CASE BASED DISCUSSION

“Close Fracture Os Femur Distal Dextra”

Submitted To Fulfill The Task And Complete One Of The Requirements In Taking The
Professional Medical Education Program in the Department of Surgery
at RSUD Soewondo Kendal Hospital

Arranged by:

Supervisor:
dr. Wisnu Murti, Sp. OT

MEDICAL FACULTY OF
SULTAN AGUNG ISLAMIC UNIVERSITY
SEMARANG
2019
 HALAMAN PENGESAHAN

Name : koass bedah periode 20 Mei 2019 – 22 Juli 2019

Fakulty : Kedokteran

University : Islam Sultan Agung Semarang

Grade : Program Pendidikan Profesi Dokter

Sub : Ilmu Bedah

Title : Close Fracture Os Femur Distal Dextra

Kendal, Juli 2019

Mengetahui dan Menyetujui

Pembimbing Kepaniteraan Klinik

Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti, Sp.OT

 CHAPTER I

INTRODUCTION

Fracture means deformation or discontinuity of the bone by energy that exceeds bone
strength. Fractures can be classified according to the fracture line (transversal, spiral, oblique,
segmental, communicative), location (diafise, metafise, epiphise) and integration of the skin
and connected networks (open or compound and closed).
Fractures of the thighbone that occur just above the knee joint are called distal
femur fractures. The distal femur is where the bone flares out like an upside-down
funnel. The distal femur is the area of the leg just above the knee joint. Distal femur
fractures most often occur either in older people whose bones are weak, or in younger
people who have high energy injuries, such as from a car crash. In both the elderly and
the young, the breaks may extend into the knee joint and may shatter the bone into many
pieces.
Distal femoral fractures comprise approximately 3%–6% of all femoral
fractures.1 The associated mechanism of injury can be of high or low energy; high-energy
mechanisms such as motor vehicle accidents are more common in the younger population as
compared with low-energy mechanisms such as fall from stand in the elderly and
osteoporotic patients.2 Distal femoral fractures are often complex, intraarticular, and
comminuted, irrespective of etiology and thus make achieving and maintaining an adequate
reduction challenging. Special care must be taken to avoid disrupting the soft tissue envelope
to reduce the risk of nonunion.3 The AO/OTA system is most universally used for fracture
classification.4 Fracture patterns include type A (extraarticular), type B (partial
articular/unicondylar), and type C (complete articular/bicondylar). Further classification into
subtypes 1, 2, and 3 indicates the progressively increasing degree of comminution.
 CHAPTER II

LITERATURE REVIEW

1. Anatomy of humerus
The knee is the largest weightbearing joint in your body. The distal femur
makes up the top part of your knee joint. The upper part of the shinbone (tibia)
supports the bottom part of your knee joint.
The ends of the femur are covered in a smooth, slippery substance called
articular cartilage. This cartilage protects and cushions the bone when you bend
and straighten your knee.

Strong muscles in the front of your thigh (quadriceps) and back of your thigh
(hamstrings) support your knee joint and allow you to bend and straighten your
knee.

2. Mechanism of fracture

Fractures of the distal femur most commonly occur in two patient types:
younger people (under age 50) and the elderly.

Distal femur fractures in younger patients are usually caused by high energy
injuries, such as falls from significant heights or motor vehicle collisions. Because
of the forceful nature of these fractures, many patients also have other injuries, often
of the head, chest, abdomen, pelvis, spine, and other limbs.

Elderly people with distal femur fractures typically have poor bone quality.
As we age, our bones get thinner. Bones can become very weak and fragile. A
lower-force event, such as a fall from standing, can cause a distal femur fracture in
an older person who has weak bones. Although these patients do not often have
other injuries, they may have concerning medical problems, such as conditions of
the heart, lungs, and kidneys, and diabetes.

3. Classification
Classification of Distal Femur Fractures [AO/ASIF]

A – Extra-articular [Supracondylar Fractures]

 A1 – Simple
 A2 – Metaphyseal, wedge
 A3 – Metaphyseal, complex
 B – Partial articular

 B1 – Lateral condyle (sagittal fracture line)

 B2 – Medial condyle (sagittal fracture line)
 B3 – Frontal (coronal fracture line) {Hoffa’s fracture}

C – Complete articular

 C1 – Articular and metaphyseal segments, simple fractures

 C2 – Articular simple, but metaphyseal multifragmentary fractures
 C3 – Articular and metaphyseal segments, multi-fragmentary fractures
4. Clinical description

Patients with a suspected distal femoral fracture often present after trauma
with pain in the knee or thigh, the inability to bear weight on the affected extremity,
and associated swelling and/or deformity.

The most common symptoms of distal femur fracture include:

 Pain with weightbearing
 Swelling and bruising
 Tenderness to touch
 Deformity — the knee may look "out of place" and the leg may appear shorter
and crooked
In most cases, these symptoms occur around the knee, but you may also have
symptoms in the thigh area.

5. Physical Examination

Physical

Initial evaluation should involve a careful assessment of the skin to check for
the possibility of an open fracture or soft tissue injury that might compromise the
surgical approach. A complete assessment of the neurovascular status of the affected
lower extremity should be performed.

Conduct a thorough examination to rule out associated injury. Hip fractures

and ligamentous knee injuries commonly are observed in association. [5] At the site
of fracture, tenderness on examination and visible deformity typically are noted.
The extremity may appear shortened, and crepitus may be noted with movement.
The thigh is often swollen secondary to hematoma formation. Perform a thorough
vascular examination on the extremity. Signs of vascular compromise should
 prompt arteriography and a vascular surgery consult. Physical signs of arterial injury
include the following: expanding hematoma, absent or diminished pulses,
progressive neurologic deficits in a closed fracture.

Because of extensive blood supply to the musculature surrounding the femur,

diaphyseal fractures may be associated with significant blood loss (ie, 1 L or more)
and resulting tachycardia and hypotension. Test distal neurologic function, though
examination is frequently unreliable because of the amount of pain associated with
these fractures. Nerve injury is rare because of protective surrounding musculature.

6. Radiological Examination

Initial imaging includes plain radiographs of the knee and femur. For
suspected type B or C fractures, Computed Tomography (CT) may be obtained for
further characterization of the articular surface and the degree of comminution. CT
is extremely useful in diagnosing the presence of a “Hoffa” fragment, a coronal
plane fracture, most commonly involving the lateral femoral condyle.5 Temporizing
measures typically involve immobilization with a long-leg splint or knee
immobilizer. In cases of extreme deformity, a closed reduction may be required.

7. Management

Emergency Department Care

Fracture reduction and immobilization: Reduce fractures to near-anatomic

alignment by using in-line traction, which reduces pain and helps prevent hematoma
formation. Hold reduction by a traction device (eg, Hare, Buck) or long-leg
posterior splint. Pneumatic splint may have additional benefits of reducing blood
loss by direct pressure and tamponade of hematoma formation. Traction is often
required to hold the femur out to length because of contraction of large muscle mass
in the thigh.

Pain management:

Pain management is the most significant intervention of the emergency physician.

Use parenteral opiate-type analgesics to the extent that respiratory and circulatory
parameters allow. Intravenous administration allows for the most reliable titration to
pain relief while providing ready access for reversal agents (ie, naloxone) if
necessary.

Infection prophylaxis:

With open fractures, administer tetanus toxoid (unless given within 5 y) and use
antibiotics with excellent staphylococcal coverage and good tissue penetration.
Often, a first-generation cephalosporin (ie, cefazolin sodium) is administered in
combination with gentamicin.

In addition to maintenance intravenous fluids, patients suspected of

significant blood loss should be resuscitated with crystalloids. Place a Foley
catheter, and restrict all patients to taking nothing by mouth (NPO) until seen by an
orthopedic surgeon. [10]

Surgical reduction and fixation of displaced, intra- articular fractures of the

distal femur is generally indicated. 6Nonsurgical management is reserved for
nonambulatory patients or patients too frail to tolerate a surgical procedure. The
goal of clinical management of distal femoral fractures is the anatomic reduction of
the articular surface and restoration of limb length, rotation, and alignment. A stabile
fixation construct is important to allow early knee range of motion to optimize
functional recovery. Preservation of the soft tissue attachments to bone fragments is
critical in reducing the risk of nonunion. Although restoring alignment in both the
coronal and sagittal planes is important in restoring normal knee range of motion
and kinematics, the coronal plane has been shown to be most significant with regard
to overall outcome. Patients with fractures that heal with greater than 15 degrees of
valgus or any degree of varus have been reported to develop posttraumatic arthritis.7

Nonsurgical management involves protected weight or non-weight bearing in

an unlocked, hinged knee brace to maintain the range of motion. Indications for
nonsurgical management include distal femoral fractures that are nondisplaced and
stable, as well as patients with medical conditions who preclude surgical treatment.
Evidence of radiographic union of the fracture is required before the gradual return
to weight bearing. Complications of nonsurgical management include those that are
associated with decreased mobility, including decubitus ulcers, thromboembolic
disease, and loss of knee function.

Surgical fixation has consistently demonstrated superior outcomes as

compared with nonsurgical treatment with respect to improvement in alignment,
bony union, knee range of motion, and functional outcome.8

Methods of surgical fixation include external fixation, fixed-angle blade

plates, dynamic condylar screws (DCS), locking plates, and intramedullary nails;
the characteristics of the fracture in addition to the overall medical condition of the
patient generally determine the type of fixation.

External fixation is typically employed as a temporizing measure for the

unstable polytrauma patient and for those with compromised overlying soft tissue.
Alternatively, external fixation may be a definitive treatment for patients with
severely comminuted or open fractures with concomitant medical conditions
incompatible with additional surgery.

The fixed-angle blade plate is a 95-degree angled plate that provides stable
fixation by controlling alignment in 3 planes. It is a very technically demanding
procedure as it is a single piece, and requires restoration of alignment in all 3 planes
for optimal function.

The DCS was introduced as an alternative to the fixed-angle plate, with a

screw replacing the blade plate. This device requires restoration of alignment in 2
rather than the 3 planes. A significant advantage is that it is 2 separate pieces, which
allows for less dissection of soft tissue before placement.

Precontoured anatomic locking plates, such as the Less Invasive Stabilization

System, afford the added versatility of multiple distal screw hole options combined
with the ability to lock or compress. Insertion is obtained with a less invasive,
submuscular plating technique, which results in decreased soft tissue disruption.
Alignment guides allow for the percutaneous placement of proximal screws. After
reduction, the plate is affixed to the lateral aspect of the femur. The plate maintains
alignment of the closed reduction and allows for relative stability and secondary
healing.9 The plate design is anatomically shaped, based on femoral CT data and
trials to maximize best fit for the most femora. Screw angle options were optimized
to allow condylar fixation without penetrating the intercondylar notch or
patellofemoral joint.

Fixation with an intramedullary nail is often used for extraarticular fractures

and simple or minimally comminuted intraarticular fractures. This implant allows
for fracture fixation with minimal disruption of the soft tissues and endosteal arterial
supply. Biomechanical studies performed by Zlowodski et al show similar axial
strength between intramedullary nailing and side-plate fixation
constructs.10,11 Complications may arise from malalignment of the fracture because
of insufficient fracture reduction, a poor starting point, or eccentric reaming.

Nonoperative

hinged knee brace with immediate ROM, NWB for 6 weeks

indications (rare)

 nondisplaced fractures

 nonambulatory patient

 patient with significant comorbidities presenting unacceptably high degree

of surgical/anesthetic risk

Operative

external fixation

 temporizing measure until soft tissues permit internal fixation, or until patient
is stable

 avoid pin placement in area of planned plate placement if possible

open reduction internal fixation

indications

 displaced fracture

 intra-articular fracture

 nonunion

goals

 need anatomic reduction of joint

 stable fixation of articular component to shaft to permit early motion

 preserve vascularity

postoperative
 Initiation of immediate postoperative knee range of motion is essential to prevent
stiffness and loss of function. This is achieved with early physical therapy and lower
extremity strengthening. A hinged knee brace may be used to protect against varus
and valgus stresses across the fracture if there is concern for the quality of fracture
fixation. Toe-touch or nonweight-bearing precautions should be maintained for 6–12
weeks after surgery or until evidence of radiographic fracture healing.

 early ROM of knee important

 non-weight bearing or toe touch weight-bearing for 6-8 weeks, up to 10-12

weeks if comminuted

 quadriceps and hamstring strength exercises

retrograde IM nail

indications

 good for supracondylar fx without significant comminution

 preferred implant in osteoporotic bone

 traditionally, 4 cm of intact distal femur needed but newer implants with very
distal interlocking options may decrease this number, can perform
independent screw stabilization of intercondylar component of fracture
around nail

distal femoral replacement

indications

 unreconstructable fracture

 fracture around prior total knee arthroplasty with loose component

8. Complication

Symptomatic hardware

lateral plate

 pain with knee flexion/extension due to IT band contact with plate

 medial screw irritation

 excessively long screws can irritate medial soft tissues

  determine appropriate intercondylar screw length by obtaining an AP
radiograph of the knee with the leg internally rotated 30 degrees

Malunions

 most commonly associated with plating, usually valgus

 functional results satisfactory if malalignment is within 5 degrees in any

plane

Nonunions

 up to 19%, most commonly in metaphyseal area, with articular portion healed

(comminution, bone loss and open fractures more likely in metaphysis)

 decreasing with less invasive techniques

 treatment with revision ORIF and autograft indicated

 consider changing fixation technique to improve biomechanics

Infection
 treat with debridement, culture-specific antibiotics, hardware removal if
fracture stability permits
Implant failure
 up to 9%
 titanium plates may be superior to stainless steel
 most likely due to improper bridge plating techniques
 CHAPTER III
CASE REPORT

I. IDENTITY
Name : Mr. AI
Age : 17 y.o
Gender : Male
Address : Reban
Occupation : Student
Religion : Islam
Come to Hospital : 10-6-2019
Room : Kenanga
MC : 581xxx

II. ANAMNESIS
a. Main problem : Pain of right knee and toe
b. History of present illness
A boy 17 years old came to IGD RSUD kendal at 11 mei 2019 felt pain on his right
lower limb, right tumb and lower jaw after his motorcycle crach a car. After the
accident patient immediately carried to RSUD limbung and got first aid before
refered to RSUD kendal. Patient didnt felt headache, dizziness, nausea, vomiting and
fever, Urinate and defecate normal.
c. Family Medical History
 History of similar injury : denied
 History of drug allergic : denied
 History of hipertension : no
 History of diabetic mellitus : no

d. Personal History, Social and Environment

 History of similar illnes : denied
 History of diabetic mellitus : no

III. PHISICAL EXAMINATION

GCS : 15
Awarness : Composmentis
Vital sign
 BP : 120//70 mmHg
 HR : 92x/minutes
 RR : 20x/ minutes
 Temp : 37 C
General Status
1. Skin : turgor (< 2 “)
2. Head : mesochepal, wound (-)
 3. Eyes : anemis (-/-), icteric (-/-)
4. Ear : discharge (-/-)
5. Nose : deviation septum (-), discharge (-/-)
6. Mouth: sianosis (-)
7. Neck : simestris, trachea deviation (-), enlargement of thyroid gland (-)

Thorax
 COR
- Inspection : ictus cordis (-)
- Palpation : ictus cordis palpable at SIC 2cm medial to the line
midclavicularis, Pulsus sternal (-), pulsus epigastrium (-)
- Percussion : cor
Bottom left : SIC V 2 cm medial line midclavicularis
Top Left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Bottom right: SIC III line parasternalis sinistra
- Auscultation : reguler I-II heart sound, gallop (-), murmur (-)

 PULMO
- Inspection : normochest, simetris, retraction (-)
- Palpation : vermitus vocal simetris (+), crepitation (-/-)
- Percussion : sonor (+/+)
- Auscultation : vesicular (+/+), Wheezing (-/-), ronchi (-/-)

 ABDOMEN
- Inspection : flat (+), simetris (+)
- Auscultation : peristaltic sound (+) normal
- Percussion : thympani (+)
- Palpation : supel, pain (-)

 EXTREMITAS EXAMINATION
Extremity Superior Inferior
Oedem -/- +/-
Cold extremity -/- -/-
Physiological reflex +/+ +/+
Sianosis -/- -/-

 BACK EXAMINATION
Inspection : kifosis (-), scoliosis (-), gibbus (-)
Palpation : pain (-), proc spinosus (+) straight

IV. LOCAL STATUS (Right Knee and Toe)

 Look : eritem (+/-), wound (+/-), hematom (+/-), deformity (+/-), Swelling
(+/-), bleeding (+/-)
 Feel : painfulness when it given a palpation (+/-), numbness (-/-), sensoric
(+/+), pulse a. dorsalis pedis (+/+), crepitation (difficult to value/-)
 Move : Movement (active-passive) (limit/+); ROM (limit/+)
  LLD :
Right Left
True length 81 cm 87 cm
Apparent length 92 cm 93 cm
Anatomic length 73 cm 74 cm

V. SUPPORTING EXAMINATION
1. X Foto Rontgen Genue dextra & Ankle joint dextra (AP-LATERAL) position

(Post orif supra condilar dextra)

2. Laboratory
Hematology Result Normal Value
HB 8,9 (L) 11,5-16,5
 Leukosit 9,6 4-10
Hematokrit 24,1 35-49
Trombosit 137 150-500

VI. ASSESMENT
Clinical Diagnosis : Closed Fractur Supra Condilar Dextra , Bone Loss Digiti I Dextra,
Anemia Dan Trombositopeni

VII. INITIAL PLAN

a. Ip. Therapy
- RL infus 20 tpm
- Inj. Dexketoprofen 1 ampul (50mg)/ 8 hour
- Inj. Ranitidin 1 ampul (50 mg)/8 hour
- Inj. Cefazolin 2 x 1 gram
b. Ip. Operative
ORIF Supra Condilar Destra
Amputasi Digiti I Pedis Dextra
c. Ip. Monitoring
- General condition
- Bleeding
- Vital sign
- Sign of shock and compartemen syndrom
d. Education
- Educate patient about her problem
- Educate patient don’t to much movement before do the surgery
- Educate patient to do some simple exercise after the treatment was received and
walk with walker.

VIII. PROGNOSIS
 Quo ad vitam : ad bonam
 Quo ad sanam : dubia ad bonam
 Quo ad fungsionam : dubia ad bonam
 CHAPTER IV
CONCLUSSION

Management of distal femoral fractures is challenging, as they are often complex,

intra-articular, and comminuted in nature. Periprosthetic fractures add an additional level of
complexity as they limit screw placement and often occur in the setting of poor bone quality.
Innovations in surgical methods, such as percutaneous plating, allow for fixation of multiple
fracture types using minimally invasive approaches. By minimizing soft tissue and endosteal
arterial disruption in addition to biomechanical advantages imparted through achieving
multiple points of fixation, percutaneous plates promote early mobilization and knee range of
motion, allowing for optimal functional recovery and bone healing. Distal femur fracturesin a
patient with an ipsilateral total hip replacement present a rare but likely increasing problem.
Further research is required to identify mechanically favorable constructs to assure a good
clinical outcome
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