BAB I

CASE REPORT
I.

II.

IDENTITAS
Name

: MF

Age

: 4 years

Gender

: Male

Addres

: Rowosari, Kendal

Job

: Buruh

Religion

: Kristen

At hosipital

: 1 Juni 2015

Room

: Kenanga

No.CM

: 419255
ANAMNESIS

A. Symptom
B. Present History

: Femur pain
:

A child who had femur pain by motor vehicle accident 2 hours before came into
emergency room. He just had hematom at his femur. The left leg cant move due to
the pain while the right foot can move freely. Patient was ride motorcycle by his
mother. No complain for both of his hand. At the time of accident, patient was fell
into left side. There is no head injury. The patient unconscious and no complain
causing by nausea and vomiting. No interference urination and defecate.
C. Medical History :
History of similiar njury
History allergy drug and food
History of log cough

: Nothing
: Nothing
: Nothing

D. Family Medical History :

History of similiar symptom
: Nothing
History of heart disease
: Nothing
History of Diabetes Militus
: Nothing
E. Personal History, Social and Environment
1

The patient's parents worked as padagang in the market . The third patient is a child of
three siblings . Both siblings of patients still attending high school . Patients school
yet .
III.

PHYSICAL EXAMINATION
GCS

: 15

Vital Sign

HR

: 110 x/menit

RR

: 20 x/menit

: 36,5 C (per rec)

Status generalis
1. Skin

: turgor (N)

2. Head

: mesocephal, wound (-)

3. Eyes

: anemis (-/-), icteric (-/-),

4. Ear

: Discharge (-/-)

5. Nose

: deviation septum (-), discharge (-/-).

6. Mouth

: sianosis (-).

7. Neck

: simetris, trachea deviaton (-),

(-), enlargment oh the tyroid gland (-),
Thoraks

normochest, simetris,

COR
Inspeksi

: ictus cordis (-)

Palpation :

ICTUS cordis palpable at SIC V, 2 cm medial to the linea

midclavicularissinistra, pulsus the sternal (-), pulsus epigastrium (-)

Percussion:

heart border

Bottom left : SIC V, 2 cm medial linea midclavicularissinistra

Top left

: SIC II linea sternalis sinistra

Top right : SIC II linea sternalis dextra

2

Waist heart : SIC III linea parasternalis sinistra

Impression : configuration of the heart normal
Auscultaion :

heart sound I-II reguler, gallop (-), murmur (-)

PULMO
Anterior
I : Statis

normochest

Posterior
(+/+), I : Statis

: normochest

simetris(+/+), retraction (-/-)

simetris(+/+), retraction (-/-)

Dinamis : simetris (+)

Dinamis : simetris (+)

(+/+),

Pa : Statis : simetris (+), nothing Pa : Statis : simetris (+), nothing

widening

between

the

ribs,

widening

between

the

ribs,

retraction (-/-)

retraction (-/-)

Dinamis : simetris (+), nothing

Dinamis : simetris (+), nothing

widening

widening

between

the

ribs,

between

the

retraction (-/-)

retraction (-/-)

Stem fremitus kanan=kiri

Stem fremitus kanan=kiri

Pe : sonor (+/+)

ribs,

Pe : sonor (+/+)

Aus: vesikuler (+/+), ronkhi (+/-), Aus: vesikuler (+/+), ronkhi (+/-),
wheezing (-/-)

wheezing (-/-)

8. Back : kifosis and lordosis (-)

9. Abdomen
Inspeksi : Tampak datar, meteorismus (-), massa (-)
Palpasi

: Supel, nyeri tekan (-), hepar dan lien tak teraba

Perkusi

: tympani (+)

Auskultasi: bowel (+) normal

10. Ekstremitas
Superior

Inferior

Akral dingin
Oedem
Capilary refill
Jejas
Hematom

IV.

(-/-)
(-/-)
<2
(-/-)
(-/-)

(-/-)
(-/-)
<2
(-/+)
(-/+)

LOCALIST STATUS
Regio Femur

V.

Look
Feel
Move

: hematom (+), wound (-), blood (-), oedem (+)

: Pain (+) at femur sinistra, warm (+)
: limited movement

SUPPORTING EXAMINATION
1. X-Foto Rontgen Hip and Cruris sinistra AP Lateral (1-6-2015)
Emergency Room
X-Ray Femur AP Lateral

X-Ray Tibia
Fibula

AP

Lateral
2.

Laboratory
(06-122014)
Emergency
Room
4

Hematologi
Hemoglobin
Leukosit
Trombosit
Hematokrit
Protrombin Time
VI.

Hasil
10.2
16,2
353
31,1
12,2

L
H
L

ASSESMENT

Clinical Diagnostic
1. Close Fracture Femur Sinistra

VII.

INITIAL PLAN
a. Ip Terapeutic
Medical treatment
- Inj. Cefotaxim
- Inj. Novaldo
- po. Cefixime
- Ibubrofen syr

3x300 mg
1x0,5 amp
2x100 mg
3x 0,5 cth

b. Ip Operatif
Open Reduction Interal Fixation Femur sinistra
c. Ip Monitoring
General Situation, Vital Sign, the result of supporting examination.
d. Education
- Describes of the disease and the prognosis to the family
- Explains the possible complication that can happen to family
VIII.

PROGNOSIS

Quo ad vitam : ad bonam

Quo ad sanam: ad bonam

Quo ad fungsionam: dubia ad bonam

BAB II
LITERATUR REVIEW
INCIDENCE
The annual rate of children who present with femoral shaft fracture has been estimated at
19 per 100,000.1 Boys have a higher risk of fracture than girls and this is consistent with
participation of boys in sporting activites.
PREVALENCE
Diaphyseal femur fractures account for 1.4%3 to 1.7%4 of all pediatric fractures.
BURDEN OF DISEASE
There are many components to consider when calculating the overall cost of treatment for
pediatric femoral fracture. The main considerations for patients and third party payers are the
relative cost and effectiveness of each treatment option. But hidden costs for pediatric patients
must also be considered. These costs include the additional home care required for a patient,
the costs of rehabilitation and of missed school for the patient, child care costs if both parents
work, and time off of work required by one or both parents to care for the pediatric patient.6
ETIOLOGY
The primary cause of diaphyseal femur fracture in children varies by age groups includes
falls, motor-vehicle accidents, and sports injuries. In addition, the Cincinnati Childrens
Hospital Medical Center states, In children less than one year of age, child abuse is the
leading cause of femoral fractures and abuse remains a significant concern in toddlers up to
about five years of age.
RISK FACTORS
Occurrences of pediatric diaphyseal femur fractures are higher in boys than in girls in all
age groups.1,2 This literature also suggests that the primary mechanism of fracture is agerelated, including falls and child abuse for younger children, falls, motor vehicle-pedestrian,
bicycle, and motor-vehicle collisions for school age children and motor-vehicle or sports
related accidents in teenagers.
6

One study suggests increased risk of fracture for blacks over whites1 and one study suggests
no difference by race/ethnicity.2 Both studies suggest that lower socioeconomic conditions
also increase fracture risk.

EMOTIONAL AND PHYSICAL IMPACT OF PEDIATRIC DIAPHYSEAL

FEMUR FRACTURES
The prolonged loss of mobility and absence from school often associated with the
treatment of pediatric diaphyseal femur fractures can lead to adverse physical, social, and
emotional consequences for the child as well as the childs family. Treatments that minimize
the childs length of immobilization and time out of school are therefore desirable.
POTENTIAL BENEFITS, HARMS, AND CONTRAINDICATIONS
Invasive and operative treatments are associated with known risks. Contraindications vary
widely based on the treatment administered. Therefore, discussion of available treatments and
procedures applicable to the individual patient rely on mutual communication between the
patients guardian and physician, weighing the potential risks and benefits for that patient.
Further, the age groups referred to in the specific recommendations are general guides.
Obviously, additional factors may affect the physicians choice of treatment including but not
limited to associated injuries the patient may present with as well as the individuals co
morbidities, skeletal maturity, and/or specific patient characteristics including obesity. The
individual patients family dynamic will also influence treatment decisions therefore; treatment
decisions made for children who border any age group should be made on the basis of the
individual. Decisions will always need to be predicated on guardian and physician mutual
communication with discussion of available treatments and procedures applicable to the
individual patient. Once the patients guardian has been informed of available therapies and
has discussed these options with his/her childs physician, an informed decision can be made.
Clinician input based on experience increases the probability of identifying patients who will
benefit from specific treatment options.
TREATMENT
To treat a child's thighbone fracture, the pieces of bone are realigned and held in place
for healing. Treatment depends on many factors, such as child's age and weight, the type of
7

fracture, how the injury happened, and whether the broken bone pierced the skin.
Nonsurgical Treatment
In some thighbone fractures, the doctor may be able to manipulate the broken bones
back into place without an operation (closed reduction). In a baby under 6 months old, a brace
(called a Pavlik Harness) may be able to hold the broken bone still enough for successful
healing.
a. Spica casting
In children between 7 months and 5 years old, a spica cast is often applied to keep the
fractured pieces in correct position until the bone is healed. There are different types of spica
casts, but, in general, a spica cast begins at the chest and extends all the way down the
fractured leg. The cast may also extend down the uninjured leg, or stop at the knee or hip.
Doctor will decide which type of spica cast is most effective for treating your child's fracture.
Doctor will sedate your child for the closed reduction, and apply a spica cast immediately (or

within 24 hours of hospitalization) to keep the fractured pieces in correct position until healing
occurs.
A young child in a hip spica cast to immobilize a femoral shaft fracture.

A thighbone fracture before and immediately after treatment with a spica cast. The femur will
remodel over time so that it appears normal.

When a bone breaks and is displaced, the pieces often overlap and shorten the normal
length of the bone. Because children's bones grow quickly, your doctor may not need to
manipulate the pieces back into perfect alignment. While in the cast, the bones will grow and
heal back into a more normal shape.
After application, the spica cast is typically changed every 6 weeks until the child has
been in the cast for 3-6 months. Improvement in the hip may not be realized until the first cast
change. While your child is in the cast, its best to pick him/her up from the waist while
supporting the trunk and thighs. Some doctors allow use of the cross bar as a handle but others
dont because of concerns that the cast may break. Either way, its best to avoid picking the
child up only underneath the arms with the weight of the cast pulling down on the.
Children between the ages of 6 months and 5 years who have femoral shortening greater
than 2 cm are usually considered to be poor candidates for a spica cast. This is because of
concern for overly aggressive reduction during cast application that can result in compartment
syndrome once the cast is applied. This concern for compartment syndrome is in immediate
spica casting, not delayed spica casting (traction followed by spica casting). Given that we
found no studies specifically addressing whether spica casting should be utilized in this
population, nor comparing spica casting to other treatment modalities, we can only say that the

current available literature is insufficient to recommend for or against the use of spica casting
when greater than 2 cm of femoral shortening is present
b. Traction
Simple skin traction rarely lasts more than 6 weeks, consider applying a traction pin. If the
shortening of the bones is too much (more than 3 cm) or if the bone is too crooked in the cast,
it may be helpful to put the leg in a weight and counterweight system (traction) to make sure
the bones are properly realigned.
Surgical Treatment
a. Intramedullary Nailing
Doctors generally agree that displaced femur fractures that have shortened more than 3 cm
are not acceptable and require treatment to correct at least a portion of the shortening.
Left, Preoperative X-ray of a child with a fracture through the midshaft of the left femur.
Right, Postoperative X-ray of the same child shows that the fracture was treated with
internal flexible nailing to restore stability and allow early mobilization.
In some more complicated injuries, the doctor may need to surgically realign the bone and
use an implant to stabilize the fracture. Doctors are treating pediatric thighbone fractures
more often with surgery than in previous years due to the benefits that have been
recognized. These include earlier mobilization, faster rehabilitation, and shorter time spent
in the hospital. In children between 6 and 10 years old, flexible intramedullary (inside the
bone) nails are often used to stabilize the fracture. Over the past decade, this treatment
method has gained great acceptance.
Occasionally, the broken bone has too many pieces and cannot be treated successfully
with flexible nails. Other options that can lead to successful outcomes in this situation
include:
1. A plate with screws that "bridges" the fractured segments

10

2. An external fixator this is often used if there has been a large open injury to
the skin and muscles
3. Prolonged traction with a pin temporarily placed into the thighbone
b. External Fixation
External fixation is often used to hold the bones together when the skin and muscles
have been injured. As the child nears the teenage years (11 years to skeletal maturity), the most
common treatment choices include either flexible intramedullary nails or a rigid locked
intramedullary nail. The rigid nail is particularly useful when the fracture is unstable. Both
types of nails allow for the child to begin walking immediately. A rigid, locked intramedullary
nail is often used for femur fractures in adolescents who are nearly full grown.
There are few statistically significant differences between treatments in healing of the
fracture. The evidence reviewed included ten studies that examined one hundred varying
outcomes. Of these one hundred outcomes twenty-one were significant. There were no studies
that directly compared flexible nails to spica casting. When flexible nails were compared to
external fixation and traction plus casting, nine outcomes were significant favoring flexible
nails, one significant outcome favored external fixation and one significant outcome favored
traction plus casting.
Study found to address this recommendation compared external fixation to spica
casting. External fixation was favored over spica casting for malunions, including
anterior/posterior angulation. Twelve other outcomes for this comparison had non-significant
results.
In summary, the overall body of evidence considered for this recommendation indicates
that there are few significant outcomes when all comparisons are considered. Further,
important comparisons have not been investigated (spica casting and flexible nails).
Study shows more rapid return to walking and school with flexible intramedullary
nailing and one illustrates less associated hospital costs when compared to traction and casting.
The ability to mobilize the patient, return them to school rapidly, and suggested decrease in
hospital costs leads the work group to suggest flexible intramedullary nailing over traction
followed by casting. There is evidence that flexible intramedullary nailing has less adverse
11

events and more rapid return to school than external fixation in both stable and unstable
fractures.
Based on the advantages suggested, less adverse events and more rapid return to
school, flexible intramedullary nailing is a treatment option for children five to eleven years
diagnosed with diaphyseal femur fractures.

There is currently insufficient literature in

specially designed pediatric rigid intramedullary nails and bridge plating for inclusion in the
current guideline
Implant Removal After Fractur Healing
Certain devices used for managing pediatric diaphyseal femur fractures, such as
external fixators, must be removed after fracture healing. However, other implants (e.g.,
flexible intramedullary nails, rigid intramedullary nails, and plates and screws) are often
routinely removed after fracture healing in asymptomatic patients. The rationale for removal is
to prevent future problems related to the implant such as pain, stress shielding of the bone,
stress riser effects, chronic metal exposure, and difficulty with future surgeries from the
implant. Although implant removal is typically a minor uncomplicated procedure,
complications such as infection, hematoma, refracture, and anesthetic risks can occur. In
addition, implant removal puts the patient and family through a second procedure.
We identified six level IV studies that presented data on implant removal after the
management of pediatric femur fractures. We identified no studies that compared routine
implant removal to implant retention, or that assessed the long-term implications of implant
retention. Refractures occurred after external fixator removal. Complications were infrequent
after removal of internal fixation but included refracture and hematoma.
Because of the limited pertinent data regarding routine implant removal versus
implant retention after internal fixation of pediatric femur fractures, it was the consensus of the
work group that routine implant removal cannot be advocated for or against.

12

Regional pain management is an option for patient comfort peri-operatively.

A hematoma block and one Level IV study of a femoral nerve block, both of which were
effective at reducing pain. In the expert opinion of the work group, the risks associated with
regional pain management, such as femoral nerve neuritis and the complications associated
with epidural anesthesia in lower extremity fractures (missed compartment syndrome), are less
than with oral or IV systemic medicines.
Long-Term Outcomes
Generally, children who sustain a thighbone fracture will heal well, regain normal
function, and have legs that are equal in length. The intramedullary nails may need to be
removed following healing if they cause irritation of the skin and tissues underneath.
Occasionally, children will require further treatment, either early on or in subsequent
years, if they have a significant difference in the length of the legs, unacceptable angulation of
the healed bone, abnormal rotation of the healed bone, infection, or (rarely) if a thighbone
fracture persists (nonunion).These problems can nearly always be resolved with further
treatment.

13

BAB III
DISCUSSION

Anamnesis :
A child who had femur pain by motor vehicle accident 2 hours before came into
emergency room. He just had hematom at his femur. The left leg cant move due to
the pain while the right foot can move freely. Patient was ride motorcycle by his
mother. No complain for both of his hand. At the time of accident, patient was fell
into left side. There is no head injury. The patient unconscious and no complain
causing by nausea and vomiting. No interference urination and defecate. Patient never
feel the complaint like this before.

Physical Examination

Regio Femur

1. Look
: hematom (+), wound (-), blood (-), oedem (+)
2. Feel
: Pain (+) at femur sinistra, warm (+)
3. Move
: limited movement
Supporting Examination :
Laboratory Examination Hb 10,2 (L), Leukosit 16,2 (H), Ht 31,1 (L), X-Ray Femur :
Close fracture 1/3 middle of the os. Femur.
Therapy
: Operative, Cefotaxim, Novaldo, Cefixime, Ibuprofen, Drainase
Patients in this case 4-year-old complained of leg pain due to traffic accidents. while
the incidence of patient falls to the left. No injuries and blood in the femur just
hematoma. On supproting examination X-Ray there is fracture 1/3 middle of the femur.
The primary cause of diaphyseal femur fracture in children varies by age groups
includes falls, motor-vehicle accidents, and sports injuries.
To treat a child's thighbone fracture, the pieces of bone are realigned and held in place
for healing. There are two types of therapy femur fractures in children. Non surgical
traeatment and Surgical treatment.
Non surgical treatment is spica cast. In children between 7 months and 5 years old, a
spica cast is often applied to keep the fractured pieces in correct position until the bone
is healed. The surgical treament is
Study shows more rapid return to walking and school with flexible intramedullary
nailing and one illustrates less associated hospital costs when compared to traction and
14

casting. The ability to mobilize the patient, return them to school rapidly, and suggested
decrease in hospital costs leads the work group to suggest flexible intramedullary
nailing over traction followed by casting. There is evidence that flexible intramedullary
nailing has less adverse events and more rapid return to school than external fixation in
both stable and unstable fractures.
There is currently insufficient literature in specially designed pediatric rigid
intramedullary nails and bridge plating for inclusion in the current guideline.
The prolonged loss of mobility and absence from school often associated with the
treatment of pediatric diaphyseal femur fractures can lead to adverse physical, social,
and emotional consequences for the child as well as the childs family. Treatments that
minimize the childs length of immobilization and time out of school are therefore
desirable.
Doctors are treating pediatric thighbone fractures more often with surgery than in
previous years due to the benefits that have been recognized. These include earlier
mobilization, faster rehabilitation, and shorter time spent in the hospital

BAB IV
CONCLUSION

15

The primary cause of diaphyseal femur fracture in children varies by age groups
includes falls motor-vehicle accidents, and sports injuries.

Doctors are treating pediatric thighbone fractures more often with surgery than in
previous years due to the benefits that have been recognized. These include earlier
mobilization, faster rehabilitation, and shorter time spent in the hospital.

A recent shift in treatment in children between ages of 5 and 12 from nonoperative to

surgical intervention has led to shorter hospital stays and earlier return to activity with
reliable fracture healing.

16

BAB V
DAFTAR PUSTAKA
1. Treatment Of Pediatric Diaphyseal Femur Fractures Evidence-Based Clinical Practice
Guideline, Adopted by the American Academy of Orthopaedic Surgeons Board of
Directors.
2.

17