Case Report

Juli 2013

OPEN FRACTURE 1/3 MIDDLE FEMUR SINISTRA

OLEH :
Dewi Pertiwi
C11108157
PEMBIMBING:
dr.Ihsan
dr.Yoga
dr.Prori
dr. Satria
KONSULEN:
dr.M. Ruksal Slaeh, Ph.D, Sp.OT
DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK
PADA BAGIAN ORTHOPEDI DAN TRAUMATOLOGI
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
MAKASSAR
2013

OPEN FRACTURE 1/3 MIDDLE FEMUR SINISTRA

Name
Age
Admission
RM number

: Mr. S
: 19 y.o
: 14th July 2013
: 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 survey
Airway: Clear, patent
Breathing: RR:18x/min, spontaneous, thoracoabdominal
Circulation: BP 110/80, HR 96x/min, CRT <2
Disability: Compos mentis (E4M6V5)
Environment: temp 36,7c
Secondary survey
Left Thigh Region
I
: 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
pain
NVD : Sensibility is good, dorsalis pedis artery was palpable, CRT < 2
Leg length
ALL
TLL
LLD

Right leg
91
88
1cm

Left leg
90
87
1 cm

LABORATORY FINDINGS
RBC : 4.650.000/mm3
HGB : 13,6 g/dl
HCT : 38,1 %
PLT : 178.000/mm3
WBC : 12.980/mm3
CT : 800
BT : 300
HbsAg : positif
Electrolit
Na : 137
K : 4,2
Cl : 106
GDS : 89
Ureum : 20
3

Creatinin : 10
GOT/GPT : 71/62

RADIOGRAPHIC FINDINGS
PELVIS XRAY (15.07.2013)

RADIOGRAPHIC
FINDINGS

RESUME
19 y.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.
DIAGNOSIS
Open fracture 1/3 middle of the left femur grade I
MANAGEMENT THERAPY
IVFD
Analgetics
Skin Traction
Plan for ORIF

DISCUSSION
OPEN 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 long
o Type II: Low- to medium-energy fracture with a laceration >1 cm long
but without extensive soft-tissue damage
o 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:

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.

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.
9

Epidemiology
Incidence

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

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.

10

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.

P.349
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.

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.

11

CLASSIFICATION
Descriptive

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 comminution
Type II:
Cortices of both fragments at least 50% intact
Type III: 50% to 100% cortical comminution
Type VI:
Circumferential comminution with no cortical contact
OTA Classification of Femoral Shaft Fractures
See Fracture and Dislocation Compendium at
http://www.ota.org/compendium/index.htm.
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.
P.350

12

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).

13

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.
P.351

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.

14

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
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.

15

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.
P.352

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.

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.

16

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 Fixation
Plate 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.
17

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

failure.

Indications include:
o Extremely narrow medullary canal where IM nailing is impossible or
difficult.
P.353

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.

18

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
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.

P.354
REHABILITATION

Early patient mobilization out of bed is recommended.

19

Early range of knee motion is indicated.

Weight bearing on the extremity is guided by a number of factors including

the patients 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,
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.

20

Heterotopic ossification may occur.

Prognosis
95% 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 68 weeks until bony union.

21