Right Open Mid-Shaft Femur Fracture

Fready Luke anak Kenidy (45583)

Abstract

Road injuries and fatalities are a growing concern in Malaysia, with more than
6000 killed and over 25,000-recorded injuries yearly for the past 5 years. Majority
of road accident fatalities involve motorcyclists, constituting more than 50% of the
total number of fatalities. This is a case of 23 years old gentleman, was alleged
for road traffic accident presented with pain, swelling and open wound at the right
thigh suspected open fracture. From this case, I get to compare and contrast the
principle of management of open fracture compared to the closed type particularly
on femur bone.

Introduction

Femur is the largest and strongest bone in the body. It has linea aspera (Latin:
rough line) a ridge of roughened surface on the posterior surface of the shaft of
the femur, to which are attached muscles and intermuscular septum. It also acts
as a compressive strut to accommodate anterior bow to femur. Mechanism of
traumatic fracture can be categorised into; 1) high-energy, which commonly occur
in younger population, often a result of high-speed motor vehicle accidents. 2)
low-energy, more common in elderly often a result of a fall from standing. Aside
from that, gunshot also contribute to low energy mechanism fracture.

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Case presentation

Mr S, a 23 years old gentleman works as factory operator admitted to

emergency and trauma department (ETD) by ambulance presented with right
thigh pain and open wound. He involved in road traffic accident; side collision
with a car while he was riding his motorcycle under the speed of 60 km/hr at
7.30 AM when was about to go to his workplace. Unfortunately, he had lost
control after a car in front of him broke accidentally. He tried to avoid the car by
doing the same (pressing the emergency break) but subsequently was thrown
forward from his motorcycle and fell on the right side of his body prominently
over the thigh. Post traumatic, he developed pain over the right thigh with
laceration wound. The pain was sudden in onset, sharp in nature, did not
radiate elsewhere, aggravated by movement and did not relieve by anything
except for painkiller with pain score 10/10. He also noticed bleeding from his
right lower limb especially thigh region. He sustained abrasion wound on right
hand and leg and laceration wound over his right heel. Thus, patient need help
to ambulate. Otherwise, he has no loss of consciousness, no nose bleed, no
nausea and vomiting, no abdominal pain, no chest pain. In SGH, he was
informed by a doctor that he was having right open mid-shaft fracture. He then
went for wound debridement and skeletal traction was put on his proximal tibial
bone.

Physical examination was done on the 3rd day of admission. On general

inspection he was pink, alert, conscious, cooperative, oriented, fair hydration
status and was not in respiratory distress. Negative pelvic and chest spring test,
his lung was clear and abdomen was soft and non-tender. Upper limb
examination showed abrasion over the dorsal aspect of the and hand. On lower
limb examination, patient was on skeletal traction inserted at proximal part of
right tibial bone. There is puncture wound on his lateral aspect of his right mid-
thigh covered by bandage which was tender on palpation. There was also
stitches over his right heel measuring 4 cm at the medial aspect. Otherwise
there was no other skin changes such as scars, sinus deformity, discoloration

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and muscle wasting seen. On feel, there was no temperature changes but there
was tenderness over the right thigh. On movement, full range of motion both
upper limb and lower limb except for right knee due to pain. For neurovascular
examination, there were no tremor, muscle wasting, fasciculation, jerky
movement, skin changes. The tone was normal and normal reflexes with intact
sensation and coordination upon all modalities testing.

The investigations that have been done to this patient are blood test a baseline
investigation such as full blood count, blood urea and serum electrolyte and
coagulation profile and all these showed normal or within the range results.
Then, anteroposterior (AP) and lateral view of the right femur X-ray revealed a
communited fracture over right mid-shaft of the femur.

Discussion

A fracture is a break in the structural continuity of bone (Soloman, Warwick and

Nayagam,2014). In this case, the fracture at the mid-shaft femur was due to
motorbike accident where he landed on his right thigh after a sudden brake.
Thus, it was a strong impacted force. There was also associated with lacerated
wound and revealed it was a communited fracture. This kind of fracture may be
complicated with circulatory impairment, nerve injury especially the median
nerve, malunion, tendon rupture and joint stiffness. For this case, he was
brought to the hospital by the ambulance. Immediate delivery of Advanced
Trauma Life Support (ATLS) by securing airway, breathing and circulation need
to be done. Transferring to the hospital, he was maintained with oxygen
saturation or ventilated using oxygen mask. In short, primary survey and
resuscitation was done to him. Next up was secondary survey once he has
been resuscitated, he was been examined head to toe to rule out any open
fracture, contusion, deformity, and also neurological assessment.

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Subsequently, X-ray of his forearm was done and revealed the was fracture at
the mid -shaft of the right femur. He was given Tablet paracetamol for the pain
and his lower limb been examined by the doctor. The wound at his right thigh
and heel underwent wound debridement. Laceration wound was close using
stitches and bandage applied over the area. He was then put skeletal traction
where the pin inserted on his right tibia.

He was admitted to the ward and currently stable. He was prescribed with
following medications; IV Cefuroxime 1.5 g stat then 750 mg TDS, T.
Paracetamol 1g QID, C. Tramadol 50 mg TDS. He was then plan for wound
debridement of right thigh and high tibial pin insertion. While waiting for the
procedure, he was nil per mouth, neurovascular charting is recorded of right
lower limb, continue analgesia and antibiotic. On the next day, he underwent
the operation. The operation was done and the findings are 0.5cm x 0.5cm
puncture wound over volar aspect of distal end radius communication with
fracture site, minimal contamination, no neurovascular damage and mid shaft
femur fracture. For post-operative orders, he is allowed orally once he gained
conscious, continue IV antibiotic and analgesia, check X-ray later of right thigh
and daily pin tract dressing.

A week later, he was plan for interlocking nail implantation over the fracture site.
This was then referred for physical therapy because he will most likely lose
muscle strength in the injured area, exercises during the healing process are
important. Physical therapy will help to restore normal muscle strength, joint
motion, and flexibility. It can also help patient manage their pain after surgery.
The therapist will also help patient learn how to use crutches or a walker.

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Gustilo’s classification of open fractures is usually used in the hospital centre
to grade the fracture in term of management.

I <1 cm long Minimal Simple low-energy fractures

II 1-10 cm long Moderate, some muscle damage Moderate comminution

IIIA Usually >10 cm long Severe deep contusion; + compartment syndrome

High-energy fracture patterns; comminuted but soft-tissue cover possible

IIIB Usually >10 cm long Severe loss of soft-tissue cover Requires soft-tissue
reconstruction for cover

IIIC Usually >10 cm long as IIIB, with need for vascular repair Requires soft-
tissue reconstruction for cover

In this case, this patient is graded as grade 3a as mentioned above.

Conclusion

In conclusion, femoral shaft fractures in young people are frequently due to

some type of high-energy collision similarly to this patient which was motorcycle
crash. There is a strong correlation of coexisting soft tissue injury to the thigh
as detected in the management of this injury. There are numerous of treatment
modalities for this fracture, and there are no significant similarities in the clinical
outcome measures used. Hence, in future hopefully to strengthen an evidence-
based model of management is pursued to develop.

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Acknowledgement

I would highly appreciate and acknowledge to my patient for his full cooperation
for being questioned and giving me an approval consent to do a physical
examination. I would also like to express my deepest gratitude to UNIMAS
medical lecturer for the guidance and advice.

References

Solomon, L., Warwick, D.J. and Nayagam, S. (2014) Apley and Solomon’s concise
system of Orthopaedics and trauma. 3rd edition. London: Hodder Arnold ;
Distributed in the United States by Oxford University Press.

Young BT, Rayan GM. Outcome following non operative treatment of displace distal
radius fractures in low demand patients older than 60 years. J Hand Surg Am.
2000;25:19-28

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Patient’s Particular

Name : Mr Syaiful Syahrin anak Beliang

Age : 23 Years Old

Gender : Male

IC No. : 961226 – 06 – 5919

R/N : 2019/006715

Race : Iban

Religion: Christian

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