CASE REPORT

CLOSED FRACTURE1/3 MIDDLE RIGHT FEMUR

Patient Identity
Name

: Mr. M

Age

: 19 years old

Sex

: Female

Date of admittance

: septemer18th, 2014

MR

: 681070

History Taking
Chief Complaint : pain at right thigh
History of illness : Suffered since

30 minutes before admitted to Wahidin General

Hospital due to traffic accident

Mechanism of trauma : Patient was ride a motorcycle and hit by another motorcycle on
the right thigh of patient
History of unconsciousness (-), nausea (-) vomiting (-)
Primary Survey
A : Patent
B : RR 16x/min regular, spontaneous thoracoabdominal type, symmetrical
C :BP 110/70 mmHg, HR = 84 x/min regular.
D : GCS 15 (E4V5M6), isochoric pupil, : 2.5 mm/ : 2.5 mm
E : T = 36,70 C (axilla)
Secondary Survey
Left ThighRegion
Inspection: Deformity (+),swelling (+), Edema (+), Hematome (+), wound (-)
Palpation:Tenderness (+)
NVD: Sensibility is good, pulsation of dorsal pedis artery is palpable, CRT < 2 second
ROM: Active and passive movement of hip and knee joint are not evaluated
due to pain

ALL

80cm

82 cm

TLL
LLD

72 cm
2cm

Clinical Picture

Laboratory Findings
WBC : 14.600/ ul

724cm

 RBC : 3.890.000/ ul
HBG : 12,0 g/dl
PLT

:264.000/ ul

CT

: 700

BT

: 300

HBsAg: non-reactive
Radiology Finding

X-ray Femur (S) AP-Lateral view

Resume

A female 19 years Suffered since 3o minutes before admitted to the hospital due to
traffic accident.

From the physical examination vital sign is normal and at the right femur

Inspection: deformity (+), swelling (+) , haematoma (+), shortened right

lower limb compared to opposite, swelling (+), haematoma (+), wound (-)

Palpation: Tenderness (+)

ROM: Active and passive motion of hip and knee joints are can not be
evaluated due to pain.

NVD: Sensibility is good, dorsalis pedis artery palpable and Capillary refill
time <2

X-Ray examination is fracture 1/3 middle (R) femur

Diagnosis
Closed fracture 1/3 middle right femur
Management
IVFD
Analgesic
Skin Traction 3 kg
Plan for ORIF

DISCUSSION : FRACTURE OF THE MIDDLE FEMUR

I. INTRODUCTION
A fracture is a break in the structural continuity of bone. It may be no more than a
crack, a crumpling or a splintering of the cortex; more often the break is complete and the
bone fragments are displaced. If the overlying skin remains intact it is a closed (or
simple)fracture; if the skin or one of the body cavities is breached it is an open (or
compound) fracture, liable to contamination and infection.1
The femoral shaft is circumferentially padded with large muscles.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. 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
Fractures of the femur are quite common in older children and are usually due to
direct violence (e.g. a road accident) or a fall from a height. However, in children under 2
years of age the commonest cause is child abuse; if there are several fractures in different
stages of healing, this is very suspicious. Pathological fractures are common in
generalized disorders such as spina bifida and osteogenesis imperfecta, and with local bone
lesions (e.g. a benign cyst or tumour).1
II. EPIDEMIOLOGY
Represent 1.6% of all fractures in the pediatric population. Boys are more
commonly affected at a ratio of 2.6:1. Bimodal distribution of incidence: The first peak is
from 2 to 4 years of age, and the second is in mid-adolescence. There is also a seasonal
distribution, with a higher incidence during the summer months. In children younger than
walking age, 80% of these injuries are caused by child abuse; this decreases to 30% in
toddlers. In adolescence, >90% of femoral fractures are caused by motor vehicle accident.2

III. ANATOMY

A. BONE
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.3
During childhood, remodeling in the femur causes a change from primarily weaker
woven bone to stronger lamellar bone. Up to age 16 years, there is a geometric increase in
the femoral shaft diameter and relative cortical thickness of the femur, resulting in a
markedly increased area moment of inertia and strength. This partially explains the
bimodal distribution of injury pattern, in which younger patients experience fractures
under load conditions reached in normal play or minor trauma, whereas in adolescence
high-energy trauma is required to reach the stresses necessary for fracture.2

B. MUSCULAR COMPARTMENTS
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 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.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 two-thirds of the cortex.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.3

IV. CLASSIFICATION OF FRACTURES

Sorting fractures into those with similar features brings advantages: it allows any
information about a fracture to be applied to others in the group (whether this concerns
treatment or prognosis) and it facilitates a common dialogue between surgeons and others
involved in the care of such injuries. Traditional classifications, which often bear the
originators name, are hampered by being applicable to that type of injury only; even then
the term is often inaccurately applied, famously in the case of Potts fracture, which is
oftenapplied to any fracture around the ankle though that is not what Sir Percival Pott

implied when he described the injury in 1765. A universal, anatomically based system
facilitates communication and the sharing of data from a variety of countries and
populations, thus contributing to advances in research and treatment. An alphanumeric
classification developed by Muller and colleagues has now been adapted and revised
(Muller et al., 1990;1
Marsh et al., 2007; Slongo and Audige 2007). Whilst it has yet to be fully validated
for reliability and reproducibility, it fulfils the objective of being comprehensive. In this
system, the first digit specifies the bone (1 = humerus, 2 = radius/ulna, 3 = femur, 4 =
tibia/fibula) and the second the segment (1 = proximal, 2 = diaphyseal, 3 = distal, 4 =
malleolar). A letter specifies the fracture pattern (for the diaphysis: A = simple, B = wedge,
C = complex; for the metaphysis: A = extra-articular, B = partial articular, C = complete
articular). Two further numbers specify the detailed morphology of the fracture. 1

V. 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 pathologicaluntil proved
otherwise. In children under 4 years the possibility of physical abuse must be kept in
mind.1
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 andoblique 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).1
Pathological anatomy Most fractures of the femoral shaft have some degree of
comminution, although it is not always apparent on x-ray. Small bone fragments, or a
single large butterflyfragment, may separate at the fracture line but usually remain
attached to the adjacent soft tissue and retain their blood supply. With more extensive
comminution there is no point of firm contact between proximal and distal fragments and
the fracture is completely unstable. This is the basis of a helpful classification (Winquist,
Hansen et al. 1984). Fracture displacement often follows a predictable pattern dictated by
the pull of muscles attached to each fragment. 1
In proximal shaft fractures the proximal fragment is flexed, abducted and
externally rotated because of gluteus medius and iliopsoas pull; the distal fragment is
frequently adducted.In mid-shaft fractures the proximal fragment is again flexed and
externally rotated but abduction is less marked. 1
In lower third fractures the proximal fragment is adducted and the distal fragment is
tilted by gastrocnemius pull. 1
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. Severe involvement from
myelomeningocele or cerebral palsy may result in generalized osteopenia and a
predisposition to fracture with minor trauma. 1
VI. CLINICAL EVALUATION

There is swelling and deformity of the limb, and anyattempt 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.1
Patients 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. The diagnosis is more
difficult in patients with multiple trauma or head injury or in nonambulatory, severely
disabled children.A careful neurovascular examination is essential.Splints or bandages
placed in the field must be removed with a careful examination of the overlying soft
tissues to rule out the possibility of an open fracture.Hypotension from an isolated femoral
shaft fracture is uncommon. The Waddell triad of head injury, intraabdominal or
intrathoracic trauma, and femoral shaft fracture is strongly.1

Radiographic Evaluation
For the radiologi 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.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.1

Femoral shaft fractures diagnosis (a) The upper fragment of this femur is adducted,
which should alert the surgeon to the possibility of (b)an associated hip dislocation. With
this combination of injuries the dislocation is frequently missed; the safest plan is to xraythe pelvis with every fracture of the femoral shaft.
For the children Anteroposterior and lateral views of the femur should be
obtained.Radiographs of the hip and knee should be obtained to rule out associated
injuries; intertrochanteric fractures, femoral neck fractures, hip dislocation, physeal
injuries to the distal femur, ligamentous disruptions, meniscal tears, and tibial fractures
have all been described in association with femoral shaft fractures.Magnetic resonance
imaging and bone scans are generally unnecessary but may aid in the diagnosis of
otherwise occult nondisplaced, buckle, or stress fractures.2
VII.

TREATMENT
The principles of treatment in children are the same as in adults but it should be

emphasized that in young children open treatment is rarely necessary. The choice of closed
method depends largely on the age and weight of the child. As children get older (and

larger), fractures take longer to heal and conservative treatment is more likely to result in
problems associated with long hospitalization and a greater risk of malunion (Poolman,
Kocher et al. 2006). Coupled to this is the cost of protracted bed occupancy.
Consequentlythere has been a trend towards treating femoral shaft fractures in older
children by operation, but the argument is flawed if this is based on cost alone many of
these children will have to return for implant removal. Perhaps it is the risk of malunion,
particularly in unstable fracture patterns, that renders surgery a better option for older
children and adolescents.1
Traction and casts Infants need no more than a fewdays in balanced traction,
followed by a spica cast for another 34 weeks. Angulation of up to 30 degrees can be
accepted, as the bone remodels quite remarkably with growth. Immediate spica casting has
also found favour and this approach does not appear to increase the risk of complications.1
Children between 2 and 10 years of age can betreated either with balanced traction
for 23 weeks followed by a spica cast for another 4 weeks, or by early reduction and a
spica cast from the outset. Shortening of 12 cm and angulation of up to 20 degrees are
acceptable.1
Teenagers require somewhat longer (46 weeks) inbalanced traction, and those
aged over 15 (or even younger adolescents if they are large and muscular) may need
skeletal traction. Once the fracture feels firm, traction is exchanged for either a spica cast
(in the case of upper third and mid-shaft fractures) or a cast-brace (for lower third
fractures), which is retained for a further 6 weeks. The position should be checked every
few weeks; the limit of acceptable angulation in this age group is 15 degrees in the
anteroposterior x-ray and 25 degrees in the lateral.1
If a satisfactory reduction cannot be achieved bytraction, internal (plates or flexible
intramedullary nails) or external fixation is justified. This applies tobolder children and
those with multiple injuries.1
Operative treatment This is growing in popularity asthere is: (1) a shorter in-patient
stay (and for the child, a quick return home); (2) a lower incidence of malunion. Against
this is the added risk of surgery, takinginto account that many such fractures have good
results when treated non-operatively. The tendency to adopt this approach in older children
and adolescents may be justified. Surgical options include fixation with flexible
intramedullary nails or trochanteric entry-point rigid nails with interlocking screws
(neither of which damages the physes), plates inserted by the MIPOtechnique and external
fixation.1

VIII. COMPLICATIONS
Malunion: Remodeling will not correct rotational deformities. An older child will
not remodel as well as a younger child. Anteroposterior remodeling occurs much more
rapidly and completely in the femur than varus/valgus angular deformity. For this reason,
greater degrees of sagittal angulation are acceptable.3
Nonunion: Rare; even with segmental fractures, children often have sufficient
osteogenic potential to fill moderate defects. Children 5 to 10 years of age with established
nonunion may require bone grafting and plate fixation, although the trend in older (>12
years) children is locked intramedullary nailing.3

REFERENCES
1. Solomon L, et all. Principles of fractures. Apleys System of Orthopaedics and
Fractures. Ninth Edition. London :Hodder Arnold. 2010; p. 687-688, 706-732,
859-873, 897-898, 904
2. Thompson, jon C. Basic Science. In Netters Concise Atlas of Orthopedics
Anatomy, 1st edition. Learning system LLC, A Subsidiary of Elsevier Inc. 2001
Chapter 1, p.1-13,288,315,320-321

3. Koval, Keneath J., Zuckerman, Joseph D. Femoral Shaft. In: Handbook of fracture,
3nd edition. New York: Lippincott Williams & Wilkins. 2006; Chapter 32, p.517527
4. Koval, Keneath J., Zuckerman, Joseph D. Pediatric femoral shaft. In: Handbook of
fracture, 3nd edition. New York: Lippincott Williams & Wilkins. 2006; Chapter 48,
p.841-940
5. Koval, Keneath J., Zuckerman, Joseph D. Femoral Shaft. In: Handbook of fracture,
4nd edition. New York: Lippincott Williams & Wilkins. 2010; p.687-689
6. Miller, Thompson, Hart. Review of Orthopaedics. Sixth Edition. Elsevier Saunders.
Philadelphia. 2012. p.760-761