1. The patient is a 6 year old Thai boy who was run over by a motorcycle 3 hours ago, suffering pain and swelling in his left thigh.
2. X-rays revealed a complete oblique fracture of the left femur shaft with angulation and 2-3cm of shortening.
3. Treatment options depend on the patient's age and fracture pattern, ranging from casting or traction for younger children, to flexible nails, plates or external fixation for older children, with the goals of restoring length, alignment and rotation while avoiding complications like osteonecrosis.
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Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
3. PRIMARY SURVEY
A : Patent airway, no stridor, and no posterior cervical
tenderness
B : Equal chest expansion , trachea in midline, equal
breath sound , both lungs clear
C : Vital signs (BT 37 c, PR 94 bpm, BP 127/66 mmHg, RR
20/min), no external bleeding, no pelvic tenderness or
ecchymosis, abdominal soft not tender
D : E4V5M6 , pupils 3 mm RTLBE
E : Deformity at Left thigh, marked tender & swelling at
Left thigh, PR: normal sphincter tone, yellow feces
4. SECONDARY SURVEY
A : no food/drug allergy
M : No current medication
P : no underlying disease, no history of
surgery
L : Last meal = 18.00
E : As present illness
5. HEAD TO TOE
EVALUATION
Vital sign: BT 37 c, PR 94 bpm, BP 127/66 mmHg,
RR 20/min
Measurement : BW= 20 Kg
GA: Good consciousness, not pale, active
HEENT : Not pale conjunctivae , anicteric
sclerae , no subconjunctivae hemorrhage, no
evidence of head trauma, no contusion
6. Lungs : Equal chest expansion , equal breath
sound , no accessory muscle use , both lungs
clear
CVS : JVP not engorged , Pulse full and regular ,
Capillary refill < 2 sec , normal S1S2, no murmur
Abdomen : No distention , soft , not tender ,
normoactive bowel sound, no rigidity , no
guarding , no rebound tender
HEAD TO TOE
EVALUATION
7. Extremities : marked tender and swelling at Left
thigh, deformity at Left thigh , mild tender at Left
knee , neurovascular intact, limit ROM due to
pain
Neuro : Good consciousness, well cooperative,
good orientation to time place person
Motor : Grade V all extremities(except Left leg
due to pain)
Sensory : Normal sensation to pain , temp and
HEAD TO TOE
EVALUATION
17. MECHANISM OF
INJURY- correlated with age due to the increasing thickness of
the cortical shaft during skeletal growth and maturity
falls most common cause in toddlers
high energy trauma is responsible for second peak in
adolescents
MVC or ped vs vehicle
- fractures after minor trauma can be the result of a
pathologic process
bone tumors, OI, osteopenia, etc.
20. CLINICAL
PRESENTATION
• inspection
- tense, swollen thigh
Blood loss in closed femoral shaft fx is 750-
1500 ml
Blood loss in open fx may be double that of
closed
- affected leg often shortened
Physical
examinations
21. CLINICAL
PRESENTATION
• motion
- examination often difficult secondary to pain
from fracture
• neurovascular
- must record and document distal neurovascular
status
Physical
examinations
30. TREATMENT
< 6 months Any fx pattern • Pavlik harness
• Early spica
casting
6 months – 5
years
< 2-3 cm
shortening
• Early spica
casting
2-3 cm
shortening
Polytrauma/m
ultiple fx/open
fx
• traction with
delayed spica
casting
• ORIF with
submuscular
bridge plating
31. TREATMENT
5-11 years Length stable fx
(Transverse/obliq
ue)
• Flexible
intramedullary
nails
Length
unstable fx
(comminuted
or spiral)
Very proximal
or distal fx
• ORIF with
submuscular
bridge plating
• external fixator
In case
polytrauma
patients for
damage control
32. TREATMENT
11 or greater
years
Patient weight <
100 Ibs
• Flexible
intramedullary
nails
Patient weight >
100 Ibs
• Antegrade IM
nail with
trochanteric or
lateral starting
point
Very proximal
or distal fx
• ORIF with
submuscular
bridge plating
35. COMPLICATION
Leg-Length Discrepancy
overgrowth
0.7 - 2 cm is common in patients between of 2 - 10 years at
time of fracture
typically presents within 2 years of injury
shortening
is acceptable if less than 2 - 3 cm because of anticipated
overgrowth
can be symptomatic if greater than 2 - 3 cm
temporary traction or internal fixation used to prevent
36. COMPLICATION
Osteonecrosis (ON) of femoral head
reported with both piriformis and greater
trochanter entry nails
femoral nailing through the piriformis fossa
is contraindicated in adolescents with open
physes because of the risk of osteonecrosis
of femoral head
main supply to femoral head is deep branch
of the medial femoral circumflex artery
branches into superior retinacular
vessels that supply the femoral head
vulnerable as it lies near the piriformis
37. Nonunion
higher risk with load bearing devices
external fixator or submuscular plates
can occur after flexible intramedullary nailing
in patients
aged over 11 years old
who weigh>49 kg (>108 lb)
COMPLICATION
38. Malunion
typical deformity is varus + flexion of the
distal fragment
remodeling is greatest in sagittal plane (ie
flexion/extension deformity)
rotational malalignment does not remodel
must be corrected at the initial surgery
COMPLICATION
39. Refracture
most common after external fixator removal
with varus malalignment
highest risk in transverse and short oblique
fractures
less likelihood of secondary callus formation
COMPLICATION
