Open Fracture 1/3 Distal femur (S) grade IIIA Open Fracture 1/3 Distal femur (S) grade IIIA Closed Fracture 1/3 Distal tibia (S) Closed Fracture 1/3 Distal tibia (S) Closed Segmental Fracture Fibula (S) Closed Segmental Fracture Fibula (S)

Presented by :

Hasmia

Advisor

dr. Benny Murtaza

dr. Jecky Chandra

Supervisordr. M.Ruksal Saleh, Ph.D, Sp.OT

Patient IdentityPatient Identity

Name : Mr. EAge : 16 years oldSex : MaleAdmittance : 20 July 2012Address : Parigi, MarosOccupation : StudentRM number : 55 51 42

History TakingHistory TakingChief complaint : wound at the left

lightAnamnesis : 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, clearB : 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 Ø 2,5mm/2,5 mm, light reflex +/+

E : T = 36,7 0 C (axillar)

Primary Survey

Secondary SurveySecondary SurveyFemur 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 painNVD : 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 painNVD : 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 Leg LLength ength DDiscrepancy iscrepancy

R L

ALL 72 cm 70 cm

TLL 67 cm 65 cm

LLD 2 cm

WBC 7,40 x 103 /uL RBC 4,11 x 106 /uL HGB 11,4 g/dL PLT 661 x 103 /uL GDS 67 mg/dl Ureum 28 mg/dl Creatinin 0,5 mg/dl SGOT 19 u/l SGPT 12 u/l

Radiological Radiological FindingsFindings

• Open Fracture 1/3 Distal femur (S) grade IIIA Open Fracture 1/3 Distal femur (S) grade IIIA • Closed Fracture 1/3 Distal tibia (S) Closed Fracture 1/3 Distal tibia (S) • Closed Segmental Fracture Fibula (S) Closed Segmental Fracture Fibula (S)

ManagementManagementIVFD RL AntibioticAnalgesicDebridement

Planning :Plan for ORIF

ResumeResumeA 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 Fracture in PediatricsPediatrics

Femur Shaft Femur Shaft Fracture in Fracture in

ChildrenChildren

Introduction 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 ANATOMY OF OF FEMURFEMUR

Muscles Compartment of the Muscles Compartment of the FemurFemur

ANTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE

Sartorius ASIS Prox. med. tibia (pes anserius)

Femoral

Rectus femoralis

1.AIIS2.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 Muscles Compartment of the FemurFemur

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 ramus2. 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 Muscles Compartment of the Femurthe FemurPOSTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE

Semitendinosus

Ischial tubersity

Proximal medial tibia (pes anserius)

Sciastic (tibial)

Semimembranosus

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 FractureClassification of FractureDescriptive Open versus closed Level of fracture: proximal, middle,

distal third Fracture pattern: transverse, spiral, or

obliqueComminuted, segmental or butterfly fragment

Angulation or rotation deformity Displacement : shortening or translation

Winquist & Hansen Winquist & Hansen Classification Classification

Stable0 : No comminutionI : Minimal comminutionII : Comminuted > 50% of cortices intact

UnstableIII : Comminuted < 50% of cortices intactIV : Complete comminution, no intact cortex

Mechanism of Mechanism of InjuryInjury

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 EvaluationClinical EvaluationPatients 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 EvaluationRadiologic 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

TreatmentTreatmentGuideline Age0 to 6 Months : Pavlik Harness7 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.

ComplicationComplicationCommonLimb Length InequalityUnacceptable AngulationRotational DeformitiesNon-union and Delayed UnionRareCompartment SyndromeInfectionInflamationVascular Injury

TIBIA FRACTURE IN TIBIA FRACTURE IN CHILDRENCHILDRENTibia 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.