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HOSPITAL KEPALA BATAS, PULAU PINANG


JALAN BERTAM 2, 13200 KEPALA BATAS
CASE STUDY
LONG BONE FRACTURE- FEMUR FRACTURE
NAME

MUHAMMAD HAFIZ BIN KAMARUDDIN

I/C NO

930421-14-5875

REG NO

18774

Greetings
PPW (Program Penempatan Wajib) Group 17
Hospital Kepala Batas, Pulau Pinang

Assalamualaikum w.b.t.
First of all I wish to say deepest gratitude because given the opportunity to
finish this assignment namely "Long Bone Fracture- femur fracture" in Malaysia
especially.
This assignment give a guide to me and all other PPWs to promote or implement the
most proper way based on latest clinical practice guidelines on management of
femur fracture. This assignment will be more concentrate to Assistant Medical
Officer Responsibility in managing femur fracture.
It is hoped so that this assignment becoming guide and jumping-off point in
realizing Lembaga Pembantu Perubatan Malaysia dream to strengthen organization
through build potential process.

Muhd Hafiz
MUHAMMAD HAFIZ BIN KAMARUDDIN
Assistant Medical Officer U29
Hospital Kepala Batas, Pulau Pinang
Sept 2016 Feb 2017

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Telefon: 019-xxxxxxx

KEMENTERIAN KESIHATAN
MALAYSIA
Perkhidmatan
Kesihatan

Kawal: MINEHEALTH
Mental

MINISTRY OF HEALTH
MALAYSIA

ACKNOWLEDGEMENT
With The Generous name of Allah with generosity. Alhamdulillah, thank God
that has awarded His blessing until I could complete this assignment prior
to compulsory component in completing PPW's programme. First I would like
to wish highest appreciation and gratitude to my supervisors Mr. Sazali bin
Ishak U32 and Mr. Mohamad Fikrie bin Mohd Noor U29 above all guidances,
reprimand and advice given along completing this assignment. Millions of
thanks also is expressed to my parents, which never idle in guiding and
give coaching that was beneficial.
Deepest gratitude also to all of my friends, PPW's team and also to
individual people that also help directly or indirectly in succeeding this
assignment. Finally, once more again I climb benediction to God existence,
so that all efforts contributed blessed by Allah s.w.t in the world and
afterworld.

Thank you

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Telefon: 019-xxxxxxx

KEMENTERIAN KESIHATAN
MALAYSIA
Perkhidmatan
Kesihatan

Kawal: MINEHEALTH
Mental

MINISTRY OF HEALTH
MALAYSIA

1.0 OBJECTIVE OF THE STUDY

To determine types of femur fractures: type 1:


spiral or transverse, type 2: communited, type 3:
open

To determine the classification of femoral shaft


fracture:
Grade I or 1: transverse or short oblique fractures with no
comminution or a small butterfly fragment of less than 25 %
%
of width of the bone
Grade II or 2: a comminuted with a butterfly fragment of
50%
% or less of the width of the bone
Grade III or 3: comminuted with a large butterfly fragment
of greater than 50%
% of the width of bone
Grade IV or 4: Segmental comminution

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1.1 RATIONALE OF ACTION

Diaphyseal fractures result from significant force transmitted from a


direct blow or from indirect force transmitted at the knee.
Pathologic fractures may occur with relatively little force. These may
be the result of bone weakness from osteoporosis or lytic lesions.
History usually is obvious in cases of femoral diaphyseal fractures.
Typically, patients describe a significant force applied to the
extremity. Significant pain and deformity are reported as well.

1.2 PROBABLE OUTCOME

Patients who survive the initial trauma associated with the injury
typically heal well. Early mobilization following intramedullary
nailing greatly reduces complications associated with prolonged
immobilization.
Age affects the speed and quality of recovery. Fractures may be caused
by underlying medical conditions such as osteoporosis or cancer
metastasis; these conditions may complicate recovery further.
Patients older than 60 years with closed fractures of femur have a
mortality rate of 17% and a complication rate of 54%.

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1.3 Abstract

Fracture usually happened due to trauma causes by excessive pressure in


bone

that

exceed

the

bone

capacity.

By

epidemiology,

more

regular

fracture happened in man of woman with comparison of 3:1. Fracture often


could happen due to traffic accident, sport accident, industrial accident,
or other diseases1.
Femur fracture is one of the type of fractures that often occurs. Femur
fracture incident in USA estimated 1 people for every 10000 residents every
year. Based on data collected by Immunoendocrinology University in Malaysia
in year 2006 from 1690 cases of traffic accidents, 249 cases or 14.7% has
experienced femur fracture.
Fracture is the lost or broken of continuity of bone, joint cartilage
bone, epiphyseal cartilage bone, either like total as well as partial.
To know the occurrence of why and how bone experience fracture should known
by bone physics condition and trauma condition that can cause fracture.
Mostly

fractures

happened

due

to

bone

cannot

hold

excessive

pressure

particularly pressure of bending, turning, and pulling2.


Trauma could happen directly or indirectly. Directly trauma cause
direct stress in bone and cause fracture in pressure area. Whereas indirect
trauma sent to area that is further from fracture area, for example fall
with extension hand can cause fracture in clavicle.

1Kumar V, Abbas AK, Fausto N, Aster JC. Bones, joints, and soft-tissue tumors. In:
Robbins and Cotran pathologic basis of disease 8 th edition. Philadelphia:
Saunders Elsevier; 2010. pg. 1219-1220.
22
American Academy of Orthopedic Surgeons. Thighbone (femur) fracture.
[Online]. 2008 [cited 2011 March 3]; Available from: URL:
http://orthoinfo.aaos.org/topic.cfm?topic=a00364.

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2.0 INTRODUCTION
2.1 Definition of closed fracture
A closed fracture is a broken bone that does not penetrate the skin. This
is an important distinction because when a broken bone penetrates the skin
(an

open

fracture)

there

is

need

for

immediate

treatment,

and

an

operation is often required to clean the area of the fracture. Furthermore,


because of the risk of infection, there are more often problems associated
with healing when a fracture is open to the skin.

2.1 Types of closed fracture


Most of the seriousness of closed bone fractures depends on what causes the
fracture. So here are the different types are in this major category.
Displaced fracture. This is the type of closed fracture where in the
bones are displaced due to hard impact or trauma.
Pathological fracture. Bone cancer or other debilitating bone diseases
cause this type of fracture. The bones become lighter because it loses
its density, thus even with low impact, the bones can fracture easily.
Osteoporosis fracture is also among the list of this type of fracture.
Hairline or stress fracture. With the stressing of the limbs due to
constant and over training, running, and dancing, the bones can develop
small hairline fractures that can lead to bigger fractures in the long
run.

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2.2 Causes of closed fracture


As is the case with all fractures, closed fractures usually occur as a
result of direct blow by high-energy trauma of an outside force on the
bone. When this force is stronger than the bones, it results to a closed
fracture. Some of the cases where force is greater than the bones are the
following:

Motor vehicular collisions or accident

Sports injuries

Falls

Sometimes, certain conditions and disorders of the body weaken the


bones in the body, increasing risks for closed fracture, such as:
o

Osteoporosis

Cancer

Indirect force

Abnormal muscular contraction

2.2 closed fracture sign and symptoms


Because a closed fracture may not be as evident as open fractures, some may
find

it

more

difficult

to

tell

if

the

bone

is

broken

or

dislocated.

Dislocations usually occur in the joints. The following are signs and
For closed bone fractures that involved nerve damage, there can be
feeling of
of closed
tingling
sensation on the area and sometimes numbness
symptoms
fractures
Bruising due to internal haemorrhages, clotting of the blood or due to
damaged tissues
Swelling around the injured area
A breaking or cracking sound heard or felt
Severe pain, especially in attempting to move, at or near the site the
injury
Difficulty moving or impossible normal movement
Loss of power/ normal function

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Deformity in the bone or abnormal twist of limb

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3.0 CASE CLERKING

CASE STUDY EMERGENCY


HOSPITAL KEPALA BATAS, PULAU PINANG

CASE CLERKING

Name

: Muhammad Hafiz bin Kamaruddin

Reg. No.

18774

Year

Sept 2016 Feb 2017

Placement

: Hospital Kepala Batas, Pulau Pinang

PART 1: PATIENT PERSONAL DETAILS

Registration number:

Identification card number:

KB00241754

930411075463

Name: Muhammad Azzahari bin Alis


Sex:

Race:

Occupation:

Age:

Male

Malay

Student

23 years old

Address:

No. Tel:

Sebelah 1006, Kota Aur Kepala Batas, Pulau Pinang

-in medical record-

Hospital/Clinic:

Date:

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Hospital Kepala Batas, Pulau Pinang

24 December 2016 @
4:50pm

3.1 CALLING INFORMATION


Date : 24 December 2016
Time : 4:20 p.m.
Category of calling case : Red
Location : Kampung Kota Aur (Sebelum masjid)

3.1.1 CALLER INFORMATION


Caller name : Khairi
Caller telephone number : 017-4912781

3.1.2 CHIEF COMPLAINT


Motor Vehicle Accident (Motorbike skidded)

3.1.3 AMBULANCE TEAM

Assistant Medical Officer: PPP Muhammad Hafiz


PPK/crew
: PPK Samsuddin
Driver
: Faridon
Ambulance : Batas 1 (WUT 5266)

3.1.4 JOURNEY NOTES

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Time out

: 4:23 p.m.

On scene

: 4:35 p.m.

Leave scene : 4:40 p.m.


At Base

: 4:50 p.m.

3.2 PRIMARY SURVEY ON SCENE

Airway

clear

Breathing

Tachypnea 26 / min

Circulation BP 149 / 59
- PR 115 / min (tachycardia)
- Spo2 95

(on air), 100% with high flow mask oxygen

Skin

Pale, sweating

Pupil

Right eye normal


- Left eye normal
- Both eyes reactive to light

GCS

E 3, V 4, M 5
- 12/15

LUNG
CVS

Bilateral clear
DRNM

3.3 PRE HOSPITAL CLERKING CASE

23 years old Malay man, involve in motor vehicle accident (Motorbike


skidded).

Both lungs clear, air entry equal

Chest spring negative

Pelvic spring negative

abrasion wound over right leg

2 Branula size 16 G inserted with 1 pint Normal Saline and 1 pint


Hartman

High flow mask oxygen 100% given to prevent hypoxia

Put bandage to stop bleeding

Put Hare Splint Traction

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Informed MECC tagging red

Patient tagging to red zone for further management

Imp : TRO Right leg closed Femur Fracture

3.4 CASE PATIENT

Name patient: Mr. Muhammad Azzahari bin Alis


Sex: Male
Race: Malay
Age: 23yrs
Status: Single
Present Diagnosis: Alleged MVA sustained closed fracture right femur
Ambulance call at Kampung Kota Aur @ 4.20pm on 24/12/2016 with

complaint alleged motor vehicle accident (MB skidded)


General condition patient at scene alert and conscious. No complaint
of loss of consciousness(LOC)
Complaint pain at right leg, unable to move, deformity at right thigh
Laceration wound over the chin and multiple abrasion wound
upper/lower limb
Apply leg splint at right leg and cover wound with gauze.

Vital sign patient


Blood Pressure

: 149/59 mmHg

Pulse

: 115/min

Spo2

: 95% under room air

Pupils

: 3mm reactive bilateral

Glasgow coma scale (GCS)

: 12/15

Capillary refill rest

: less than 2 second

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4.0 MANAGEMENT

4.1 PRE-HOSPITAL CARE


Primary survey (Using Danger, Respond follow by ABCDE)
Scene survey = Danger look for any dangerous that will cause any
injury to patient while at the site.
-make sure patient is in safety are
-Note for any mechanism of injury on patient.
-At scene patient clear from any dangerous or injury.
R= Respond ask patient are you ok to know level consciousness of
patient. At site patient can answer any question and can follow
instruction.
A = Airway - To determine and assessing the airway either blocked
by foreign body.
-

Secure airway if necessary.

At the scene patient airway clear, no trauma or


foreign body seen.

B = Breathing - To assess breathing which is to determine either


patient is having difficulty in breathing or any respiratory problem.
-

Look, Listen, Feel & auscultate: Is the patient


distressed or any sign and symptom of life
threatening condition.

At the scene patient no determine of difficulty in


breathing or any sign and symptom of respiratory
problem.

C = Circulation & haemorrhage control check big artery: carotid


pulse either femoral.

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Look and feel for the skin colour, condition, and check
patients temperature to determine sign and symptom of
hypovolemic shock.

Establish intravenous line using branula size e.g. 18G


(according to patient body size) and at the scene patient
no sign and symptom hypovolemic shock.

Skin colour patient pink and pulse can feel.

D = Disability -Assess state of consciousness.


-Intervention - AVPU

-Glasgow coma scale


-Assess pupils size, reactivity & equity.
- Patient GCS: 12/15. Pupils size patient 3mm reactive both
side. No complaint loss conscious.

E = Exposure - To be done to rule out further examination to detect


any other injury involve.
-

Laceration wound at the chin, cover with gauze the


wound and abrasion wound at the right and left leg.

Deformity at right leg. Apply leg splint at the


right leg to reduce leg from active movement and to
maintain the alignment.

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4.2 EMERGENCY DEPARTMENT (secondary survey)


Continuing stabilization patient using ABCDE method.
Apply skin traction at right femur, to prevent further injury.
Check vital sign to recognize any sign and symptom of hypovolemic
shock.
Take history patient follow (AMPLE)
-

Allergic

Medication

Nil

Past medical/ surgical history

Nil

Childhood asthma, no past surgical history

Last meal

Around 12noon

MB skidded.

Event

Do a complete physical examination.

4.2.1 Examination of the head to toe


1. Head:

Inspection:

- No hematoma or swelling.
- No wound or scar noted
- No abnormality detected
(Laceration wound at chin)

Palpation:

No abnormality detected

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2. Eye (Bilateral):

Inspection: - No jaundice
- No discharge
- Pupil: both equal reacting to light.
- Size: both eye 3mm
- No Raccoons eyes

Palpation:

- No abnormality detected

3. Ears (Bilateral):

Inspection: - No bleeding or discharge from the ears


- No swelling or hematoma.
- No hearing lost.
- No battle sign

Palpation:

- No abnormality detected

4. Nose:

Inspection: - No bleeding or wound noted


- No swelling or scar noted
- No nasal discharge.

Palpation:

- No abnormality detected

5. Neck:

Inspection: - No bruises or open wound.


- No neck vein distension.
- No swelling.

Palpation:

- No neck stiffness.
- No bruit felt
- Trachea not shifted

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Respiratory System: (IPPA)

Inspection: - Respiratory rate was 22 per minutes


- Breathing pattern eupnoea
- Chest expansion was bilaterally symmetrical.
- Shape of the chest looked normal.

Palpation:

- The body temperature was normal


- No mass, lump or pulsation felt
- No tenderness or crepitus
- Chest spring test: negative
- Chest excursion found normal.

Percussion:

Auscultation:

- Normal resonance on both side

- Good heart sound, No crepitation sound, Lungs clear and good air
entry

Good in chest expansion and symmetry.

Lungs clear and no cardiomegaly

Cardiovascular System: (IPPA)

Inspection: - No abnormality noted and no abnormal pulsation seen.

Palpation:

- Apex beat was in normal position at 5th intercostals,

left midclavicular line.


-

Heart impulse are normal, no sign of pericardial


effusion

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Percussion: - Cardiac dullness is normal

Auscultation: - Normal heart sound.


- Dual Rhythm No Murmur

Alimentary System: (IPPA)

Inspection:

- No abdominal distension and no hematoma, no wound


- Symmetric

Auscultation: - Normal bowel sounds heard about 8 times per minutes


- No bruit, venous hump or friction rub heard.

Percussion:

- No abnormality detected.

Palpation:

- Abdomen soft, no guarding. Non tender.


- No superficial or deep tenderness on deep
palpation, all quadran.
- No sign of intraabdominalinjury.

Soft, non-tender

Nervous System:
A) Glasgow Coma Scale
EYE OPEN
SPONTANEOUSLY
TO VERBAL COMMAND
TO PAIN
NO RESPONE

SCORE
4
3
2
1

VERBAL RESPONE
ORIENTATED
CONFUSED
IN APPRORIATED WORD
IN COMPREHENSIBLE SOUND
NO RESPONE

5
4
3
2
1

MOTOR RESPONDE
OBEYS COMMAND
LOCALIZED PAIN
WITHDRAWAL TO PAIN

6
5
4

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PATIENT SCORE

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ABNORMAL FLEXION
EXTENSION TO PAIN
NO RESPONE

3
2
1
TOTAL SCORE PATIENT

5
12/15

Pelvic Region:

Inspection: -Tenderness left side pelvic


-No bleeding and wound noted.

Palpation: - Pelvic Spring Test : negative both side

Spine Region:
**Log roll done **

Inspection: - No scar or wound seen.


- No sign of swelling or hematoma.

Palpation:

- No deformity or tenderness

Muscular System:
(Include hands and legs)

A. Upper Extremities:

Right and Left upper limb

Inspection: - No abnormality seen or

multiple abrasion wound both

side ( no active bleeding)

Palpation:

- Brachial and Radial Pulse palpable


- Capillary refill less than 2 seconds

B).Lower Extremities:

Right and Left lower limb

Inspection:
-

Palpation:

multiple abrasion
No active bleeding.
- Femoral and dorsalis pedis pulse palpable

- Capillary refill less than 2 second.

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- No loss of sensation, able to move lower limbs but at right side


weakness due to pain
- Deformity at right thigh
5.0 Type of Investigation Relevance clinical features and the rational of
investigation

1)

X-ray Right femur -

communited fracture of the right femur

- Skull, chest, cervical, lumbar sacral, pelvic: appear normal


- Right tibia-fibula: no obvious Fracture and dislocation.

(X-Ray of extremities- To find out any abnormality of the upper and lower
extremities, assist in the diagnosis of fractures.)

Based on the x-ray taken it shows that there


was communited fracture on 1/3 mid shaft
femur.

Chest x-ray

Take blood for lab investigation such as Full Blood Count,


Blood Urea Serum Electrolyte, PT, APTT and grouping cross match
to standby if needed during operation.

2) Full Blood Count

HB

- 7.3

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WBC

- 11.4

PLT

- 128

(Full Blood Count

- To assess any sign of infection (increase WBC, FBC.

Haemoglobin to detect anaemia. Platelet to detect any risk of bleeding


tendency)

3)

Buse / Creatinine
(Bl
Sodium

138

Potassium
Chloride
Urea

3.7

101

2.5

Creatinine

67

ood Urea/Creatinine - To assess the blood urea and serum electrolyte level
and Serum Electrolyte (BUSE) renal function.)

5.1 Medication and treatment given at ED


-

IM ATT 0.5ml

IM Voltaren 75mg

IV

Iv zinacef 1.5g

1 pint run 2 hours

Toilet and suture done at chin under local anaesthesia

Dressing done at wound with normal saline and apply flavine

Refer to orthopaedic specialist in HSJ for further management.

Flagyl 500mg

Final diagnosis:
Closed communited 1/3 midshaft right femur fracture

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Treatment:
Open Reduction Internal Fixation (ORIF)

Follow up on 25/12/2016
S Right thigh immovable, painful if driven.
O Pulse: 82 bpm, RR: 20 br/min, Temp: 37c, BP: 120/80mmHg
Status of right inferior extremity:
Look: Swollen, deformity at 1/3 midshaft femur, seems shorten
compared to left part, tarsal part edema
Feel: Dorsalis Pedis is palpable, crepitation (-), feel warm when
palpate at right femoral region
Move: Limitation of active movement or passive movement.
A Closed communited 1/3 midshaft right femur fracture.
P Plan for ORIF

Follow up on 26/12/2016 patient request to go home (At own risk Discharge)

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6.0 DISCUSSION
6.1 Complication

The

ends

of

broken

bones

are

often

sharp

and

can

cut

or

tear

surrounding blood vessels or nerves.

Acute compartment syndrome may develop. This is a painful condition


that occurs when pressure within the muscles builds to dangerous
levels.

This

pressure

can

decrease

blood

flow,

which

prevents

nourishment and oxygen from reaching nerve and muscle cells. Unless
the pressure is relieved quickly, permanent disability may result.
This is a surgical emergency. During the procedure, your surgeon
makes incisions in your skin and the muscle coverings to relieve the
pressure.

6.2 Administer First Aid for Closed Fractures


Although it is not as serious as open fractures, closed fractures should
still be given first aid nonetheless. First aid for close fractures will
depend on the location and severity of the closed fracture. However, the
following hints are generally advised in cases of closed fractures:

Assess the fracture.

Immobilize the injured area. Do not attempt to push back the bone
thats visibly sticking out or misplaced. If one is trained to apply
splint, apply a splint above and below the fractured area. Pads may
be added to add comfort.

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Apply ice packs on the injured area to limit swelling and reduce
pain. Ice should not be applied directly to the skin. Wrap the ice in
towel or cloth.

Elevate the fractured area to limit swelling.

Remove

any

tight

clothing

and

jewelleries

to

avoid

impeding

circulation.

Check and monitor for symptoms of shock. If shock symptoms begin to


show, treat for shock.

If necessary, initiate CPR.

Though it is the least dangerous type of fracture, first aid should still
be administered to give comfort to the victim.

6.3 Prevention of closed bone injury


As it has been said, there would be no fracture if there is no assault to
the bone. However, accidents do happen whether we like or not and some
people sometimes do not mind if they might sustain fractures as long as
they enjoy what they are doing. The best prevention therefore is convincing
the people to be aware of their actions and wear protective gears when
involving themselves with sports that can possibly injure them. Children at
young age must also be warned about the consequences of their actions so
most likely they will listen if you can tell them exactly what could happen
if they do things dangerously.

6.3 Diagnostic procedures may include:

The physician makes the diagnosis with physical examination and diagnostic
tests. During the examination the physician obtains a complete medical
history

of

the

patient

and

asks

how

the

injury

occurred.

Diagnostic

procedures may include:

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X-rays - a diagnostic test which uses invisible electromagnetic energy


beams to produce images of internal tissues, bones, and organs onto
film.

Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a


combination

of

large

magnets,

radiofrequencies,

and

computer

to

produce detailed images of organs and structures within the body. This
test is done to rule out any associated abnormalities of the spinal cord
and nerves.

Computed tomography scan (Also called a CT or CAT scan.) - A diagnostic


imaging

procedure

that

uses

combination

of

x-rays

and

computer

technology to produce cross-sectional images (often called slices), both


horizontally and vertically, of the body. A CT scan shows detailed
images of any part of the body, including the bones, muscles, fat, and
organs. CT scans are more detailed than general x-rays.

6.4 Closed Fracture treatment

Treatments of closed fractures are highly dependent on the extent and type
of injury. Since closed fractures happen internally, they do not pose risks
of having infections thus making surgery as the last treatment option. This
type of fracture is also treatable and professionals encourage application
of first-aid since they do not need immediate emergency treatments. In
applying first aid for people with closed fractures, the injured individual
should be immobilized first by having him in a lying and unmoving position.
The injured area should be raised in an angle in order to minimize the
swelling. Ice packs should be applied to moderate the pain.

Most cases of closed fractures only need external fixation or the use of
slings, casts, or crutches as their treatment. However, surgery can be
immediately required in situations when there is internal bleeding on the
tissues and when the bones have been shattered into small pieces. Internal

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fixation uses devices like rods, screws, and plates that are implanted
inside the body and used to hold bones together that are fragmented.
Physical therapy is also added to the treatment regardless if the patient
had an internal fixation or external fixation. In physical therapy, range
exercises are conducted to help condition the affected body parts back into
its normal condition.

Treatment may include:

Splint/cast - immobilizes the injured area to promote bone alignment and healing to protect
the injured area from motion or use.

medication (for pain control)

Traction - the application of a force to stretch certain parts of the body in a specific
direction. Traction consists or pulleys, strings, weights, and a metal frame attached
over or on the bed. The purpose of traction is to stretch the muscles and tendons
around the broken bone to allow the bone ends to align and heal.

Surgery - required putting certain types of broken bones back into place. Occasionally,
internal fixation (metal rods or pins located inside the bone) or external fixation devices
(metal rods or pins located outside of the body) are used to hold the bone fragments in
place to allow alignment and healing.

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7.0 CONCLUSION
Treatment depends on the part of the femur that is fractured. Traction may
be useful for femoral shaft fractures because it counteracts the force of
the muscle pulling the two separated parts together, causing the two halves
to rip through otherwise undamaged tissue.
Traction is contraindicated in femoral neck fractures and also when there
is any other trauma to the leg.

7.1 Prehospital Care


Prehospital personnel should splint the extremity in the position it was
found. If signs of neurovascular compromise are observed, the limb may be
reduced
with

or

after

administering

without

adequate

neurovascular

analgesia.

injury,

can

be

Well-aligned
immobilized

fractures,
by

using

traction device. Hare or Thomas traction splints are most commonly used.
Apply wet sterile dressings over an open fracture. If the wound is grossly
contaminated,

sterile

saline

irrigation

may

be

used

to

remove

large

contaminants.
7.2 Fracture reduction and immobilization

Reduce fractures to near-anatomic alignment by using in-line traction.


This reduces pain and helps prevent hematoma formation. Hold reduction

by a traction device (eg, Hare, Buck) or long-leg posterior splint.


Pneumatic splint may have additional benefits of reducing blood loss by
direct pressure and tamponade of hematoma formation. Traction is often

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required to hold the femur out to length because of contraction of large


muscle mass in the thigh.
Pain management: Pain management is the most significant intervention of
the

emergency

extent

that

physician.

respiratory

Use
and

parenteral

opiate-type

circulatory

parameters

analgesics
allow.

to

the

Intravenous

administration allows for the most reliable titration to pain relief while
providing ready access for reversal agents (i.e., naloxone) if necessary.
Infection

prophylaxis:

With

open

fractures,

administer

tetanus

toxoid

(unless given within 5 y) and use antibiotics with excellent staphylococcal


coverage

and

good

tissue

penetration.

Often,

first-generation

cephalosporin (i.e., cefazolin sodium) is administered in combination with


gentamicin.
Other: In addition to maintenance intravenous fluids, patients suspected of
significant blood loss should be resuscitated with crystalloids. Place a
Foley catheter, and restrict all patients to taking nothing by mouth (NPO)
until seen by an orthopedic surgeon.

7.3 Complications
7.3.1 Hemorrhagic shock

Closed fractures of the femur can result in significant blood loss (eg,
1

L)

within

the

thigh.

Open

fractures

have

the

potential

for

even

greater blood loss.


Because of the high rate of associated injuries, actively seek out other
sources of blood loss in patients with femur fractures and hypovolemic
shock.

7.3.2 Neurovascular injury

Injuries

cushion of muscle protecting neurovascular structures.


Compartment syndrome of the thigh does not occur often, and peroneal

to

the

neurovascular

bundle

are

rare

because

of

the

large

nerve contusion is seen occasionally.

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Infection: While open fractures are at high risk of soft-tissue and bony
infection,

postoperative

infection

is

rare

following

repair

of

closed

fractures.

Respiratory demise: Fat embolism and adult respiratory distress syndrome


(ARDS) can occur. Femur fractures at a level one trauma center have been
associated with double the risk of developing ARDS (odds ratio [OR], 2.129;
95% confidence interval [CI], 1.382-3.278)[17] compared with other patients
admitted for musculoskeletal injury. The risk trends upward with delays in
surgical repair greater than 24 hours.
More delayed complications include permanent stiffness of the hip or knee,
shortening

of

the

extremity,

or

malrotation,

resulting

in

permanent

deformity and decreased performance.


Complications directly related to repair include (in order of increasing
frequency) breakage of fixator hardware, nonunion, malunion, or delayed
union.
Finally, refracture has occurred at the initial injury site.

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8.0 REFERENCES

1. Closed Fracture by Jonathan Cluett, M.D. Updated July 31, 2013


2. Posted by Ibrar on Aug 4, 2013 in Broken Ankle and Broken Foot First Aid
3. By a healthcare professional. 2009 Staywell Custom Communications
4. Kumar V, Abbas AK, Fausto N, Aster JC. Bones, joints, and soft-tissue
tumors. In: Robbins and Cotran pathologic basis of disease 8th edition.
Philadelphia: Saunders Elsevier; 2010. Pg. 1219-1220.
5. American Academy of Orthopaedic Surgeons. Thighbone (femur) fracture.
[Online]. 2008 [cited 2016 Dec 24]; Available from: URL:
http://orthoinfo.aaos.org/topic.cfm?topic=a00364.
6. Cluett J. Femur fracture. [Online]. 2005. [cited 2016 Dec 24]; Available
from: http://orthopedics.about.com/od/brokenbones/a/femur.htm.
7. Hoppenfeld S, Murthy VL. Treatment & Rehabilitation of Fractures.
Philadelphia: Lippincott Williams & Walkins; 2000.
8. Perry CR, Elstrom JA. Handbooks of fracture. Ed 2nd. United State of
America: McGraw-Hill; 2000.

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