied and a lateral radiograph checked to assess fracture length.
Distal femoral pins should be placed in an extracapsular location to avoid the
possibility of septic arthritis. Proximal tibia pins are typically positioned at the level
of the tibial tubercle and are placed in a bicortical location. Safe pin placement is
usually from medial to lateral at the distal femur (directed away from the femoral
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10. artery) and from lateral to medial at the proximal tibia (directed away from the
peroneal nerve). Problems with use of skeletal traction for definitive fracture
treatment include knee stiffness, limb shortening, prolonged hospitalization,
respiratory and skin ailments, and malunion.
• Operative
Operative stabilization is the standard of care for most femoral shaft fractures.
Surgical stabilization should occur within 24 hours, if possible. Early stabilization of
long bone injuries appears to be particularly important in the multiply injured patient.
Intramedullary (IM) Nailing, this is the standard of care for femoral shaft fractures.
External Fixation, use as definitive treatment for femoral shaft fractures has limited
medication. Plate fixation for femoral shaft stabilization has decreased with the use of
IM nails.
7. 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.
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11. 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.
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12. REFERENCES
1. Koval K.J, Zuckerman J.D. Handbook of fractures 3rd
edition 2006.
2. Solomon L, Warwick D, Nayagam S..Apley’s System of Orthopedic and Fracture 9th
ed. 2010. Hodder Arnold
3. Thompson, Jon C. Netter’s Concise Orthopaedics Anatomy 2nd Edition
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