7/30/2019 Case Report Fr Femur and Patella
1/50
Closed Fracture 1/3 Distal of The Left Radius
and Left Ulna
Closed Fracture 1/3 Distal of The Right RadiusClosed Comminuted Fracture 1/3 Middle of the
Left Femur
Presented by :
Hasmia
Advisor
dr. Bennydr. Jacky
Supervisor
dr. M.Ruksal Saleh, Ph.D, Sp.OT
7/30/2019 Case Report Fr Femur and Patella
2/50
Patient Identity
Name : Mr. E
Age : 16 years old
Sex : MaleAdmittance : 3rd July 2012
Address : Parigi, Maros
Occupation : Student RM number : 55 51 42
7/30/2019 Case Report Fr Femur and Patella
3/50
History Taking
Chief complaint : wound at the left light Anamnesis : suffered since + 4 hours before
admitted to Wahidin Sudirohosodo hospitaldue to traffic accident.
Injury mechanism : He was riding amotocycle, and then hit the tree.
History of unconsciousness (-), nausea (-),vomit (-)
History of prior treatment at SoppengHospital
7/30/2019 Case Report Fr Femur and Patella
4/50
A : Patent
B : RR = 20 x/min, simetris,
spontaneous, thoracoabdominal
type.
C : PR= 88 x/min regular, strong.
D : GCS 15 (E4V5M6), pupil isochors
2,5mm/2,5 mm, light reflex +/+
E : T = 36,5 0 C (axillar)
Primary Survey
7/30/2019 Case Report Fr Femur and Patella
5/50
Secondary Survey
Right Antebrachii region :
I : Deformity (+), swelling (+), hematoma (-
),
wound (-)
P : Tenderness (+)
ROM :Active and passive motion at elbow and
wrist joints are limited due to pain.NVD : Sensibility is good , radial
artery pulse is palpable, capillary refill
time is
7/30/2019 Case Report Fr Femur and Patella
6/50
Left Antebrachii region :
I : Deformity (+), swelling (+),hematoma (+), wound (-)
P : Tenderness (+)
ROM:Active and passive motion at elbowand wrist joints are limited due to pain.
NVD: Sensibility is good , radial
artery pulse is palpable, capillaryrefill
time is
7/30/2019 Case Report Fr Femur and Patella
7/50
Femoral region :
I : Deformity (+), swelling (+), hematoma (-),wound (-)
P : Tenderness (+)
ROM:Active and passive motion at hip and knee
joints are limited due to pain.
NVD: Sensibility is good , dorsalis pedis
arterypulse is palpable, capillary refill time is
7/30/2019 Case Report Fr Femur and Patella
8/50
Leg Length Discrepancy
R L
ALL 78 cm 77 cm
TLL 76 cm 75 cm
LLD 1 cm
7/30/2019 Case Report Fr Femur and Patella
9/50
The Right Forearm
7/30/2019 Case Report Fr Femur and Patella
10/50
The Left Forearm
7/30/2019 Case Report Fr Femur and Patella
11/50
The Lower Limb
7/30/2019 Case Report Fr Femur and Patella
12/50
7/30/2019 Case Report Fr Femur and Patella
13/50
WBC 8,92 x 103/uL
RBC 5,14 x 106/uL
HGB 14,9 g/dL
PLT 236 x 103 /uL
Ureum 16 mg/dl Creatinin 0,7 mg/dl
SGOT 20 u/l
SGPT 27 u/l
CT 800
BT 200
PT 12,7 control 13,6
APTT 22,2 control 26,3
7/30/2019 Case Report Fr Femur and Patella
14/50
Radiological Findings
X-Ray AP/Lat
of The Right
Antebrachiu
m
7/30/2019 Case Report Fr Femur and Patella
15/50
X-Ray AP/Latof The Left
Antebrachium
7/30/2019 Case Report Fr Femur and Patella
16/50
X-Ray
AP/Lat ofLeft Femur
7/30/2019 Case Report Fr Femur and Patella
17/50
Closed Fracture 1/3 Distal of the Left Radiusand Left Ulna
Closed Fracture 1/3 Distal of The Right
Radius Closed Comminuted Fracture 1/3 Middle of
The Left Femur
7/30/2019 Case Report Fr Femur and Patella
18/50
Management
IVFD RL
Analgesic
Immobilization
Plan for ORIF
7/30/2019 Case Report Fr Femur and Patella
19/50
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 andlimited 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.
7/30/2019 Case Report Fr Femur and Patella
20/50
The diagnosis are Closed Fracture 1/3distal of the Left Radius and Left Ulna,
Closed Fracture 1/3 distal of the right
Radius, and Closed comminutedfracture 1/3 middle of the Left Femur.
7/30/2019 Case Report Fr Femur and Patella
21/50
Fracture in Pediatrics
7/30/2019 Case Report Fr Femur and Patella
22/50
Distal Forearm Fracture in
Children
7/30/2019 Case Report Fr Femur and Patella
23/50
Introduction
Fractures of the forearm is common inchildren, accounting for 30% to 40% of all
fractures in children.
Most forearm fractures occur in children olderthan 5 years. The location of the fracture
advances distally with increasing age of the
child, probably because of the anatomic
changes in the metaphyseal-diaphysealjunction that occur with maturity
The distal forearm is the site of 70% to 80% of
fractures of the radius and ulna.
7/30/2019 Case Report Fr Femur and Patella
24/50
BONE ANATOMY IN CHILDREN
Bone in Children:
- Less mineralized.
- Have more vascularchannels than the
bones of adults.
- Periosteal is thick
- Elastis of ligament
- There are Growth
plate (physis)
7/30/2019 Case Report Fr Femur and Patella
25/50
ANATOMY OF RADIUS ULNA
7/30/2019 Case Report Fr Femur and Patella
26/50
7/30/2019 Case Report Fr Femur and Patella
27/50
7/30/2019 Case Report Fr Femur and Patella
28/50
7/30/2019 Case Report Fr Femur and Patella
29/50
MECHANISM OF INJURY
Indirect: The mechanism is a fall onto anoutstretched hand. Forearm rotation
determines the direction of angulation:
Pronation: flexion injury (dorsal angulation) Supination: extension injury (volar
angulation)
Direct: Direct trauma to the radial orulnar shaft.
7/30/2019 Case Report Fr Femur and Patella
30/50
Classification of The Distal
Forearm Fractures Buckle or torus fracture
Greenstick fracture
Metaphyseal fracture
Physeal fracture
Galleazzi fracture
7/30/2019 Case Report Fr Femur and Patella
31/50
Greenstick Fracture
7/30/2019 Case Report Fr Femur and Patella
32/50
Buckle or Torus Fracture
7/30/2019 Case Report Fr Femur and Patella
33/50
CLINICAL EVALUATION
Wrist deformity and displacement ofthe hand in relation to the wrist. The
wrist is typically swollen with
ecchymosis, tenderness, and painfulrange of motion.
7/30/2019 Case Report Fr Femur and Patella
34/50
DIAGNOSIS
Anamnesis Physical examination
X- ray, with AP and lateral view
7/30/2019 Case Report Fr Femur and Patella
35/50
MANAGEMENT
NonOperatif
Simple Closed
reduction
Immobilization
long arm casting
Operative
External Fixation
ORIF
7/30/2019 Case Report Fr Femur and Patella
36/50
COMPLICATIONS
Malunion Re-fracture
Growth arrest
Peripheral nerve injury
Compartement syndrome
Non-union, cross union
Reflex sympathetic dystrophy.
7/30/2019 Case Report Fr Femur and Patella
37/50
Femur Shaft
Fracture inChildren
7/30/2019 Case Report Fr Femur and Patella
38/50
Introduction
Fracture of the femur are quite commonand are usually due to direct violence or
a fall from high.
Between 1 and 4 years of age, 30 % offemoral shaft fracture are attributed to
abuse.
In the adolescent age group, highvelocity motor vehicle accidents are
more often the mechanism of injury and
account for up to 90% of all femoral shaft
fractures.
7/30/2019 Case Report Fr Femur and Patella
39/50
ANATOMY
OF
FEMUR
Muscles Compartment of the
7/30/2019 Case Report Fr Femur and Patella
40/50
Muscles Compartment of the
Femur
ANTERIOR COMPARTMENTMUSCLE ORIGIN INSERTION NERVE
Sartorius ASIS Prox. med. tibia
(pes anserius)
Femoral
Rectus
femoralis
1.AIIS2.Sup. acetab. rim
Patella/tibiatubercle
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/tibiatubercle
Femoral
Muscles Compartment of the
7/30/2019 Case Report Fr Femur and Patella
41/50
Muscles Compartment of the
Femur
MEDIALCOMPARTMENT
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 inferiorpubic ramus
Prox. med. tibia(pes anserius)
Obturator
Pectineus Pectineal line of
pubis
Pectineal line of
femur
Femoral
Muscles Compartment of the
7/30/2019 Case Report Fr Femur and Patella
42/50
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)
7/30/2019 Case Report Fr Femur and Patella
43/50
Classification of Fracture
Descriptive Open versus closed
Level of fracture: proximal, middle, distal
third Fracture pattern: transverse, spiral, or
oblique
Comminuted, segmental or butterflyfragment
Angulation or rotation deformity
Displacement : shortening or translation
Stable
7/30/2019 Case Report Fr Femur and Patella
44/50
Winquist & Hansen
Classification
Stable0 : No comminutionI : Minimal comminutionII : Comminuted > 50% of cortices intact
UnstableIII : Comminuted < 50% of cortices intactIV : Complete comminution, no intact cortex
7/30/2019 Case Report Fr Femur and Patella
45/50
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.
7/30/2019 Case Report Fr Femur and Patella
46/50
Clinical Evaluation
Patients with a history of high-energy injuryshould undergo full trauma evaluation as
indicated.
The presence of a femoral shaft fractureresults in an inability to ambulate, with
extreme pain, variable swelling, and variable
gross deformity.
A careful neurovascular examination is
essential.
7/30/2019 Case Report Fr Femur and Patella
47/50
Radiologic Evaluation
Anteroposterior (AP)and lateral views of the
femur should be
obtained.
Radiographs of the hipand knee should be
obtained to rule out
associated injuries
7/30/2019 Case Report Fr Femur and Patella
48/50
TreatmentGuideline 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
7/30/2019 Case Report Fr Femur and Patella
49/50
Complication
Common
Limb Length Inequality
Unacceptable Angulation
Rotational Deformities
Non-union and Delayed Union
Rare
Compartment Syndrome Infection
Inflamation
Vascular Injury
7/30/2019 Case Report Fr Femur and Patella
50/50