Sri Mahtufa Riski C 111 09 759

Advisor :
dr. Dwi Indra | dr. Herbert Y.

Supervisor :
dr. Muhammad Sakti, M.Kes. Sp.OT
Closed Fracture
Supracondylar Right Femur
Department Of Orthopaedic and Traumatology
Faculty Of Medicine Hasanuddin University
Makassar 2014
Identity
Mr. E Name
14 years old Age
August, 19
th
2014 Addmision
084733 Registration Number
Perum. Mangga III, Daya Address
Student Job
BPJS Payment
History Taking

Chief complaint: Pain on the right tight
Suffered since 1 hour before admitted to Wahidin General Hospital due
to traffic accident.
Mechanism of trauma:
History of Fainting (-), nausea (-), vomiting (-), dizziness (-)
Prior treatment (-)
Past history of disease
Frequent fractures with or without trauma denied.
Family history of disease
No family members have a history of frequent fractures with
or without trauma.
History habits
He denied drinking alcoholic beverages and smoking. He also
admitted to rarely exercise.
History of allergies
He denies any drug or food allergies
Physical Examination
Primary
survey
Secondary
survey
A : Clear
B : RR 20 x/min, spontaneous, thoracoabdominal type
C : BP 110/70 mmHg, HR 96 x/min strong, regular
D : GCS 15 (E
4
M
6
V
5
), Pupil isochoric, diameter 3
mm/3mm, light reflex +/+
E : T: 36,7
0
C (axillary)
Primary survey
Deformity (+) is shortening, Swelling (+),
Hematome (+), wound (-)
L
Tenderness (+)
F
Active and passive motions of hip joint can not be evaluated due to
pain.
Active and passive motions of knee joint can not be evaluated due to
pain.
M
Sensibility is good,
pulsation of artery dorsalis pedis is palpable
Capillary Refill Time (CRT) < 2 Second
NVD
Localized status : Regio Femoris Dextra
Secondary Survey
R L
ALL 90 cm 92 cm
TLL 83 cm 85 cm
LLD 2 cm
Leg Length Discrepancies (LLD)
Clinical Findings
Photo 1 Lower Extrimity from anterior aspect

Photo 2. lower limb from lateral aspect
Photo 3. lower limb from medial aspect
Laboratory Findings
19/8/2014
WBC 9.2 x 10/Ul
GDS 82 mg/dL
RBC 4.84x 10/uL
Ur 22 mg/dL
HB 13.8 g/dL
Cr 0.50 mg/dL
HCT 40.2 %
SGOT 39 u/L
PLT 288 x 10/uL
SGPT 20 u/L
CT 600
Na 140 mmol/L
BT 300
K 4.2 mmol/L
HbsAg Negative
Cl 107 mmol/L
Radiology Findings
Photo 4 Plain photo of Pelvic AP
Result : no
visualization
of abnormality
in this pelvis
plain photo.
Result :
oblique
fracture of
distal Os.
Femur dextra
Photo 5
Plain photo of femur dextra
AP + Lateral
Photo 6
Plain photo of Genu dextra AP + Lateral
Resume
A boy, 14 years old came with chief complaints of pain on the
right thigh after motorcycle accident 1 hour prior
hospitalization.
On physical examination, we found at the right tight region :
Look : Deformity (+) shortening, Swelling (+), Hematome (+), Feel :
Tenderness (+). Move : Active and passive motions of hip joint and knee
joint cant be evaluated due to pain. NVD : Sensibility is good, Capillary
Refill Time (CRT) < 2 Second, pulsation of artery dorsalis pedis is
palpable. On radiological finding: oblique fracture 1/3 distal Os.
Femur dextra


Diagnose
Closed
Fracture
Supracondylar
Right Femur
Management
IVFD RL
Analgesic
Apply Skin traction at right lower extremity
Plan for Open Reduction Internal Fixation (ORIF)
Discusion
Anatomy
Os. Femur
Netter, Frank H. Netters Concise Orthopaedic Anatomy 2
nd
edition. Saunders Elseiver.

Arteries of thigh
Netter, Frank H. Netters Concise Orthopaedic Anatomy 2
nd
edition. Saunders Elseiver.



Introduction
If overlying skin remains intact : Closed fractured
If skin not intact : Open fractured
Fracture is a break in the structural continuity of
bone
Solomon, L, Warwick D.L, Nayagam,S. Apleys system of orthopedic and fractures. 8
th
editions. 2008
Beaty, James H.; Kasser, James R. Rockwood and Wilkins Fractures in Adult. 6
th
Edition. 2006.
Supracondylar fracture is a fracture at area of the
femur at the zone between the femoral condyles
and the junction of the metaphysis with the
femoral shaft.
Epidemology
Supracondylar fracture of the femur in adults
occurs in 7% of cases of all cases of femur
fractures.
Fracture incidence is increasing in frequency due
to the modern lifestyle and high driving transport.
Accidents are the main cause of this trauma at the
age of 17-30 years.
Bucholz Robert W, Heckman James D. Rockwood and Greens Fractures in Adult. 7
th
Ed. 2010
Solomon, L, Warwick D.L, Nayagam,S. Apleys system of orthopedic and fractures. 8
th
editions. 2008.
Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H. 5-Minutes Orthopaedic Consult, 2nd Edition. 2007


Mechanism
of
Injury
In young adults,
this force is typically
the result of high-
energy trauma such as
motor vehicle collision
or fall from a height.
In the elderly
the force may result
from a minor slip or
fall onto a flexed knee.
Robert, W Bucholz. Heckman, James. Rockwood and Wilkins Fractures in Adult. 7
th
Edition. 2010.
How to Diagnose ?
Chief complaint
(Pain,
swelling,
bruising, &
inability to
walk)
Anamnesis
Look,
Feel,
Move
Clinical
manifestation
X- ray, with
AP and lateral
view
Laboratory
examination
Additional
exam
Tscherne Classification of Closed Fractures
This classifies soft tissue injury in closed fractures and takes into
account indirect or direct injury mechanisms.
Egol, Kenneth A, etc. Handbook of Fracture 4
th
Ed. USA. 2010
Grade 1
Injury from indirect forces with negligible soft tissue damage
Grade 2
Closed fracture caused by low-moderate energy mechanisms, with
superficial abrasions or contusions of soft tissues overlying
the fracture
Grade 3
Closed fracture with significant muscle contusion, with
possible deep, contaminated skin abrasions associated with
moderate to severe energy mechanisms and skeletal injury; high
risk for compartment syndrome
Grade 4
Extensive crushing of soft tissues, with subcutaneous degloving
or avulsion, with arterial disruption or established compartment
syndrome
Classification
I : minimally displaced < 1 cm
II : medial displacement of the condyles > 1 cm
III : lateral displacement of the condyles > 1 cm
IV : conjoined supracondylar and shaft fracture

Neer classification.
This classification is based on the direction of the shift of the distal fragment. It is
structured to be able to identify the mechanisms and patterns of soft tissue
damage and therapy will be provided.
Kamel Kasem. Management of Supracondylar Fracture of The Femur. Department of Orthopaedic Surgery &
Traumatology Faculty of Medicine Minia University. 2004.
AO (Muller and colleagues)
Classification
Group A: extra-articular fractures
A1: simple
A2: metaphysical slices
A3: metafisial complex (comminuted)
This classification is the most widely used in cases of supracondylar fracture.
In this classification, identified three types of supracondylar fractures with
three subtypes based on the radiological picture.
Kamel Kasem. Management of Supracondylar Fracture of The Femur. Department of Orthopaedic Surgery &
Traumatology Faculty of Medicine Minia University. 2004.
Group B:
partial articular fractures
B1: condylus lateral
(sagittal)
B2: condylus medial
(sagittal)
B3: condylus lateral or
medial (coronal)
Group C:
total articular fractures
C1: articular simple,
simple metaphysical
C2: articular simple,
metaphysical
multifragment
C3: articular
multifragment

Kamel Kasem. Management of Supracondylar Fracture of The Femur. Department of Orthopaedic Surgery &
Traumatology Faculty of Medicine Minia University. 2004.
Additional Examination
Radiology examination
Radiological examination should show the overall femur on the AP and
lateral
Including pelvic and knee joints associated injury.
x-ray of fracture supracondylar of femur

Alan Graham Appley. Appleys System of Orthopedics and Fracture 9
th
edition. Butterworths Medical Publications.
2010.

Management
Indication non-
operative
Non-displaced / incomplete
fractures
Acceptable angulation in children
patients
impacted stable fractures in
elderly patients
severe osteopenia
advanced underlying medical
conditions
select gunshot injuries
Indication Operative
Multiple trauma
Segmental or comminuted type
Open fracture
Neurovascular injury
Articular fractures
Pathologic fracture
In elderly patients with severe
osteopenia or those with
contralateral amputation
Egol, Kenneth A.MD, etc.Handbook of Fracture 4
th
Ed. 2010. USA
Non-operative
Treatment is mobilization of the extremity in a
hinged knee brace
Non-operative treatment entails a 6 to l2 weeks
period of casting with acceptance of resultant
deformity followed by bracing.


Egol, Kenneth A.MD, etc.Handbook of Fracture 4
th
Ed. 2010. USA
Operative Technique
Screw fixation
Frontal view of the definitive
lag screw fixation of the
articular fragments.
Condylar plate/dynamic
condylar screw (DCS)
Colton, C. L., etc. AO Principles of Fracture Management. Thieme Stuttgart. New York. 2000


Retrograde nailing
Complication
Early
Damage to the vessels
Late
Non union
Malunion
Stiffness of the knee
joint
Warwick D.L, Nayagam,S. Apleys system of orthopedic and fractures. 8
th
editions. 2008.