Laporan Kasus

Januari 2015

FRAKTUR TERBUKA KOMINUTIF TIBIA DEKSTRA GRADE IIIAFRAKTUR TERBUKA SEGMENTAL FIBULA DEKSTRA GRADE IIIA

OLEH :Irham KhairiC111 10 820

PEMBIMBING:dr.Lutfi

dr. Andika

SUPERVISOR:dr.Muhammad Sakti, Sp.OT

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIKPADA BAGIAN ORTHOPEDI DAN TRAUMATOLOGI

FAKULTAS KEDOKTERANUNIVERSITAS HASANUDDIN

MAKASSAR2015

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OPEN FRACTURE 1/3 MIDDLE FEMUR SINISTRA

Name : Mr. SAge : 19 y.oAdmission : 14th July 2013RM number : 618759

Chief Complaint : Wound at the left thigh

History of illness : suffered since 12 hours before admitted to hospital due to traffic accident.

Mechanism of trauma: Patient was driving a bike and suddenly crushed by another motorcycle from opposite direction. Then patient fell down and then his left thigt crushed the road.

History of unconscious (-), nausea (-), vomiting (-)Prior treatment at Pare hospital.

Primary surveyAirway: Clear, patentBreathing: RR:18x/min, spontaneous, thoracoabdominalCirculation: BP 110/80, HR 96x/min, CRT <2’’Disability: Compos mentis (E4M6V5)Environment: temp 36,7⁰cSecondary surveyLeft Thigh RegionI : Laceration wound size 0,5x0,5 cm at 1/3 in the middle from anterior aspect

deformity (+), swelling (+), hematoma (+)P : tenderness (+)RoM : Active and passive motion on hip and knee joints can not be evaluated due to

painNVD : Sensibility is good, dorsalis pedis artery was palpable, CRT < 2”

Leg lengthRight leg Left leg

ALL 91 90TLL 88 87LLD 1cm 1 cm

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LABORATORY FINDINGSRBC : 4.650.000/mm3HGB : 13,6 g/dlHCT : 38,1 %PLT : 178.000/mm3WBC : 12.980/mm3CT : 8’00”BT : 3’00”HbsAg : positifElectrolit

Na : 137K : 4,2Cl : 106

GDS : 89Ureum : 20Creatinin : 10

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GOT/GPT : 71/62

RADIOGRAPHIC FINDINGSPELVIS XRAY (15.07.2013)

RADIOGRAPHIC FINDINGS

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RESUME19y.o boy was admitted to the hospital with wound at the left femur which

was suffered since 12 hours ago due to traffic accident. Patient was drove a bike and suddenly crushed by another motorcycle from opposite direction.History of unconscious (-), nausea (-), vomiting (-)

At the anterior aspect of the femur, there is a wound with size 0,5 cm , deformity (+) oedem (+) hematom (+) . The region was tender on palpation, with active and passive motion of hip and knee joint can not be eavaluated due to pain. Sensibility good, a. dorsalis pedis palpable, CRT < 2”.

DIAGNOSISOpen fracture 1/3 middle of the left femur grade I

MANAGEMENT THERAPYIVFD Analgetics Skin TractionPlan for ORIF

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DISCUSSIONOPEN FRACTURE FEMORAL SHAFT

Open fractures are defined as situations in which the fracture site communicates with the outside environment.

o The bone does not need to protrude from the skin for the injury to be an open fracture.

o Any full-thickness skin laceration in the zone of fracture injury is considered an open fracture.

Open fractures can be classified by the Gustilo-Anderson system (1).

o Type I: Low-energy fracture with a clean wound <1 cm longo Type II: Low- to medium-energy fracture with a laceration >1 cm long

but without extensive soft-tissue damageo Type III:

High-energy fracture Segmental fractures, gunshot injuries More extensive soft-tissue devitalization than in type II Type IIIA: Adequate soft-tissue coverage of bone Type IIIB: Inadequate soft-tissue coverage of bone, fractures

that need rotational or free flap coverage Type IIIC: Fracture with an arterial injury

Femoral shaft fractures occur in the diaphysis of the bone. High-energy trauma such as vehicular accidents, falls, or gunshots are the

common causes of these fractures in normal bone. Low-energy trauma may cause femoral shaft fractures in pathologic or

osteoporotic bone. Classification:

o Winquist and Hansen (1) assessed fractures according to the proportion of cortical contact between proximal and distal fragments:

Type I: >75% bony contact Type II: At least 50% cortical contact Type III: <50% contact Type IV: No bone contact

o The AO/Orthopaedic Trauma Association (2) classifies these fractures as:

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Type 32A (simple), 32B (wedge), or 32C (complex) Each type is subdivided as 1, 2, or 3 according to the inherent

instability of the fracture configuration.

General Prevention

Accident prevention and safety measures for both pedestrians and vehicle occupants

Reduction and prevention of gun crime Preemptive stabilization of impending pathologic fractures

ANATOMY

The femur is the largest tubular bone in the body and is surrounded by the largest mass of muscle. An important feature of the femoral shaft is its anterior bow.

The medial cortex is under compression, whereas the lateral cortex is under tension.

The isthmus of the femur is the region with the smallest intramedullary (IM) diameter; the diameter of the isthmus affects the size of the IM nail that can be inserted into the femoral shaft.

The femoral shaft is subjected to major muscular deforming forces (Fig. 32.1):

o Abductors (gluteus medius and minimus): They insert on the greater trochanter and abduct the proximal femur following subtrochanteric and proximal shaft fractures.

o Iliopsoas: It flexes and externally rotates the proximal fragment by its attachment to the lesser trochanter.

o Adductors: They span most shaft fractures and exert a strong axial and varus load to the bone by traction on the distal fragment.

o Gastrocnemius: It acts on distal shaft fractures and supracondylar fractures by flexing the distal fragment.

o Fascia lata: It acts as a tension band by resisting the medial angulating forces of the adductors.

The thigh musculature is divided into three distinct fascial compartments (Fig. 32.2):

o Anterior compartment: This is composed of the quadriceps femoris, iliopsoas, sartorius, and pectineus, as well as the femoral artery, vein, and nerve, and the lateral femoral cutaneous nerve.

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o Medial compartment: This contains the gracilis, adductor longus, brevis, magnus, and obturator externus muscles along with the obturator artery, vein, and nerve, and the profunda femoris artery.

o Posterior compartment: This includes the biceps femoris, semitendinosus, and semimembranosus, a portion of the adductor magnus muscle, branches of the profunda femoris artery, the sciatic nerve, and the posterior femoral cutaneous nerve.

o Because of the large volume of the three fascial compartments of the thigh, compartment syndromes are much less common than in the lower leg.

o The vascular supply to the femoral shaft is derived mainly from the profunda femoral artery. The one to two nutrient vessels usually enter the bone proximally and posteriorly along the linea aspera. This artery then arborizes proximally and distally to provide the endosteal circulation to the shaft. The periosteal vessels also enter the bone along the linea aspera and supply blood to the outer one-third of the cortex. The endosteal vessels supply the inner two-thirds of the cortex.

o Following most femoral shaft fractures, the endosteal blood supply is disrupted, and the periosteal vessels proliferate to act as the primary source of blood for healing. The medullary supply is eventually restored late in the healing process.

o Reaming may further obliterate the endosteal circulation, but it returns fairly rapidly, in 3 to 4 weeks.

o Femoral shaft fractures heal readily if the blood supply is not excessively compromised. Therefore, it is important to avoid excessive periosteal stripping, especially posteriorly, where the arteries enter the bone at the linea aspera.

EpidemiologyIncidence

Bimodal incidence, <25 years old and >65 years old (3) Estimated to be 1 per 10,000 persons per year (3).

Risk Factors

Young adult males Urban living Alcohol or drug abuse

MECHANISM OF INJURY

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Femoral shaft fractures in adults are almost always the result of high-energy trauma. These fractures result from motor vehicle accident, gunshot injury, or fall from a height.

Pathologic fractures, especially in the elderly, commonly occur at the relatively weak metaphyseal-diaphyseal junction. Any fracture that is inconsistent with the degree of trauma should arouse suspicion for pathologic fracture.

Stress fractures occur mainly in military recruits or runners. Most patients report a recent increase in training intensity just before the onset of thigh pain.

CLINICAL EVALUATION

Because these fractures tend to be the result of high-energy trauma, a full trauma survey is indicated.

The diagnosis of femoral shaft fracture is usually obvious, with the patient presenting nonambulatory with pain, variable gross deformity, swelling, and shortening of the affected extremity.

A careful neurovascular examination is essential, although neurovascular injury is uncommonly associated with femoral shaft fractures.

Thorough examination of the ipsilateral hip and knee should be performed, including systematic inspection and palpation. Range-of-motion or ligamentous testing is often not feasible in the setting of a femoral shaft fracture and may result in displacement. Knee ligament injuries are common, however, and need to be assessed after fracture fixation.

Major blood loss into the thigh may occur. The average blood loss in one series was greater than 1200 mL, and 40% of patients ultimately required transfusions. Therefore, a careful preoperative assessment of hemodynamic stability is essential, regardless of the presence or absence of associated injuries.

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ASSOCIATED INJURIES

Associated injuries are common and may be present in up to 5% to 15% of cases, with patients presenting with multisystem trauma, spine, pelvis, and ipsilateral lower extremity injuries.

Ligamentous and meniscal injuries of the ipsilateral knee are present in 50% of patients with closed femoral shaft fractures.

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RADIOGRAPHIC EVALUATION

Anteroposterior (AP) and lateral views of the femur, hip, and knee as well as an AP view of the pelvis should be obtained.

The radiographs should be critically evaluated to determine the fracture pattern, the bone quality, the presence of bone loss, associated comminution, the presence of air in the soft tissues, and the amount of fracture shortening.

One must evaluate the region of the proximal femur for evidence of an associated femoral neck or intertrochanteric fracture.

If a computed tomography scan of the abdomen and/or pelvis is obtained for other reasons, this should be reviewed because it may provide evidence of injury to the ipsilateral acetabulum or femoral neck.

CLASSIFICATIONDescriptive

Open versus closed injury Location: proximal, middle, or distal one-third Location: isthmal, infraisthmal or supracondylar Pattern: spiral, oblique, or transverse Comminuted, segmental, or butterfly fragment Angulation or rotational deformity Displacement: shortening or translation

Winquist and Hansen (Fig. 32.3)

This is based on fracture comminution. It was used before routine placement of statically locked IM nails.

Type I: Minimal or no comminutionType II: Cortices of both fragments at least 50% intactType III:50% to 100% cortical comminutionType VI:Circumferential comminution with no cortical contactOTA Classification of Femoral Shaft FracturesSee Fracture and Dislocation Compendium at http://www.ota.org/compendium/index.htm.TREATMENTNonoperativeSkeletal Traction

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Currently, closed management as definitive treatment for femoral shaft fractures is largely limited to adult patients with such significant medical comorbidities that operative management is contraindicated.

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The goal of skeletal traction is to restore femoral length, limit rotational and angular deformities, reduce painful spasms, and minimize blood loss into the thigh.

Figure 32.3. Winquist and Hansen classification of femoral shaft fractures. (From Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. Philadelphia: WB Saunders, 1992:1537.)

Skeletal traction is usually used as a temporizing measure before surgery to stabilize the fracture and prevent fracture shortening.

Twenty to 40 lb of traction is usually applied and a lateral radiograph checked to assess fracture length.

Distal femoral pins should be placed in an extracapsular location to avoid the possibility of septic arthritis. Proximal tibia pins are typically positioned at the level of the tibial tubercle and are placed in a bicortical location.

Safe pin placement is usually from medial to lateral at the distal femur (directed away from the femoral artery) and from lateral to medial at the proximal tibia (directed away from the peroneal nerve).

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Problems with use of skeletal traction for definitive fracture treatment include knee stiffness, limb shortening, prolonged hospitalization, respiratory and skin ailments, and malunion.

Operative

Operative stabilization is the standard of care for most femoral shaft fractures. Surgical stabilization should occur within 24 hours, if possible. Early stabilization of long bone injuries appears to be particularly important in

the multiply injured patient.

Intramedullary (IM) Nailing

This is the standard of care for femoral shaft fractures. Its IM location results in lower tensile and shear stresses on the implant than

plate fixation. Benefits of IM nailing over plate fixation include less extensive exposure and dissection, lower infection rate, and less quadriceps scarring.

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Closed IM nailing in closed fractures has the advantage of maintaining both the fracture hematoma and the attached periosteum. If reaming is performed, these elements provide a combination of osteoinductive and osteoconductive materials to the site of the fracture.

Other advantages include early functional use of the extremity, restoration of length and alignment with comminuted fractures, rapid and high union (>95%), and low refracture rates.

Antegrade Inserted Intramedullary (IM) Nailing

Surgery can be performed on a fracture table or on a radiolucent table with or without skeletal traction.

The patient can be positioned supine or lateral. Supine positioning allows unencumbered access to the entire patient. Lateral positioning facilitates identification of the piriformis starting point but may be contraindicated in the presence of pulmonary compromise.

One can use either a piriformis fossa or greater trochanteric starting point. The advantage of a piriformis starting point is that it is in line with the medullary canal of the femur. However, it is easier to locate the greater trochanteric

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starting point. Use of a greater trochanteric starting point requires use of a nail with a valgus proximal bow to negotiate the off starting point axis.

With the currently available nails, the placement of large diameter nails with an intimate fit along a long length of the medullary canal is no longer necessary.

The role of unreamed IM nailing for the treatment of femoral shaft fractures remains unclear. The potentially negative effects of reaming for insertion of IM nails include elevated IM pressures, elevated pulmonary artery pressures, increased fat embolism, and increased pulmonary dysfunction. The potential advantages of reaming rate include the ability to place a larger implant, increased union, and decreased hardware failure.

All IM nails should be statically locked to maintain femoral length and control rotation. The number of distal interlocking screws necessary to maintain the proper length, alignment, and rotation of the implant bone construct depends on numerous factors including fracture comminution, fracture location, implant size, patient size, bone quality, and patient activity.

Retrograde Inserted Intramedullary (IM) Nailing

The major advantage with a retrograde entry portal is the ease in properly identifying the starting point.

Relative indications include:o Ipsilateral injuries such as femoral neck, pertrochanteric, acetabular,

patellar, or tibial shaft fractures.o Bilateral femoral shaft fractures.o Morbidly obese patient.o Pregnant woman.o Periprosthetic fracture above a total knee arthroplasty.o Ipsilateral through knee amputation in a patient with an associated

femoral shaft fracture.

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Contraindications include:o Restricted knee motion <60 degrees.o Patella baja.o The presence of an associated open traumatic wound, secondary to the

risk of intraarticular knee sepsis.

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External Fixation

Use as definitive treatment for femoral shaft fractures has limited indications. Its use is most often provisional. Advantages include the following:

o The procedure is rapid; A temporary external fixator can be applied in less than 30 minutes.

o The vascular supply to the femur is minimally damaged during application.

o No additional foreign material is introduced in the region of the fracture.

o It allows access to the medullary canal and the surrounding tissues in open fractures with significant contamination.

Disadvantages: Most are related to use of this technique as a definitive treatment and include:

o Pin tract infection.o Loss of knee motion.o Angular malunion and femoral shortening.o Limited ability to adequately stabilize the femoral shaft.o Potential infection risk associated with conversion to an IM nail.

Indications for use of external fixation include:o Use as a temporary bridge to IM nailing in the severely injured patient.o Ipsilateral arterial injury that requires repair.o Patients with severe soft tissue contamination in whom a second

debridement would be limited by other devices.

Plate FixationPlate fixation for femoral shaft stabilization has decreased with the use of IM nails.

Advantages to plating include:o Ability to obtain an anatomic reduction in appropriate fracture

patterns.o Lack of additional trauma to remote locations such as the femoral

neck, the acetabulum, and the distal femur. Disadvantages compared with IM nailing include:

o Need for an extensive surgical approach with its associated blood loss, risk of infection, and soft tissue insult. This can result in quadriceps scarring and its effects on knee motion and quadriceps strength.

o Decreased vascularization beneath the plate and the stress shielding of the bone spanned by the plate.

o The plate is a load bearing implant; therefore, higher rate of implant failure.

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Indications include:o Extremely narrow medullary canal where IM nailing is impossible or

difficult.

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o Fractures that occur adjacent to or through a previous malunion.o Obliteration of the medullary canal due to infection or previous closed

management.o Fractures that have associated proximal or distal extension into the

pertrochanteric or condylar regions.o In patients with an associated vascular injury, the exposure for the

vascular repair frequently involves a wide exposure of the medial femur. If rapid femoral stabilization is desired, a plate can be applied quickly through the medial open exposure.

An open or a submuscular technique may be applicable. As the fracture comminution increases, so should the plate length such that at

least four to five screw holes of plate length are present on each side of the fracture.

The routine use of cancellous bone grafting in plated femoral shaft fractures is questionable if indirect reduction techniques are used.

Femur Fracture in Multiply Injured Patient

The impact of femoral nailing and reaming is controversial in the polytrauma patient.

In a specific subpopulation of patients with multiple injuries, early IM nailing is associated with elevation of certain proinflammatory markers.

It has been recommended that early external fixation of long bone fractures followed by delayed IM nailing may minimize the additional surgical impact in patients at high risk for developing complications (i.e., patients in extremis or underresuscitated).

Ipsilateral Fractures of the Proximal or Distal Femur

Concomitant femoral neck fractures occur in 3% to 10% of patients with femoral shaft fractures. Options for operative fixation include antegrade IM nailing with multiple screw fixation of the femoral neck, retrograde femoral nailing with multiple screw fixation of the femoral neck, and compression

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plating with screw fixation of the femoral neck. The sequence of surgical stabilization is controversial.

Ipsilateral fractures of the distal femur may exist as a distal extension of the shaft fracture or as a distinct fracture. Options for fixation include fixation of both fractures with a single plate, fixation of the shaft and distal femoral fractures with separate plates, IM nailing of the shaft fracture with plate fixation of the distal femoral fracture, or interlocked IM nailing spanning both fractures (high supracondylar fractures).

Open Femoral Shaft Fractures

These are typically the result of high-energy trauma. Patients frequently have multiple other orthopaedic injuries and involvement

of several organ systems. Treatment is emergency debridement with skeletal stabilization. Stabilization can usually involve placement of a reamed IM nail.

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REHABILITATION

Early patient mobilization out of bed is recommended. Early range of knee motion is indicated. Weight bearing on the extremity is guided by a number of factors including

the patient’s associated injuries, soft tissue status, and the location of the fracture.

COMPLICATIONS

Nerve injury: This is uncommon because the femoral and sciatic nerves are encased in muscle throughout the length of the thigh. Most injuries occur as a result of traction or compression during surgery.

Vascular injury: This may result from tethering of the femoral artery at the adductor hiatus.

Compartment syndrome: This occurs only with significant bleeding. It presents as pain out of proportion, tense thigh swelling, numbness or paresthesias to medial thigh (saphenous nerve distribution), or painful passive quadriceps stretch.

Infection (<1% incidence in closed fractures): The risk is greater with open versus closed IM nailing. Grades I, II, and IIIA open fractures carry a low risk of infection with IM nailing, whereas fractures with gross contamination,

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exposed bone, and extensive soft tissue injury (grades IIIB, IIIC) have a higher risk of infection regardless of treatment method.

Refracture: Patients are vulnerable during early callus formation and after hardware removal. It is usually associated with plate or external fixation.

Nonunion and delayed union: This is unusual. Delayed union is defined as healing taking longer than 6 months, usually related to insufficient blood supply (i.e., excessive periosteal stripping), uncontrolled repetitive stresses, infection, and heavy smoking. Nonunion is diagnosed once the fracture has no further potential to unite.

Malunion: This is usually varus, internal rotation, and/or shortening owing to muscular deforming forces or surgical technique.

Fixation device failure: This results from nonunion or “cycling†of �device, especially with plate fixation.

Heterotopic ossification may occur.

Prognosis95% of femoral shaft fractures unite without complications.Complications

Fat embolization, adults respiratory distress syndrome, and pulmonary complications can result from reamed femoral nailing, particularly in the polytrauma patient with chest and head trauma.

Nonunion is uncommon and usually is treated successfully by exchange nailing.

o Rotational malunions and limb-length inequalities can occur, particularly in comminuted shaft fractures.

o Rotational malalignments of >15° and length discrepancies of >2 cm should be corrected (3,9).

Vascular injuries are uncommon in femoral shaft fractures, except in those caused by penetrating trauma.

Nerve injuries resulting at the same time as shaft fracture are uncommon, although there are reported cases of pudendal nerve palsies resulting from the peroneal post while the patient is on the traction table (10).

Heterotopic ossification can occur around the hip after anterograde nailing, particularly in a patient with a head injury.

Compartment syndrome in the thigh may occur pre- or postoperatively.

Patient Monitoring

Neurovascular check postoperatively to assess for compartment syndrome Radiographs are taken every 6–8 weeks until bony union.

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