Open Fracture 1/3 Distal femur (S) grade IIIA

Closed Fracture 1/3 Distal tibia (S)

Closed Segmental Fracture Fibula (S)

Presented by :
Hasmia

Advisor
dr. Benny Murtaza
dr. Jecky Chandra

Supervisor
dr. M.Ruksal Saleh, Ph.D, Sp.OT
Patient Identity
Name : Mr. E
Age : 16 years old
Sex : Male
Admittance : 20

July 2012
Address : Parigi, Maros
Occupation : Student
RM number : 55 51 42


History Taking
Chief complaint : wound at the left light
Anamnesis : suffered since + 4 hours before
admitted to Wahidin Sudirohosodo hospital
due to traffic accident.
Injury mechanism : He was riding a
motocycle, and then hit the tree.
History of unconsciousness (-), nausea (-),
vomit (-).


A : Patent, clear
B : RR = 18 x/min, simetris,
spontaneous, thoracoabdominal
type.
C : BP: 90/60 mmHg, PR= 88 x/min
regular, strong.
D : GCS 15 (E4V5M6), pupil isochors
2,5mm/2,5 mm, light reflex +/+
E : T = 36,7
0
C (axillar)


Primary Survey
Secondary Survey
Femur sinistra region :
I : Lacerated wound at anterior aspect,
size
10 cm x 5 cm, deformity (+), swelling
(+), hematoma (+), muscle exposed
(+), bone exposed (+).
P : Tenderness (+)
ROM : active and passive motion at knee
and
ankle joint are limited due to pain
NVD : sensibility is good, the pulse of
dorsalis pedis artery is
palpable, capillary refill time < 2



Cruris sinistra region :
I : Lacerated wound at anterior aspect,
size
2 cm x 2 cm, deformity (-), swelling (-
), hematoma (-), muscle exposed (-),
bone exposed (-).
P : Tenderness (+)
ROM : active and passive motion at knee
and
ankle joint are limited due to pain
NVD : sensibility is good, the pulse of
dorsalis pedis artery is
palpable, capillary refill time < 2

Cruris dextra region :
I : Lacerated wound at anterior aspect,
size
2 cm x 1 cm, deformity (-), swelling (-
), hematoma (-), muscle exposed (-),
bone exposed (-).
abration wound at anterior aspect,
size 2cm x 2cm, deformity (-),
hematoma(+),

Leg Length Discrepancy
R L
ALL 72 cm 70 cm
TLL 67 cm 65 cm
LLD 2 cm
WBC 7,40 x 10
3
/uL
RBC 4,11 x 10
6
/uL
HGB 11,4 g/dL
PLT 661 x 10
3
/uL
GDS 67 mg/dl
Ureum 28 mg/dl
Creatinin 0,5 mg/dl
SGOT 19 u/l
SGPT 12 u/l
Radiological Findings
Open Fracture 1/3 Distal femur (S) grade IIIA
Closed Fracture 1/3 Distal tibia (S)
Closed Segmental Fracture Fibula (S)

Management
IVFD RL
Antibiotic
Analgesic
Debridement

Planning :
Plan for ORIF
Resume
A 13 years old with Deformity (+) edema
(+) and tenderness at the antebrachii region,
limited active and passive motion of elbow and
wrist joint due to pain. Deformity (+) edema (+)
and tenderness at the femoral region and
limited active and passive motion of hip joint
and knee joint due to pain. Sensibility is good,
dorsalis pedis artery palpable, Capillary refill
time < 2. Radiological finding with distal
fracture of left radius and left ulna, distal
fracture of right radius, and comminuted
fracture of left femur shaft.








The diagnosis are Closed Fracture 1/3
distal of the Left Radius and Left Ulna,
Closed Fracture 1/3 distal of the right
Radius, and Closed comminuted
fracture 1/3 middle of the Left Femur.
Fracture in Pediatrics
Femur Shaft
Fracture in
Children
Introduction
Fracture of the femur are quite common
and are usually due to direct violence or
a fall from high.
Between 1 and 4 years of age, 30 % of
femoral shaft fracture are attributed to
abuse.
In the adolescent age group, high
velocity motor vehicle accidents are
more often the mechanism of injury and
account for up to 90% of all femoral shaft
fractures.

ANATOMY
OF
FEMUR
Muscles Compartment of the
Femur
ANTERIOR COMPARTMENT
MUSCLE ORIGIN INSERTION NERVE
Sartorius ASIS Prox. med. tibia
(pes anserius)
Femoral
Rectus
femoralis
1.AIIS
2.Sup. acetab. rim
Patella/tibia
tubercle
Femoral

Vastus
lateralis
Gtr. trochanter, lat.
linea aspera
Lat. patella/tibia
tubercle
Femoral

Vastus
intermedius
Proximal femoral
shaft
Patella/tibia
tubercle
Femoral

Vastus
medialis
Intertrochant. line,
med. linea aspera
Medial
patella/tibia
tubercle
Femoral

Muscles Compartment of the
Femur
MEDIAL COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE
Obturator
externus
Ischiopubic rami,
obturator memb
Piriformis fossa Obturator
Adductor
longus
Body of pubis
(inferior)
Linea aspera
(mid 1/3)
Obturator
Adductor
brevis
Body and inferior
pubic ramus
Pectineal line,
linea aspera
Obturator
Adductor
magnus
1.Pubic ramus
2. Isxhial tub.
Linea aspera,
add. tubercle
1.Obturator
2.Sciastic
Gracilis Body and inferior
pubic ramus
Prox. med. tibia
(pes anserius)
Obturator
Pectineus Pectineal line of
pubis
Pectineal line of
femur
Femoral
Muscles Compartment of the
Femur
POSTERIOR COMPARTMENT


MUSCLE ORIGIN INSERTION NERVE
Semitendinosus Ischial
tubersity
Proximal medial
tibia (pes
anserius)
Sciastic
(tibial)
Semimembrano
sus
Ischial
tubersity
Posterior medial
tibial condyle
Sciastic
(tibial)
Biceps femoris :
Long head
Ischial
tubersity
Head of fibula Sciastic
(tibial)
Biceps femoris
:Short head
Linea aspera,
supracondylar
line
Fibula, lateral
tibia
Sciastic
(peroneal)

Classification of Fracture
Descriptive
Open versus closed
Level of fracture: proximal, middle, distal
third
Fracture pattern: transverse, spiral, or
oblique
Comminuted, segmental or butterfly
fragment
Angulation or rotation deformity
Displacement : shortening or translation



Winquist & Hansen
Classification
Stable
0 : No comminution
I : Minimal comminution
II : Comminuted > 50% of cortices intact

Unstable
III : Comminuted < 50% of cortices intact
IV : Complete comminution, no intact cortex

Mechanism of Injury
Direct trauma: Motor vehicle accident,
pedestrian injury, fall, and child abuse
are causes.
Indirect trauma: Rotational injury.
Pathologic fractures: Causes include
osteogenesis imperfecta, nonossifying
fibroma, bone cysts, and tumors.

Clinical Evaluation
Patients with a history of high-energy injury
should undergo full trauma evaluation as
indicated.
The presence of a femoral shaft fracture
results in an inability to ambulate, with
extreme pain, variable swelling, and variable
gross deformity.

A careful neurovascular examination is
essential.
Radiologic Evaluation
Anteroposterior (AP)
and lateral views of the
femur should be
obtained.
Radiographs of the hip
and knee should be
obtained to rule out
associated injuries

Treatment
Guideline Age
0 to 6 Months : Pavlik Harness
7 Months to 5 Years : Closed Reduction
with Spica Cast Application, Skin or
Skeletal Traction, Flexible Intramedullary
Rods.
6 to 10 Years : Open Reduction with
Flexible Rods.
11 Years to Skeletal Maturity : Flexible
Intramedullary Rodding, Submuscular
Plate Fixation, Rigid Intramedullary
Rodding.
Complication
Common
Limb Length Inequality
Unacceptable Angulation
Rotational Deformities
Non-union and Delayed Union
Rare
Compartment Syndrome
Infection
Inflamation
Vascular Injury
TIBIA FRACTURE IN
CHILDREN
Tibia fractures represent the third
most common pediatric long bone
fracture, after femur and forearm
fractures.
They represent 15% of pediatric
fractures.
The average age of occurrence is 8
years of age.
Of these fractures, 30% are
associated with ipsilateral fibular
fractures.
Ratio of incidence in boys and girls is
2:1.