SEPTEMBER 2013

CASE REPORT:
CLOSED FRACTURE 1/3 MIDDLE OF THE RIGHT FEMUR

Written By:
Marson Rubianto (C 111 08 281)
Advisors:
dr.Satria
dr.Yoga
Supervisor:
dr. W. Supriyadi, Sp.OT


ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY
MAKASSAR
2013



CASE REPORT: CLOSED FRACTURE 1/3 MI DDLE OF THE LEFT FEMUR

PATIENT IDENTITY
Name : H
Age : 7 years old
Sex : Male
Date of admittance : 31
th
August 2013
MR Number : 62.25.22

HISTORY
Chief Complaint : pain at the right thigh
History of illness : Suffered since 8 hours before admitted to the hospital due
to an accident
Mechanism of trauma : Patient was standing on a park and suddenly he was hit
by a car dan crushed his right thigh. History of unconsciousness (-), nausea (-)
vomiting (-).Prior treatment at Sinjai Hospital.



PHYSICAL EXAMINATION
PRIMARY SURVEY
Airway : patent
Breathing : RR=18x/min, symmetrical, spontaneous, thoracoabdominal type
Circulation : BP=100/70 mmHg, RR=80x/minute regular and strong
Disability : GCS 15 (E
4
M
6
V
5
), isochoric pupil 2.5 mm/2.5 mm
Environment : Axillary temperature of 36.7
o
C
SECONDARY SURVEY (LEFT FEMUR REGION)
Inspection :

deformity (+), hematoma (+), edema (+), swelling (+)
Palpation :
Tenderness (+)
ROM :
Active and passive motion of hip joint and knee joint is limited due
to pain.
NVD :
Sensibility is good, dorsalis pedis artery, Capillary refill time <2
LEG DISCREPANCY







CLINICAL PICTURE














LABORATORY FINDINGS
WBC : 12,1. 10
3
/uL
HGB : 10,9 g/dl
RBC : 4,15.10
6

PLT : 447.10
3
/uL
Ur : 33
Cr : 0.3
GOT : 39
GPT : 20
CT : 800
BT : 300
Right Left
ALL 68 70
TLL 63 65
LLD 2 cm


RADIOLOGICAL FINDINGS
Right Femur AP/Lateral Position


DIAGNOSIS
Closed fracture 1/3 middle of the right femur

MANAGEMENT
IVFD and analgetics
Skin Traction

RESUME
A boy 7 y.o was admitted to the hospital with pain at the left thight suffered since 8 hours
before admitted to the hospital due to an accident. Patient was standing on a park and
suddenly he was hit by a car dan crushed his right thigh. History of unconsciousness (-),
vomiting (-), nausea (-). Prior treatment at Sinjai Hospital.
From the Physical examination on right thigh : Deformity (+), swelling (+), hematom (+),
tenderness (+), active and passive motion of hip joint and knee joint limited due to pain.
Sensibility normal, dorsalis pedis is palpable, CRT < 2 , extend big toe (+). LLD 2 cm
From the Radiological finding : fracture 1/3 middle right femur.






















DISCUSSION:
FRACTURE OF THE PEDI ATRI C FEMUR SHAFT

1. Introduction
There are several underlying differences between the pediatric and the adult
bone. These differences determine the variation between the diagnosis and the
clinical management of fractures of the pediatric bone compared to the adult. Many
fractures in children are similar to their counterparts in adults. However, the added
factor of growth contributes to the unique issues of fracture care in children.
Pediatric bone is softer and more easily broken than adult cortical bone. Thus, the
amount of energy required to produce a fracture is less in the child, even as soft-
tissue injury is frequently less severe in the child than in the adult. In addition, the
periosteal membrane in children is far thicker and more osteogenic than in adults.
The periosteum is so leathery in immature humans that it frequently holds bone
ends together, contributing greatly to stability and ease of manipulative reduction.
The excellent osteogenic potential of pediatric periosteum permits rapid,
aggressive fracture healing, so nonunions are extremely rare in children.
1

2. Anatomy of the Femur
The primary bone of the thigh is the femur, which is also the longest bone in
the body. The femur has the following characteristic features:
1,2,3

o The femoral head articulates with the acetabulum of the hip bone at the hip
joint. It extends from the femoral neck and is rounded, smooth and covered
with articular cartilage. This configuration permits a wide range of
movement. The head faces medially, upwards and forwards into the
acetabulum. The fovea is the central depression on the head to which the
ligamentum teres is attached.
o The femoral neck forms an angle of 125 with the femoral shaft..
o The femoral shaft constitutes the length of the bone. At its upper end it
carries the greater trochanter and, posteromedially, the lesser trochanter.
Anteriorly the rough trochanteric line, and posteriorly the smooth
trochanteric crest, demarcate the junction between the shaft and neck. The
linea aspera is the crest seen running longitudinally along the posterior
surface of the femur splitting in the lower portion into the supracondylar
lines. The medial supracondylar line terminates at the adductor tubercle.
o The lower end of the femur comprises the medial and lateral femoral
condyles. These bear the articular surfaces for articulation with the tibia at
the knee joint. The lateral condyle is more prominent than the medial. This
prevents lateral displacement of the patella. The condyles are separated
posteriorly by a deep intercondylar notch. Anteriorly the lower femoral
aspect is smooth for articulation with the posterior surface of the patella.


\













Picture 1. The Femur

The thigh is divided into three compartments, the anterior, medial and posterior
compartment:
4,5
o Anterior Compartment: the anterior compartment of the thigh is comprised of
muscles that function as hip flexors and knee extensors such as sartorius,
iliacus, psoas, pectineus and quadriceps femoris. The main artery in this
compartment is the femoral artery, and the nerve found within this compartment
is the femoral nerve.























Picture 2. The Anterior Compartment of the Thigh
o Medial Compartment: comprises of muscles that function as hip adductors
which are the gracilis, adductor longus, adductor brevis, adductor magnus and
obturator externus muscle. The artery within this compartment is the deep
femoral artery while the nerve found within this compartment is the obturator
nerve.
o Posterior Compartment: the posterior compartment contains the hamstring
muscles which function for knee flexion and hip extension. They include: biceps
femoris, semitendinosus, semimembranosus and the hamstring part of adductor
magnus. The nerve found in this compartment is the sciatic nerve







3. Types of Femur Shaft Fractures
Fractures of the femur shaft can be classified based on the configuration of the
fracture. As shown in the picture below, fractures of the femur shaft can be in the
form of a transverse, spiral, comminuted, or segmental fracture.
2,4











Picture 3. Fracture of Shaft Femur

4. Etiology
The mechanism of injury underlying the pediatric femur shaft fracture ranges
from traumatic, as well as non traumatic causes:
o Direct trauma: motor vehicle accident, pedestrian injury, fall, and child abuse
are causes.
o Indirect trauma: rotational injury.
o Pathologic fractures: causes include osteogenesis imperfecta, nonossifying
fibroma, bone cysts, and tumors. Severe involvement from myelomeningocele
or cerebral palsy may result in generalized osteopenia and a predisposition to
fracture with minor trauma.

5. The Pediatric Bone
There are several differences between the pediatric and the adult bone that
determine the resulting difference in management and clinical outcome of pediatric
fractures:
1
o Pediatric bone has a higher water content and lower mineral content per unit
volume than adult bone. Therefore, pediatric bone has a lower modulus of
elasticity (less brittle) and a higher ultimate strain-to-failure than adult bone.
o The physis (growth plate) is a unique cartilaginous structure that varies in
thickness depending on age and location. It is frequently weaker than bone in
torsion, shear, and bending, predisposing the child to injury through this delicate
area.
o The physis is traditionally divided into four zones: reserve (resting/germinal),
proliferative, hypertrophic, and provisional calcification (or enchondral
ossification)
o The periosteum in a child is a thick fibrous structure (up to several millimeters)
that encompasses the entire bone except the articular ends. The periosteum
thickens and is continuous with the physis at the perichondral ring (ring of
LaCroix), offering additional resistance to shear force.
o As a general rule, ligaments in children are functionally stronger than bone.
Therefore, a higher proportion of injuries that produce sprains in adults result in
fractures in children.
o The blood supply to the growing bone includes a rich metaphyseal circulation
with fine capillary loops ending at the physis (in the neonate, small vessels may
traverse the physis, ending in the epiphysis).
6. Clinical Evaluation
2,3

o Patients with a history of high-energy injury should undergo full trauma
evaluation as indicated.
o The presence of a femoral shaft fracture results in an inability to ambulate, with
extreme pain, variable swelling, and variable gross deformity. The diagnosis is
more difficult in patients with multiple trauma or head injury or in
nonambulatory, severely disabled children.
o A careful neurovascular examination is essential.
o Splints or bandages placed in the field must be removed with a careful
examination of the overlying soft tissues to rule out the possibility of an open
fracture.
o Hypotension from an isolated femoral shaft fracture is uncommon. The Waddell
triad of head injury, intraabdominal or intrathoracic trauma, and femoral shaft
fracture is strongly associated with vehicular trauma and is a more likely cause
of volume loss. However, the presence of a severely swollen thigh may indicate
large volume loss into muscle compartments surrounding the fracture.

7. Radiologic Evaluation
2,3

During the radiological evaluation of a pediatric femur shaft fracture, there are
several principles that should be kept in mind:
o Anteroposterior and lateral views of the femur should be obtained.
o Radiographs of the hip and knee should be obtained to rule out associated
injuries; intertrochanteric fractures, femoral neck fractures, hip dislocation,
physeal injuries to the distal femur, ligamentous disruptions, meniscal tears,
and tibial fractures have all been described in association with femoral shaft
fractures.
o Magnetic resonance imaging and bone scans are generally unnecessary but
may aid in the diagnosis of otherwise occult nondisplaced, buckle, or stress
fractures.

8. Management
Treatment is age dependent, with considerable overlap among age groups.
The size of the child must be considered when choosing a treatment method, as
well as the mechanism of the injury (i.e., isolated, low-energy versus high-
energy polytrauma).
2,3

Age <6 Months
Pavlik harness or a
posterior splint is
indicated.
Ages 6 Months to 6 Years
Immediate spica casting
is nearly always the
9. Complications
2,3

o Malunion: Remodeling will not correct rotational deformities. An older
child will not remodel as well as a younger child. Anteroposterior
remodeling occurs much more rapidly and completely in the femur than
varus/valgus angular deformity. For this reason, greater degrees of sagittal
angulation are acceptable.
o Nonunion: Rare; even with segmental fractures, children often have
sufficient osteogenic potential to fill moderate defects. Children 5 to 10
years of age with established nonunion may require bone grafting and plate
fixation, although the trend in older (>12 years) children is locked
intramedullary nailing.
o Muscle weakness: Many patients demonstrate weakness, typically in hip
abductors, quadriceps, or hamstrings, with up to a 30% decrease in strength
and 1 cm thigh atrophy as compared with the contralateral, uninjured lower
extremity, although this is seldom clinically significant.
o Leg length discrepancy: Secondary to shortening or overgrowth. It
represents the most common complication after femoral shaft fracture.
o Overgrowth: Overgrowth of 1.5 to 2.0 cm is common in the 2- to
10-year age range. It is most common during the initial 2 years after
fracture, especially with fractures of the distal third of the femur and
those associated with greater degrees of trauma.
o Shortening: Up to 2.0 cm (age dependent) of initial shortening is
acceptable because of the potential for overgrowth. For fractures
with greater than 3.0 cm of shortening, skeletal traction may be
employed before spica casting to obtain adequate length. If the
shortening is unacceptable at 6 weeks after fracture, the decision
must be made whether osteoclasis and distraction with external
fixation are preferable to a later limb length equalization procedure.



DAFTAR PUSTAKA
1. Wilkins EK, Aroojis JA. Incidences Of Fracture In Children. In: Beaty JH, Kasser
JR, editors. Rockwood And Greens Fractures In Children. 6th ed. Lippincot
Williams & Wilkins.2006. p 1-18.
2. Koval KJ, Zuckerman JD. Handbook of Fractures, 3rd Edition. New York:
Lippincott Williams and Wilkins. 2006; chapter 48, p. 578-82.
3. Beaty JH, Kasser JR. Femoral Shaft Fracture. In: Beaty JH, Kasser JR, editors.
Rockwood And Greens Fractures In Children. 6th ed. Lippincot Williams &
Wilkins.2006. p 893-934.
4. Thompson JC. Netters Concise Atlas of Orthopaedic Anatomy. Secomd Edition.
New York. Saunders Elsevier. 2004, chapter 8, p. 251, 256,266-9.
5. Cole A, Pavlou P, Warwick D. Injuries of Hp and Femur. In: Solomon L, Warwick
CD, Nayagam S, eds. Apleys System of Orthopaedics and Fractures, 9th. UK:
Hodder Arnold. 2010; p. 868-870.