CASE REPORT

Patient Identity Name Age Sex Medical record Admittance : Mrs. M. W. : 53th years old : Female : 014668 : 21 October 2013

History Taking : Chief complaint : Pain at the Hip History of illness It was felt since 1 years ago, it was feel burn arround the hip as level 3 finger from the centre of body, the pain was feel start from the lower hip and radiated to both of leg, the pain is intermittent and become worse during activity heavy lift. At the first the pain was felt mild and by the time the pain is slowly progressive. The patient did not feel pain when bend position. Cramp(-) History of disease : History of long cough (-), History of fever (-), History of trauma (+). The pain was occur when fall in the sit position at toilet (10 years ago), but the pain is neglected. History of decrease body weight (-). History of heavy lifting (-) Urinate and Defecation is normal Physical Examination General Status : Moderate illnes/good nutrition/composmentis Vital Sign: Blood Pressure Pulse Respiration Temperature Local Status Vertebra Region(Lumbosakral) : I P : Deformity (-),swelling (-),hematom(-),gibbus (-) : Tenderness(-)
1

: 130/80 mmHg : 82 x/menit,regular : 22/menit,regular : 36.6 oC (axillar)

Clinical Findings

Laboratory Findings Test WBC RBC HGB PLT GDS CT BT Ur/Cr GOT/GPT Electrolyte Na K Cl Result 4,65 [10^3uL] 4,23 [10^6uL] 12,1 [g/dl] 254[10^3uL] 111mg/l 700 200 32/0,6 mg /L 18/19 U/L 137 mmc 4,2 mmc 105 mmc

Additional test Lasegue Test (SLR) : R (-) L (-) Reflex Test

Radiological Findings

X-Ray of lumbosacral AP/lat

3

MRI Sagital Section

MRI Axial Section

4

Summary Female 53 years old admit to the hospital. It was felt since 1 years ago, it was feel burn around the hip as level 3 finger from the centre of body, the pain was feel start from the lower hip and radiated to both of leg, the pain is intermittent and become worse during activity heavy lift. At the first the pain was felt mild and by the time the pain is slowly progressive. On MRI there is extrusio of disc and filling defect at intervertebrae discus at L4-L5 level.

Diagnosis Low Back Pain e.c. Hernia Nucleus Pulposus L4-5

Management Planning Bed Rest Analgetik Planning : dekompresi

DISCUSSION
1. Femoral Shaft Fracture A femoral shaft fracture is a fracture of the femoral diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle.The femoral shaft is circumferentially padded with large muscles. This provides advantages and disadvantages: reduction can be difficult as muscle contraction displaces the fracture; however, healing potential is improved by having this well-vascularized sleeve containing a source of mesenchymal stem cells, and open fractures often need no more than split thickness skin grafts to obtain satisfactory cover.1

2. 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.1,2

The femoral shaft is subjected to major muscular deforming forces :Abductors (gluteus medius and minimus): They insert on the greater trochanter and abduct the proximal femur following subtrochanteric and proximal shaft fractures.Iliopsoas: It flexes and externally rotates the proximal fragment by its attachment to the lesser trochanter.Adductors: They span most shaft fractures and exert a strong axial and varus load to the bone by traction on the distal fragment.Gastrocnemius: It acts on distal shaft fractures and supracondylar fractures by flexing the distal fragment. Fascia lata: It acts as a tension band by resisting the medial angulating forces of the adductors.2,3

The thigh musculature is divided into three distinct fascial compartments : 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. Medial
7

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. 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.2,3

Because of the large volume of the three fascial compartments of the thigh, compartment syndromes are much less common than in the lower leg. 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 twothirds of the cortex.1,3

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.Reaming may further obliterate the endosteal circulation, but it returns fairly rapidly, in 3 to 4 weeks.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.1,3

3. Mechanism of Injury This is usually a fracture of young adults and results from a high energy injury. Diaphyseal fractures in elderly patients should be considered pathological until proved otherwise. In children under 4 years the possibility of physical abuse must be kept in mind.2 Fracture patterns are clues to the type of force that produced the break. A spiral fracture is usually caused by a fall in which the foot is anchored while a twisting force is transmitted to the femur. Transverse and oblique fractures are more often due to angulation or direct violence and are therefore particularly common in road accidents. With severe violence (often a combination of direct and indirect forces) the fracture may be comminuted, or the bone may be broken in more than one place (a segmental fracture).2

4. Femoral Shaft Fractures Classification Winquists classification reflects the observation that the degrees of soft-tissue damage and fracture instability increase with increasing grades of comminution. In Type 11 there is only a tiny cortical fragment. In Type 2 the butterfly fragment is larger but there is still at least 50 per cent cortical contact between the main fragments. In Type 3 the butterfly fragment involves more than 50 per cent of the bone width. Type 4 is essentially a segmental fracture.1,3

5. Diagnose There is swelling and deformity of the limb, and any attempt to move the limb is painful. With the exception of a fracture through pathological bone, the large forces needed to break the femur usually produce accompanying injuries nearby and sometimes further afield. Careful clinical scrutiny is necessary to exclude neurovascular problems and other lower limb or pelvic fractures. An ipsilateral femoral neck fracture occurs in about 10 per cent of cases and, if present, there is a one in three chance of a significant knee injury as well. The combination of femoral shaft and tibial shaft fractures on the same side, producing a floating knee, signals a high risk of multi-system injury in the patient. The effects of blood loss and other injuries, some of which can be life-threatening, may dominate the clinical picture.2,3 It may be difficult to obtain adequate views in the Accident and Emergency Room setting, especially views that provide reliable information on proximal or distal fracture extensions or joint involvement; these can be postponed until better facilities and easier patient positioning are possible. But never forget to xray the hip and knee as well (Figure 29.21). A baseline chest x-ray is useful as there is a risk of adult respiratory distress syndrome (ARDS) in those with multiple injuries. The fracture pattern should be noted; it will form a guide to treatment.2,3

10

6. Treatment Nonoperative

Skeletal Traction 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. 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.1,2 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.1,2 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). Problems with use of skeletal traction for definitive fracture treatment include knee stiffness, limb shortening, prolonged hospitalization, respiratory and skin ailments, and malunion.1,3 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. External Fixation, use as definitive treatment for femoral shaft fractures has limited medication. Plate fixation for femoral shaft stabilization has decreased with the use of IM nails.1,3

7. 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.2,3
11

Vascular injury: This may result from tethering of the femoral artery at the adductor hiatus.2,3 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.1,3 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, exposed bone, and extensive soft tissue injury (grades IIIB, IIIC) have a higher risk of infection regardless of treatment method.1,2 Refracture: Patients are vulnerable during early callus formation and after hardware removal. It is usually associated with plate or external fixation.1,2 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.1,2 Malunion: This is usually varus, internal rotation, and/or shortening owing to muscular deforming forces or surgical technique.1,2 Fixation device failure: This results from nonunion or cycling of device, especially with plate fixation.1,2 Heterotopic ossification may occur.1,2

12

REFERENCES 1. Koval K.J, Zuckerman J.D. Handbook of fractures 3rd edition 2006. 2. Solomon L, Warwick D, Nayagam S..Apleys System of Orthopedic and Fracture 9th ed. 2010. Hodder Arnold 3. Thompson, Jon C. Netters Concise Orthopaedics Anatomy 2nd Edition

13