Case Report

“Nonunion 1/3 Tengah os. Femur fracture”

Submitted To Fulfill The Task And Complete One Of The Requirements In Taking The
Professional Medical Education Program in the Department of Surgery
at RSUD Soewondo Kendal Hospital

Arranged by:

Advisor:
dr. Wisnu Murti, Sp. OT

EDICAL FACULTY OF
SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2019
HALAMAN PENGESAHAN

Nama :

Fakultas : Kedokteran

Universitas : Islam Sultan Agung Semarang

Tingkat : Program Pendidikan Profesi Dokter

Bagian : Ilmu Bedah

Judul : Nonunion 1/3 tengah os. Femur fracture

Kendal, Mei 2019

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti, Sp.OT

 CHAPTER I

INTRODUCTION

Fracture is a discontinuity of bone. Fractures are divided into two, closed fractures and
open fractures. Closed (simple) fracture, if the skin placed above it is still intact (there is no
connection between fragments and outside world), while the fracture is open (combined)
that is if the overlying skin is not intact where this large fracture on dangerous for
contamination and infection.1,2

Fracture os. femur is most often place affected by traffic accident. There are several
variations placed reported, such as: Femoral neck fractures, fracture 1/3 proksimal, fracture
1/3 mid, 1/3 distal were more common happened in traffic acident 1,2.

Management of fractures consists of preoperative, intraoperative and postoperative

treatment. Preoperative in the form of initial assesment (basic life assistance) known as
ABC. ABC in trauma includes A for airway or airway, namely airway release; B for
breathing, pay attention to whether there are signs of hemothorax, pneumothorax, flail chest;
C for circulation or heart circulation / function to prevent or handle shock; D for disability is
to evaluate neurological status quickly; and E for exposure / environment that is conducting
a careful examination, the patient's clothes must be removed, besides that it should be
avoided the occurrence of hypothermia.
 CHAPTER II

LITERATURE REVIEW

I. ANATOMY
The femur is the longest and heaviest bone in the body, continuing the body
weight of the os coxae to the tibia when we stand. The femoral head is craniomedial
and slightly ventral when jointed with the acetabulum. The proximal end of the femur
consists of a femoral caput and two trochanters (major trochanters and minor
trochanters).2

Figure 1. Anatomy of os.femur.3

The intertrochanter area of the femur is the distal part of the femoral column and
proximal to the femoral stem. This area is located between a major trochanter and a
minor trochanter. The femoral head and femoral neck form angles (1150-1400) against
the long axis of the corpus femoris, these angles vary with age and sex. Corpus
femoris is curved, which is convex to the anterior. The distal end of the femur, ends in
two condyluses, the medial epicondylus and the arched lateral epicondylus are like a
screw. The femoral caput obtains blood flow from three sources, namely the
intramedular blood vessels in the neck of the femur, the ascending cervical artery
branches from the anastomosis of the media and lateral circumflex arteries that pass
through the retinaculum before entering the femoral head, and the blood vessels of the
 teres ligament2

Figure 2. Vaskularitation of os.femur.3

When a fracture occurs, the intramedular blood vessels and retinaculum blood
vessels experience tears when a fragment shifts. Transervical fractures are intracapsular
fractures that have very low capacity in healing due to damage to blood vessels, fragile
periosteum, and barriers from synovial fluid. The hip and neck joints of the femur are
wrapped by a capsule that is medially attached to the labrum acetabuli, laterally, to the
front attached to the trochanteric femoris line and to the back at the half of the posterior
surface of the collateral femur. These capsules consist of the iliofemoral, pubofemoral, and
ischiofemoral ligaments. The iliofemoral ligament is a ligament that is strong and shaped
like an inverted Y letter. Basically on the upper side is an anterior inferior iliac spine
attached, under the two Y arms attached to the upper and lower lines of the
intertrochanterica. This ligament serves to prevent excessive extension during standing.
Triangle-shaped pubofemoral ligament. The base of the ligament is attached to the
superior ramus of the ossis pubis, and the apex is attached below at the bottom of the
intertrochanterica line. This ligament serves to limit the extension of motion and
abduction. The ischifemoral ligament is shaped spiral and attached to the corpus ossis
ischia near margo acetabuli and at the bottom attached to the major trochanter. This
ligament limits the movement of extension.
 Figure 3. Anatomy of ligament on femur.3

II. FRACTURE MECHANISM

Femoral shaft fractures are observed in all age groups and can be associated with
various mechanisms. The mechanism of trauma in young patients is likely due to motor
vehicle accidents, motorcycle accidents, pedestrians attacked by vehicles, or falling from
a height. The mechanism of injury to motor vehicle accidents at 78%, motorcycle
accidents at 9%, pedestrians hit at 4%, falling from a height of 3%, gunshot wounds at
2%, and other mechanisms in 3%. Oblique fracture pattern at 51%, transverse 29% and
spiral 6%.

The process of fracture depends on the physical state of the bone and the trauma
that can cause the bone to break. Cortical bone has a structure that can resist compression
and twisting pressure. Most fractures occur because the failure of the bone to resist the
pressure, especially the pressure of bending, twisting, and pulling

Trauma can be:

- Direct trauma  causes direct pressure on the bone and fractures occur in the pressure
area. Fractures that occur are communicative and soft tissue is damaged.

- Indirect trauma  if trauma is delivered to areas farther away from the fracture area
and usually soft tissue remains intact
III. FRACTURE HEALING PROCESS
The process of healing fractures varies according to the type of bone affected and
the number of movements in the place of fracture. Healing begins with five stages, namely as
follows:
a. Stage of tissue damage and hematoma formation (1-3 days)
At this stage begins with torn blood vessels and hematomas are formed around
and in the fracture. The bone on the fracture surface, which does not have a blood
supply, will die for one or two millimeters. This hematoma will then become a
medium for the growth of fibrosis and vascular cells so that the hematoma changes
into fibrosis tissue with capillaries in it.
b. Inflammatory stages and cellular proliferation (3 days - 2 weeks)
After hematoma formation there is an acute inflammatory reaction accompanied
by proliferation of cells under the periosteum and in the penetrated medullary canal.
The end of the fragment is surrounded by cell tissue that connects the fracture site.
Freezing hematomas slowly absorb and smooth new capillaries develop into the area.
c. Stage of callus formation (2-6 weeks)
Cells that proliferate have condrogenic and osteogenic potential, if given the right
conditions, the cell will begin to form bone and in some circumstances, also the
cartilage. Cell populations also include osteoclasts which begin to clear dead bones.
Thick cell mass, with immature bone islands and cartilages, forming calluses or stabs
on the periosteal and endosteal surfaces. While immature fibrous bone becomes more
dense, movement at the fracture site decreases at four weeks after the fracture fuses.
d. Osification (3 weeks-6 months)
Callus (woven bone) will form a primary callus and gradually be transformed
 into more mature bones by the activity of osteoblasts which become lamellar
structures and excess callus will be resorbed gradually. Callus formation begins within
2-3 weeks after fractures through the endocondrial reinforcement process. Minerals
are continually piled up until the bones are truly united.
If osteoclastic and osteoblastic activity continues, immature fibrous changes into
lamellar bone. The system is now rigid enough to allow osteoclasts to break through
the debris on the fracture line, and near behind the osteoblasts fill the remaining gaps
between the fragments and the new bone. This is a slow process and may need before
the bones are strong enough to carry a normal load
e. Remodeling (6-12 months)
The fracture has been bridged by a solid bone cuff. For several months, or even
several years, this rough welding is reshaped by resorption processes and bone
formation will obtain a shape similar to its normal form.

IV. CLINICAL PRESENTATION

Signs and symptoms of femoral shaft fracture In conscious patients, the diagnosis
of femoral shaft fracture is usually clear. The patient usually has significant pain localized to
the thigh. However, the presence of a related injury or other fracture can be disruptive, both
for the patient and the examining doctor. The mechanism of injury is an important aspect of
history that might indicate fracture location, fracture configuration, and associated soft tissue
injury. The time of injury provides information about the potential for extensive blood loss,
the overall condition of the patient, and the possibility of significant associated soft tissue
injury. The location of the accident can provide information about the potential of certain
organisms that contaminate open fractures and the impact of environmental temperature on
the overall condition of the patient. Identification of each associated medical comorbid is also
an important aspect. Although this information has little impact on the diagnosis of the actual
femur fracture, this can determine the time of treatment, the type of fixation, and the need for
special evaluation. Physical examination can be difficult in patients with femoral fractures.
However, the examination should not be limited to sites that have obvious aches and
deformities. Further trauma life support protocols must be followed in the initial evaluation.
Orthopedic examinations should include visual inspection and palpation of all extremities,
pelvis and spine. Femoral fractures have an impact on the patient's hemodynamic status,
mainly because of the potential for blood loss to the soft tissue surrounding the thigh. In this
case, the patient was in a state of good consciousness, there was no history of head injury
during the accident. The patient comes with a complaint of pain in the right thigh, unable to
move his right foot. On physical examination, the edema is found in the middle of the right
thigh, there is deformity, angulation, external rotation and the right leg is shortened compared
to the left leg. There is tenderness in the middle of the thigh, with distal artery pulses still
palpable and saturation that is good or within normal limits

V. ADDITIONAL EXAMINATION
Radiology
Non union fracture cam make pseudoarthroses. Types of pseudoarthroses include:
 Hypertrophic pseudoarthrosis
 Oligotrophic pseudoarthrosis
 Atrophic pseudoarthrosis
 Hypotrophic (non-vital) pseudoarthrosis
 Defect pseudoarthrosis
 Infected pseudoarthrosis

VI. MANAGEMENT

a. External Fixation

~ Indications:

 Massive fracture

 Requires immediate stabilization of vascular repair

 Infection

 Multiple trauma

~ Strengths:

 Quick settings

 Minimal invasive deficiencies

 Pin tract infections

 Decreased joint movements

b. Intramedullary Nail

~ Indications: young age with non-comminutive fractures

~ Strengths:
  Short hospital stay

 Rapid joint movement

 Immediately able to walk

 Time of total disability decreases

~ Weaknesses: not all fractures can use this technique

c. Compression Plate

~ Indication:

 Good for distal junction fractures of metaphyseal-diaphyseal.

 Performed on fractures that can be seen directly and can reduce anatomically.

~ Strengths:

 early mobilization

 rigid fracture fixation, & improved knee movement

~ Complications:

 failed fixation

 infection

 nonunion

 devitalization of fracture fragments

 possible refraction due to excessive plate pressure.

 CHAPTER III

MEDICAL RECORD

I. IDENTITY
Name : Mr. S
Age : 59 years old
Gender : Male
Address : Kendal
Occupation : Unemployment
Religion : Islam
Come to Hospital : 4-5-2019
Room : Kenanga
No. CM : 488376

II. ANAMNESIS
a. Main problem : Pain of right thight
b. History of present illness
Pasien feel pain on his right thight since 5 days before come to hospital.
Patient feel pain after slipped and fall with his right knee got down first to the floor.
After that, his hip got pain especially when patient move his right leg, deformity, and
swelling. Patient also told he used 1 kruk after 3 weeks patient got operated on his
right thight. Normal urinate and defecate normal.
c. Family Medical History
 History of operation : Yes ( ORIF right thight on November 2018)
 History of similar injury : denied
 History of drug allergic : denied
 History of hypertension : No
 History of diabetic : No

d. Personal History, Social and Environment

 History of similar illnes : denied
 History of diabetic : denied

III. PHISICAL EXAMINATION

GCS : 15
Awarness : Composmentis
Vital sign
 BP : 120/80
 HR : 84x/minutes
 RR : 18x/ minutes
 Temp : 37 C
General Status
1. Skin : turgor (< 2 “)
 2. Head : mesochepal, wound (-)
3. Eyes : anemis (-/-), icteric (-/-)
4. Ear : discharge (-/-)
5. Nose : deviation septum (-), discharge (-/-)
6. Mouth: sianosis (-)
7. Neck : simestris, trachea deviation (-), enlargement of thyroid gland (-)

Thorax
 COR
- Inspection : ictus cordis (-)
- Palpation : ictus cordis palpable at SIC 2cm medial to the line
midclavicularis, Pulsus sternal (-), pulsus epigastrium (-)
- Percussion : Batas jantung
Bottom left : SIC V 2 cm medial line midclavicularis
Top Left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Bottom right: SIC III line parasternalis sinistra
- Auscultation : reguler I-II heart sound, gallop (-), murmur (-)

 PULMO
- Inspection : normochest, simetris, retraction (-)
- Palpation : vermitus vocal simetris (+), crepitation (-/-)
- Percussion : sonor (+/+)
- Auscultation : vesicular (+/+), Wheezing (-/-), ronchi (-/-)

 ABDOMEN
- Inspection : flat (+), simetris (+)
- Auscultation : peristaltic sound (+) normal
- Percussion : thympani (+)
- Palpation : supel, pain (-)

 EXTREMITAS EXAMINATION
Extremity superior Inferior
Oedem -/- +/-
Cold extremity -/- -/-
Physiological reflex +/+ +/+
Sianosis -/- -/-

 BACK EXAMINATION
Inspection : kifosis (-), scoliosis (-), gibbus (-)
Palpation : pain (-), proc spinosus (+) straight

IV. LOCAL STATUS

Right Tight
 Look : eritem (-), wound (-), deformity (+), Swelling (+)
 Feel : painfulness when it given a palpation, numbness (-), sensoric (+),
pulse a. dorsalis pedis (+)
 Move : Dissability of ROM and pain of movement
  LLD :
Right Left
True length 83 cm 84 cm
Apparent length 90 cm 91 cm
Anatomic length 42 cm 43 cm

V. SUPPORTING EXAMINATION
1. Radiology Femur dextra (AP-LATERAL) position after operation on November 2018

2. Radiology Femur dextra (AP-LATERAL) position Mei 2019

 3. Laboratory
Hematology Result Normal Value
HB 13,1 11,5-16,5
Leukosit 6,86 4-10
Platelet 431 150-500
Hematokrit 38,4 35-49
Protombin time 14,4 11,3-14,7
APTT 34,2 27,4-39,3

VI. ASSESMENT
Clinical Diagnosis : Nonunion 1/3 medial os. Femur fracture
VII. INITIAL PLAN
a. Ip. Therapy
- RL infus 20 tpm
- Inj. Ketorolac 1 ampul (30 mg) / 8 hour
- Inj. Ranitidin 1 ampul (50 mg)/8 hour
- Inj. Cefazolin 2 x 1 gram
b. Ip. Operative
ORIF + Reconstruction
c. Ip. Monitoring
- General condition
- Bleeding
- Vital sign
- The result of supporting examination
d. Education
- Educate patient to reduce body weight after operative treatment
 - Educate patient to do some simple exercise after the treatment was received.
VIII. PROGNOSIS
 Quo ad vitam : dubia ad bonam
 Quo ad sanam : dubia ad bonam
 Quo ad fungsionam : dubia ad bonam
 CHAPTER IV
CONCLUSSION

Fracture is a discontinuity of bone. Fracture os. femur is most often place affected by
traffic accident. There are several variations placed reported, such as: Femoral neck
fractures, fracture 1/3 proksimal, fracture 1/3 mid, 1/3 distal were more common happened
in traffic acident. Management of fractures consists of preoperative, intraoperative and
postoperative treatment.
On physical examination can find Look (Inspection): Deformity and swelling of
right tight; Feel (Palpation): pain on palpation; Move: dissability of ROM on left tight.
Patients with fractures may find it difficult to move and fractures should be suspected if there
is pain that creates limitations. On imaging examination can use the anteroposterior position
x-ray (AP) and lateral position of the tight indicated for cases of suspected nonunion fracture
1/3 tengah os. Femur sinistra.
Management of nonunion fracture 1/3 tengah os. Femur sinistra is operative theraphy.
Type of operations are eksternal fixation, intramedullary nail, and compression plate.
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