Department Of Orthopaedic And Traumatology Case Report

Faculty Of Medicine
Hasanuddin University

Neck Femur Fracture

Giovanni Felicityana Popang Membia C014202089

Supervisor : Residents :
dr. Putu Acarya N W
Dr. dr. Karya Triko Biakto, Sp.OT(K) Spine,MARS dr. Ardian Mario
dr. Muhammad Fadillah Faidzin Akbar
dr. Timothy Alexander Liwang
dr. Muhammad Zulkifli
 PATIENT IDENTITY

Name : Mrs. M

Age : 68 years old/female

Admission : March 10 st, 2023

Registration : 01010474
 HISTORY TAKING
Chief Complaint : Pain at the left hip
Suffered since 7 weeks before admitted to Wahidin Sudirohusodo Hospital. The patient fell while
walking on a slippery floor with the left hip hit the floor first. The pain worsens when the leg is moved
and relieved with rest.
After the incident, patient can not walk or stand due to pain. 2 weeks after the fall, the patient was able
to walk with a cane. Before the incident, patient can walk normally without aid.
The patient then brought to Sidrap Hospital for initial treatment and reffered to Wahidin Sudirohusodo
General Hospital for further treatment
HISTORY TAKING
There was no history of loss of consciousness
There was no history projectile vomiting
There was no history of going to bone setter
There was no history of diabetes mellitus and hypertension
 PHYSICAL EXAMINATION
General Status :
Conscious / well nourished

Vital Signs :
• Blood Pressure : 130/80 mmHg
• Pulse Rate : 105x/min
• Respiratory Rate : 21x/min
• Temperature : 36.7 0C
• NRS : 5/10
CLINICAL FINDING
 LOCALIZED STATUS
Left Thigh Region

Look : Deformity (+), Hematom (-), Swelling (+), Wound (-)

Feel : Tenderness (+)

Move : Active and passive movement of hip and knee joint cannot be evaluated due to
pain

NVD : Sensory is good.

Pulsation of dorsalis pedis artery and tibialis posterior artery are palpable
Capillary Refill Time less than 2 seconds
LEG LENGTH DISCREPANCY
Right Left

ALL 85 83

TLL 79 77

LLD 2 cm
RADIOLOGY
FINDING
Xray Hip AP
RADIOLOGY FINDING
Xray Femur (S) Ap/Lateral
 NILAI
PEMERIKSAAN HASIL RUJUKAN SATUAN

WBC 7.0 4,00 – 10,0 10^3 / ul

RBC 4.83 3,80 – 5,20 10^6 / ul
LABORATORY HGB 13.5 12,0 – 16,0 Gr/dl
FINDING HCT 42 37,0 – 48,0 %
MCV 87 80,0 – 97,0 Fl
MCH 28 26,5 – 33,5 Pg
MCHC 32 31,0 – 35,0 gr/dl
PLT 197 150 - 400 10^3 / ul
PT 9.8 10-14 menit
APTT 21.8 22-30 menit
DIAGNOSIS

Closed Fracture
Left Neck Femur Garden Type II
 MANAGEMENT

• IVFD ringer lactate

• Analgetics
• Apply Skin traction with 3 kg load
• Refer to Orthopedic Consultant
Thank You