HALAMAN PENGESAHAN

Nama : Ulfa Elsanata

NIM : 01.211.6546
Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Bedah
Judul : Femur fracture

Semarang, Maret 2016

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

 CHAPTER I

INTRODUCTION

Injuries in and around the shoulder, including acromioclavicular joint injuries, occur most
commonly in active or athletic young adults. However, pediatric acromioclavicular injuries
have also increased owing to the rising popularity of dangerous summer and winter sporting
activities. Proper knowledge of the different problems and treatment options for shoulder
disorders is necessary to help patients return to their preinjury state.
Acromioclavicular joint injuries are often seen after bicycle wrecks, contact sports, and car
accidents. The acromioclavicular joint is located at the top of the shoulder where the
acromion process and the clavicle meet to form a joint . Several ligaments surround this joint,
and depending on the severity of the injury, a person may tear one or all of the ligaments.
Torn ligaments lead to acromioclavicular joint sprains and separations.
The distal clavicle and acromion process can also be fractured. Injury to the
acromioclavicular joint may injure the cartilage within the joint and can later cause arthritis
of the acromioclavicular joint.
Treatment of acromioclavicular separations has been a subject of debate. In general, types I
and II injuries are treated nonoperatively in the acute setting, and types IV, V, and VI injuries
generally require surgical repair. However, reaching a consensus regarding the optimal
management of acute type III injuries has been difficult .
 CHAPTER II

PATIENT’S STATUS

I. IDENTITY
a. Name : Mr. F
b. Age : 37 years old
c. Sex : male
d. Religion : Islam
e. Job : swasta
f. Address : Kendal
g. Room : Kenanga
h. Register number : 487.401
i. Date of in patient : 18 March 2016

II. ANAMNESA
Autoanamnesa with the patient and held on March 22, 2016 in Kenanga room and
also supported by medical records.

Main complaints: Pain in the left lower extremity

Present status:
Patients come to orthopedic department hospitals in Kendal with complaints of
pain in the left lower extremity post ORIF 2 month ago, since 2 days ago.
Patients complain of pain in the left lower extremity because previous patient fall
on the bathroom. Patient fall it self and not treat to the doctor but to quack
massage. After several days, the patient felt no improvement, but getting worse.
The patient feels pain when he walk, patient difficulty in moving his left foot. The
patient complain no chance in position on his left foot, left foot more than higher
than the right foot. Patient no fever, no problems with urination and defecation,
and patient just can’t move his left foot.
 Medical condition history:
-History femur trauma(fracture) : yes about 2 month ago
- History of asthma and allergies: denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Family history:
- History of asthma and allergies: denied
- History of heart disease : denied
- History of hypertension : denied
- History of diabetes : denied

Socioeconomic status :
Patients working as an employee.
Impression: enough in socioeconomic.

III. Physical Examination

Held on March 22, 2016 at 7 a.m in Kenanga room of Kendal Hospital
Primary survey:
Airway and cervical spine stabilisation : cleared
Breathing : adequate breathing ( respiration rate : 20x/minutes) nothing
abnormality.
Circulation : adequate circulation
Disability : E4M5V6, pupil refleks +/+ isokor
Exposure : abnormality on lower left extremity

 General Condition : Looks weak

 Awareness: Composmentis, GCS 15
 Vital Signs
1. Blood pressure : 120/80 mmHg
2. Heart rate : 78 x / minute, regular
3. Temperature : 36,5oC
 4. Breathing : 20 x / min
Status generalis
 Skin : haematom on left lower extremities
 Head : mesocephal, wound (-)
 Eyes : anemis (-/-), icteric (-/-)
 Ear : discharge(-/-)
 Nose : deviation septum (-), discharge (-/-)
 Mouth : sianosis (-)
 Neck : simetris, trachea deviation (-)
 Thorax : simetris, normal
 Backbone : kifosis and lordosis (-)
 Abdomen
Inspeksi : normal
Palpasi : supel , pain (-), hepar lien are not papble
Perkusi : tympani (+)
Auskultasi : bowel (+), normal
EXTREMITY SUPERIOR INFERIOR
Akral dingin -/- -/-
Oedem -/- -/-
Capillary refill <2” <2”
Jejas -/- -/+
Hematom +/- -/-

IV. Localized status of left lower extremities

Thigh
Look : deformity (+), hematom (-), wound (-), blood (-), oedem (+),
Feel : pain (+) at left lower extrimity, skin temperature warm,
Move
Active :
o Extension : (+)minimun
o Flexion : (+)minimum
o Endorotation : hard to evaluate
o Exorotation : hard to evaluate
 Pasif :
o Extension : (+)minimum
o Flexion : (+)minimum
o Endorotation : hard to evaluate
o Exorotation : hard to evaluate

Lower extremity Dextra Sinistra

LLD
True lenght 76 75
Appearance lenght 81 80
Anatomical 44 43

V. Laboratory Results
1. Blood laboratory
Examines Results Normal Results
Hb 14,6 gr% 13 – 18 gr%
Leucosite 7.500 cell/mm3 4.000 – 10.000 cell/mm3
Trombosite 360.000 cell/mm3 150.000 – 500.000 cell/mm3
Ht 47,1 % 39 – 54 %
PT 11,4 seconds 11,3-14,7 seconds
APTT 30,4 seconds 27,4 – 39,3 seconds
GDS 99 75-115 mg/dl
Ureum 20 10-50 mg/dl
Creatinin 1,19 0,5-1,1 mg/dl
 2. Radiology
 X- ray Femur Sinistra

18-03-2016

VI. DIAGNOSE
Non union femur sinistra post ORIF and osteomyelitis
VI. PLANNING THERAPY
 Medical
 IVFD RL 20 drops per minute
 Injeksi cefazoline 2x1 gr
 Non-Medical :
 Conservative :
 Vital Sign evaluation
 Operative :
 Consul to orthopedic
 Can be performed recontruction and ORIF
 BAB III
CONTENTS REVIEW

3.1. Anatomy
The acromioclavicular joint is made up of 2 bones (the clavicle and the acromion), 4
ligaments, and a meniscus inside the joint. The normal width of the acromioclavicular joint is
1-3 mm in younger individuals; it narrows to 0.5 mm or less in individuals older than 60
years.
The acromioclavicular joint is a diarthrodial articulation with an interposed fibrocartilaginous
meniscal disk that links the hyaline cartilage articular surfaces of the acromial process and the
clavicle. The joint is horizontally and vertically stabilized in anterior and posterior translation
by a combination of dynamic muscular and static ligamentous structures, which allow a
normal anatomic range of motion. Because of the transverse orientation of the articulation,
direct downward forces may result in shear stresses that cause disruption of these stabilizing
structures and create displacement beyond the normal limits. This is evidenced by abnormal
positioning of the clavicle relative to the acromion, usually in the superior direction.
The acromioclavicular capsular ligaments provide most of the joint stability in the
anteroposterior (AP) direction.
The 2 coracoclavicular ligaments (the conoid and the trapezoid ligaments) are found medial
to the acromioclavicular joint and attach from the coracoid process on the scapula to the
inferior surface of the distal clavicle. These ligaments provide vertical (superior-inferior)
stability to the joint (see the following image). Compression of the joint is restrained mainly
by the trapezoid ligament. The deltoid and trapezius muscles are especially important in
providing dynamic stabilization when these ligamentous structures are damaged.
Torn acromioclavicular joint ligaments and/or torn coracoclavicular ligaments are seen in
acromioclavicular joint sprains. The meniscus that lies in the joint may also be injured during
sprains or fractures around the acromioclavicular joint.
The coracoacromial ligament runs from the superior surface of the coracoid process to the
inferior surface of the acromial process in a nearly horizontal direction. Although it is not an
acromioclavicular joint–stabilizing structure, during operative repair of type III
acromioclavicular injuries, the coracoacromial ligament may be resected from its acromial
insertion and used to reconstruct the torn coracoclavicular ligament. (See
Pathophysiology [intratopic link] for the classification of acromioclavicular injuries.)
The superior shoulder suspensory complex (SSSC) is a bony and soft-tissue ring composed of
the glenoid process, the coracoid process, the coracoclavicular ligament, the distal clavicle,
the acromioclavicular joint, and the acromial process at the end of a superior bony strut (the
midshaft clavicle) and an inferior bony strut (the junction of the lateral scapular body and the
medial glenoid neck).
Type III, IV, V, and VI acromioclavicular separations are double disruptions of the SSSC
characterized by disruptions of both the coracoclavicular and acromioclavicular ligaments.
As a result, these constitute unstable injuries that must be accounted for or that require
surgical reduction and stabilization.
Tabel 1. classification of acromioclavicular joint injury
type Anatomy Clinical examination Radiograph
examination
I Sprain of the AC AC joint tenderness, No abnormality
ligament minimal pain with
arm motion, no pain
in coracoclavicular
interspace
II AC ligament tear Distal clavicle Slight elevation of
with joint disruption, slightly superior to the distal end of the
coracoclavicular acromion and mobile clavicle ; AC joint
ligaments sprained to palpation, widening . stress
tenderness in the films show
coracoclavicular coracoclavicular
space space unchanged
from normal shoulder
III AC and The upper extremity Radiographs
corcacoclavicular and distal fragment demonstrate the
ligaments torn with are depressed and the distal clavicle
AC joint dislocation. distal end of the superior to the
The deltoid and proximal fragment medial border of the
trapezius muscles are may tent the skin. acromion; stress
usually detached The AC joint is views reveal a
from the distal tender, and widened
clavicle coracoclavicular coracoclavicular
widening is evident. interspace 25% to
100% greater than
the normal side.
IV Distal clavicle There is more pain Axillary radiograph
displaced posteriorly than in type III; the or computed
into or though the distal clavicle is tomography scan
trapezius. The deltoid displaced posterioly demonstrates
and trapezius away from the posterior
muscles are detached acromion. displacement of the
from the distal distal clavicle.
clavicle
V Distal clavicle Typically associated Radiograph
grossly and severely with tenting of the demonstrate the
displaced superioly skin coracoclavicular
(>100%). The deltoid interspace to be
and trapezius muscle 100% to 300%
are detached from the greater than the
 distal clavicle normal side.
VI The AC joint is The shoulder has a One of two types of
dislocated, with the flat appearance with inferior dislocation
clavicle displaced a prominent subacromial or
inferior to the acromion; associated subcoracoid.
acromion or the clavicle and upper rib
coracoid, the fractures and brachial
coracoclavicular plexus injuries result
interspace is from high energy
decreased compared trauma
with normal. The
deltoid and trapezius
muscles are detached
from the distal
clavicle.

3.2. Pathofisiology
Multiple indirect forces can result in an acromioclavicular joint injury. The most common
mechanism for an acromioclavicular joint injury is a fall directly onto the acromion, with the
arm adducted up against the body. When a person falls onto their shoulder, the force pushes
the tip of the shoulder down. The clavicle is usually kept in its anatomic position, whereas the
shoulder is driven down, which injures the different ligaments or causes a fracture. A fall
onto an outstretched hand (FOOSH injury) and a downward force on the upper extremity
have also been implicated in acromioclavicular joint injuries.
The severity of an acromioclavicular separation is dependent upon the degree of ligamentous
injury. When the ligaments are injured they are either sprained or, in more severe cases, torn.
Severe forces resulting from significant falls are often associated with type III-VI injuries.
Classification of adult acromioclavicular joint injuries
Acromioclavicular joint sprains have been classified according to the severity of injury to the
acromioclavicular and coracoclavicular ligaments, the acromioclavicular joint capsule, and
the supporting muscles of the shoulder (trapezius and deltoid) that attach to the clavicle.
An acromioclavicular joint sprain is more common than a fracture after an injury. However,
fractures of the distal clavicle and the acromion process may occur, so the healthcare provider
must be aware of such injuries and ready to diagnose and treat them as well.Allman and
Tossy initially proposed a 3-grade classification.that Rockwood expanded to 6 types of injury
(see the following images). Type I and II injuries are the same in both classification schemes,
with type III injuries in the Tossy classification subdivided into grades III, IV, V, and VI in
the Rockwood classification. Type I-III acromioclavicular injuries are the most common
injuries.
Classification of acromioclavicular joint injuries.

Allman/Rockwood classification of acromioclavicular injuries.

The Rockwood classification of acromioclavicular injuries in adults is as follows
Type I: Minor sprain of the acromioclavicular ligament, intact joint capsule, intact
coracoclavicular ligament, intact deltoid and trapezius
Type II: Rupture of the acromioclavicular ligament and joint capsule, sprain of the
coracoclavicular ligament but intact coracoclavicular interspace, minimal detachment of the
deltoid and trapezius
Type III: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular
ligament; elevated clavicle (≤100% displacement); detachment of the deltoid and trapezius
Type IV: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular
ligament; posteriorly displaced clavicle into the trapezius; detachment of the deltoid and
trapezius
Type V: Rupture of the acromioclavicular ligament, joint capsule, and coracoclavicular
ligament; elevated clavicle (>100% displacement); detachment of the deltoid and trapezius
Type VI (rare): Rupture of acromioclavicular ligament, joint capsule, and coracoclavicular
ligament; the clavicle is displaced behind the tendons of the biceps and coracobrachialis
In a type I sprain, a mild force applied to the acromioclavicular and coracoclavicular
ligaments does not tear them. The injury simply results in a sprain, which hurts, but the
shoulder does not show any gross evidence of an acromioclavicular joint dislocation.
Type II sprains are seen when a heavier force is applied to the shoulder, disrupting the
acromioclavicular ligaments but leaving the sprained coracoclavicular ligaments intact. When
these injuries occur, the lateral clavicle becomes a little more prominent.
As noted earlier, type III, IV, V, and VI acromioclavicular separations are double disruptions
of the superior shoulder suspensory complex (SSSC).
In type III sprains, the force applied to the shoulder completely disrupts the acromioclavicular
and coracoclavicular ligaments, leading to complete separation of the clavicle and obvious
changes in appearance. The lateral clavicle is very prominent.
Type IV injuries are defined by posterior displacement of the clavicle relative to the acromion
with buttonholing through the trapezius muscle.
In type V injuries, the clavicle is widely displaced superiorly relative to the acromion as a
result of disruption of muscle attachments.
The rare type VI injuries are characterized by inferior displacement of the distal clavicle
below the acromial process or the coracoid process.
Pediatric acromioclavicular injuries
Acromioclavicular joint injuries in children are relatively uncommon, and they differ
anatomically from such injuries in adults. The immature clavicle is encased in a periosteal
tube. The coracoclavicular ligament is within this tissue, whereas the acromioclavicular
ligament is exterior to it. This anatomic relationship explains why the acromioclavicular
ligament is frequently injured with direct trauma, whereas the coracoclavicular ligament
remains intact.
The pediatric Rockwood classification of acromioclavicular injuries is as follows:
Type I : Stable clavicle; radiographically normal joint
Type II : Partial tear of the periosteal tube, allowing for some mobility of the distal
clavicle; disrupted acromioclavicular ligament
Types III-VI : Larger tear through the periosteal tube, allowing for greater clavicle mobility
and gross instability with clavicle positioning; the coracoclavicular ligament remains attached
to the clavicle periosteal tube
When evaluating a pediatric radiograph, remember that incomplete closure of or failure of an
ossification center may appear to be a fracture.

3.3. Etiology
The most common mechanism of injury to the acromioclavicular and coracoclavicular
ligaments is a direct force applied to the superior aspect of the acromion, usually from a fall
with the arm in an adducted position. This impact drives the acromion inferiorly, spraining
the intra-articular acromioclavicular ligaments. If the force is great enough, the extra-articular
coracoclavicular ligament may also be damaged.
Less commonly, an indirect force may be transmitted up the arm as a result of a fall on an
outstretched hand (FOOSH injury). The force continues through the humeral head to the
acromial process, displacing it superiorly and stressing the acromioclavicular ligaments. The
coracoacromial ligaments are not injured with this type of mechanism.
Other injuries, depending on the force of injury, may include tears of the deltoid and
trapezius attachments at the clavicle and fractures of the acromion, clavicle, and coracoid (or
of their cartilaginous attachments).

3.4. Epidemiology
United States statistics
The true incidence of acromioclavicular injury is not known, as many affected individuals do
not seek treatment. Approximately 12% of all dislocations involving the shoulder affect the
acromioclavicular joint.
Athletes participating in contact sports (eg, football, rugby, hockey, martial arts) are at
increased risk of acromioclavicular joint injuries, and injuries to the acromioclavicular joint
are the most common reason that athletes seek medical attention following an acute shoulder
injury (glenohumeral dislocations are the second most common injuries seen. Patients
involved in motor vehicle collisions with direct trauma to the apex of the shoulder are also at
risk for such injuries.
Males are more commonly affected than females, with a male-to-female ratio of
approximately 5:1, and younger individuals (< 35 ) sustain more acromioclavicular injuries,
primarily due their greater participation in high-risk activities. Men in their second through
fourth decades of life have the greatest frequency of acromioclavicular joint injuries, which
are most often incomplete tears of the ligaments.
No difference in injury patterns exists among various racial or ethnic backgrounds.

3.5. Prognosis
Significant morbidity is negligible with type I and II acromioclavicular injuries.
For type I injuries, the prognosis following nonoperative care is excellent. Affected patients
may usually return to sports in 1-2 weeks. Some studies have shown mild symptoms
occurring in approximately 30% of heavy laborers, but significant symptoms are much less
common.
Following nonoperative management of type II injuries, patients in most long-term studies
have shown good-to-excellent outcomes as well. These patients usually require a longer
period of recovery that those with type I injuries, usually returning to sports in 2-4 weeks.
However, a small portion of the population with type II injuries will report symptomatic
acromioclavicular degenerative disease that necessitates surgery. Reports exist of patients
with type II injuries who continue to experience some subjective loss of strength up to 3 years
after injury. Although the literature does not contain studies investigating the natural history
of acromioclavicular joint degenerative disease, some studies report that athletes with distal
clavicle osteolysis often experience resolution of symptoms with avoidance of provocative
activities.
Morbidity is highest with type III injuries, which may be due to the controversy surrounding
management. However, those treated nonoperatively generally do quite well. There is a
scarcity of literature regarding long-term follow-up after surgical repair of type III.
Types IV, V, and VI injuries generally do well with surgical repair. Published studies of
patients undergoing both arthroscopic and open resection have reported good or excellent
results in approximately 60-100% of cases of acromioclavicular joint injuries. A 2007
prospective comparison of open versus arthroscopic treatment and retrospective studies have
shown similar long-term results. Patients undergoing arthroscopic treatment are likely to
return to activity more quickly than other patients.
Mortality is not commonly associated with acromioclavicular injuries.

3.6. Complications
Just like any other joint in the body, once the acromioclavicular joint has been injured, it has
a tendency for arthritis and pain, with pain in the joint being the most common problem after
these injuries. In type III sprains, the most common setback is also instability in the clavicle
from the torn ligaments.
Acromioclavicular separations may be accompanied by fractures and other disruptions, as
well as by injuries to nonorthopedic systems. Most frequent are midclavicular, distal
clavicular, acromial, and coracoid fractures.
Degenerative changes involving the acromioclavicular joint are common late complications.
Symptomatic traumatic arthritis may develop following nonoperative management of type I
or II injuries. Surgery is often indicated to alleviate symptoms. However, symptomatic
acromioclavicular joint arthritis may also develop in patients who undergo surgical
management acutely.
Impingement symptoms, muscle-fatigue discomfort, and/or neurovascular symptomatology
may occur in patients treated nonoperatively for type III separations and may require a
surgical reconstruction.
Postoperative complications may also arise. The most common complication is mild residual
instability after ligament reconstruction. This complication was more common when screws,
sutures, suture tape, and Kirschner wires (K-wires) were being used to repair coracoclavicular
ligament tears. Migration may also occur if pins or wires are used for fixation. Other
postprocedure complications include osteomyelitis, soft-tissue ossification, and failure of
fixation with recurrent deformity. Infections (eg, wound infection) may also occur, but these
are rare, occurring less than 1% of the time.
When a patient is dealing with an arthritic acromioclavicular joint, the most common problem
is inadequate resection of the clavicle during surgery. This causes continued
acromioclavicular joint pain in these patients, but it is easily fixed with proper arthroscopic
resection of the fragment.
Other complications from acromioclavicular joint injuries may include the following:
 Cosmetic deformity
 Accelerated osteoarthrosis
 Decreased shoulder range of motion/upper extremity strength
 Distal clavicle osteolysis

3.7. Treatment
Type I
Rest for 7 to 10 days, ice packe, sling. Refrain from full activity until painless, full
range of motion ( 2 weeks).
Type II
Sling for 1 to 2 weeks, gentle range of motion as soon as possible. Refrain from heavy
activity for 6 weeks. More than 50% of patients with type I and II injuries remain symtomatic
at long-term follow up.
Type III
For inactive, nonlaboring, or recreational athletic patients, especially for the nondominant
arm, nonoperative treatment is indicated : sling, early range of motion, strengthening and
acceptance of deformity. Younger, more active patinets with more severe degree of
displacement and laborers whos use their upper extremity above the horizontal plane may
benefit from operative stabilization. Repair is generally avoided in contact athletes because of
the risk of reinjury.
Type IV
Open reduction and surgical repair of the coracoclavicular ligaments are performed for
vertical stability.
Type V
Open reduction and surgical repair of the coracoclavicular ligaments are indicated.
Type VI
Open reduction and surgical repair of the coracoclavicular ligaments are indicated.
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