CASE REPORT

FRACTURE OF OS.FEMUR SINISTRA 1/3 PROKSIMAL

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian Ilmu Bedah di RSUD
Kendal

Disusun oleh:
Dewi Arnilia (01.211.6363)
Pembimbing:
dr. Wisnu Murti., Sp.OT
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG SEMARANG
SEMARANG
2015

HALAMAN PENGESAHAN
Nama

: Dewi Arnilia

NIM

: 012116363

Fakultas

: Kedokteran

Unuversitas

: Universitas Islam Sultan Agung Semarang

Tingkat

: Program Pendidikan Profesi Dokter

Bagian

: Ilmu Bedah

Judul

: Close fracture of os. Femur sinistra 1/3 proksimal

Semarang, Agustus 2015

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti., Sp,OT

CHAPTER I
INTRODUCTION
A thigh bone (femur) fracture is a break in the upper bone of the leg. Because the
femur is the longest, strongest bone in the body, unless the bone is diseased, it takes great
force to break it. Fractures of the femur near the hip are generally termed "hip fractures," with

the term "femur fracture" used for fractures that occur in the shaft of the femur or near the
knee.
Femur fractures are classified on the basis of the fracture line, whether the bone
fragment breaks through the skin, and the location in which the break occurs. Fractures are
classified by types, including simple, comminuted, closed, open, pathological, and stress.
Simple fractures consist of a break in only one place in the bone. In a comminuted fracture,
the bone is broken in more than two places. In a closed fracture, the skin is not broken by the
fracture, while in an open fracture, the skin is broken and the bone fragments are exposed. A
pathological fracture occurs after the bone has been weakened by disease, and a stress
fracture consists of a gradually occurring break that is so slight that it may not even appear on
x-ray.
A traumatic femur fracture is usually fairly obvious from an accident or severe
impact. The patient will feel severe pain in the thigh. There may be deformity in the thigh for
example the leg may be at an angle or the injured leg appearing shorter than the other. The
spectrum of femur fractures is wide and ranges from non-displaced femoral stress fractures
to fractures associated with severe comminution and significant soft-tissue injury. Femur
fractures are typically described by location (proximal, shaft, distal).
Traumatic femur fractures in the young individual are generally caused by highenergy forces and are often associated with multisystem trauma. In the elderly population,
femur fractures are typically caused by a low energy mechanism such as a fall from standing
height. Isolated injuries can occur with repetitive stress and in the presence of metabolic bone
diseases, metastatic disease or primary bone tumors. A considerable amount of swelling may be
visible and the patient will be unable to move their leg. It is important to look out for signs of injury to
other structures, such as blood vessels and nerves. These include immediate bruising, a cold or pale
lower leg or foot which might indicate restricted circulation. Tingling or numbness in the lower leg or
foot could indicate nerve damage.

CHAPTER II
CONTENS REVIEW

ANATOMY OF FEMUR

The femur is the only bone located within the human thigh. It is both the longest
and the strongest bone in the human body, extending from the hip to the knee. It is
classed as a long bone, and is in fact the longest bone in the body. The main function
of the femur is to transmit forces from the tibia to the hip joint. It acts as the place of
origin and attachment of many muscles and ligaments so we shall split it into three
areas; proximal, shaft and distal.

Picture 1. Femur; anterior and posterior view

Proximal
The proximal area of the femur forms the hip joint with the pelvis. It consists
of a head and neck, and two bony processes called trochanters. There are also two
bony ridges connecting the two trochanters
Head Has a smooth surface with a depression on the medial surface this is for
the attachment of the ligament of the head. At the hip joint, it articulates with the
acetabulum of the pelvis.
Neck Connects the head of the femur with the shaft. It is cylindrical, projecting in
a superior and medial direction this angle of projection allows for an increased
range of movement at the hip joint.
Greater trochanter this is a projection of bone that originates from the anterior
shaft, just lateral to where the neck joins. It is angled superiorly and posteriorly, and
can be found on both the anterior and posterior sides of the femur. It is the site of
attachment of the abductor and lateral rotator muscles of the leg.

Lesser trochanter much smaller than the greater trochanter. It projects from the
posteromedial side of the side, just inferior to the neck-shaft junction. The psoas
major and iliacus muscles attach here.
Intertrochanteric line a ridge of bone that runs in a inferomedial direction on the
anterior surface of the femur, connecting the two trochanters together. The
iliofemoral ligament attaches here a very strong ligament of the hip joint. After it
passes the lesser trochanter on the posterior surface, it is known as the pectineal line.
Intertrochanteric crest similar to the intertrochanteric line, this is a ridge of bone
that connects the two trochanters together. It is located on the posterior surface of the
femur. There is a rounded tubercle on its superior half, this is called the quadrate
tubercle, which is where the quadratus femoris attaches.

Picture 2. (A) Proximal femur in anterior view and (B) posterior view
The Shaft
The shaft descends in a slight medial direction. This brings the knees closer to
the bodys center of gravity, increasing stability. On the posterior surface of the
femoral shaft, there are roughened ridges of bone, these are called the linea
aspera (Latin for rough line)
Proximally, the medial border of the linea aspera becomes the pectineal
line. The lateral border becomes the gluteal tuberosity, where the gluteus maximus
attaches. Distally, the linea aspera widens and forms the floor of the popliteal fossa,
the medial and lateral borders form the the medial and lateral supracondylar lines.
The medial supracondyle line stops at the adductor tubercle, where the adductor
magnus attaches.
Distal

The distal end is characterised by the presence of the medial and lateral
condyles, which articulate with the tibia and patella, forming the knee joint.
Medial and lateral condyles rounded areas at the end of the femur. The
posterior and inferior surfaces articulate with the tibia and menisci of the knee, while
the anterior surface articulates with the patella.
Medial and lateral epicondyles bony elevations on the non articular areas
of the condyles. They are the area of attachment of some muscles and the collateral
ligaments of the knee joint.
Intercondylar fossa A depression found on the posterior surface of the
femur, it lies in between the two condyles. It contains two facets for attachment of
internal knee ligaments.
Facet for attachment of the posterior cruciate ligament found on the
medial wall of the intercondylar fossa, it is a large rounded flat face, where the
posterior crucitate ligament of the knee attaches.
Facet for attachment of anterior cruciate ligament found on the lateral
wall of the intercondylar fossa, it is smaller than the facet on the medial wall, and is
where the anterior cruciate ligament of the knee attaches.

Picture 3. C. Posterior Surface of the Shaft , (D) Anterior and (E) Posterior Surface
of the Distal Portion of the Femur
Arteries of Femur
The main artery of the femur is femoral artery. It is a continuation of the external
iliac artery (terminal branch of the abdominal aorta). The external iliac becomes the
femoral artery when it crosses under the inguinal ligament and enters the femoral
triangle.

In the femoral triangle, the profunda femoris artery arises from the posterolateral
aspect of the femoral artery. It travels posteriorly and distally, giving off three main
branches:

Perforating branches Consists of three or four arteries that perforate the

adductor magnus, contributing to the supply of the muscles in the medial and

posterior thigh.
Lateral femoral circumflex artery Wraps round the anterior, lateral side

of the femur, supplying some of the muscles in the lateral side of the thigh.
Medial femoral circumflex artery Wraps round the posterior side of the
femur, supplying the neck and head of the femur. In a fracture of the femoral
neck, this artery can easily be damaged, and avascular necrosis of the femur
head can occur.

Picture 4. Arteries of femur

I.

FEMUR FRACTURE
Femoral head fractures
Femoral head fractures are relatively uncommon injuries; however,
appropriate treatment of these fractures is of prime importance to help prevent the
development of post-traumatic osteoarthritis. Approximately six to 16 % of
posterior hip dislocations have been noted to be associated with a femoral head
fracture. Since the first description of a femoral head fracture, several case series
have been published; however, no firm conclusions have been reached regarding
optimal treatment. Historically, these fracture patterns have been associated with
poor functional outcomes.

The vast majority of patients that present with a fracture-dislocation of the

hip have been involved in high-energy trauma. A thorough history and physical
examination is thus crucial not only to diagnose the hip injury but also to identify
any associated injuries. It is imperative that concomitant injuries, such as head,
intra-abdominal, and chest injuries are identified and treated appropriately.

The classic mechanism of injury for femoral head fracture is traumatic

posterior dislocation of the hip. Shear forces against the femoral head as it exits
the contained acetabulum are thought to cause the femoral head fracture during
hip dislocation. Due to the inherent stability of the hip joint, dislocation of the hip
with associated femoral head fracture requires high amounts of energy, most often
due to motor vehicle collisions, fall from a height, motor vehicle-pedestrian
accidents, and sports injuries. A common position of the lower extremity during
dislocation of the hip is akin to the position during a dashboard injury to the knee,

in which the hip is positioned in flexion, adduction, and internal rotation.

Fracture-dislocation of the hip is a true

orthopaedic emergency. Provided that no
contraindications exist (e.g., associated
femoral neck fracture), emergent closed
reduction should be attempted as soon as feasible, preferably within 6 hours, given
the direct relationship between delayed reduction and the increased risk of femoral
head osteonecrosis. An irreducible fracture-dislocation of the hip or a femoral
head fracture with associated femoral neck fracture are indications for emergent
open reduction. In these settings, a preoperative CT scan should be obtained if
feasible in a timely manner.

The goals of definitive treatment of femoral head fractures are to achieve an

anatomic reduction, achieve and maintain joint stability, and remove any
interposed bone fragments. This may be obtained either nonsurgically or
surgically. The size, location, and displacement of the fracture are factors in this
decision-making process.
Neck of femur fractures (NOF)
Neck of femur fracture is common injury sustained by older patients who
are both more likely to have unsteadiness of gait and reduced bone mineral
density, predisposing to fracture. These fractures are often associated with
multiple injuries and high rates of avascular necrosis and nonunion.
Elderly osteoporotic women are at greatest risk. In elderly patients, the
mechanism of injury various from falls directly onto the hip to a twisting
mechanism in which the patients foot is planted and the body rotates. There is
generally deficient elastic resistance in the fractured bone. The mechanism in
young patients is predominantly axial loading during high force trauma , with an
abducted hip during injury causing a neck of femur fracture and an adducted hip
causing a hip fracture-dislocation.
Garden described the classification of femoral neck fractures. In this
classification, femoral neck fractures are divided into the following 4 grades based
on the degree of displacement of the fracture fragment:
Grade I is an incomplete or valgus impacted fracture.
Grade II is a complete fracture without bone displacement.
Grade III is a complete fracture with partial displacement of the fracture
fragments.
Grade IV is a complete fracture with total displacement of the fracture fragments.
Frandersen et al concluded that clinically differentiating the 4 grades of
fractures is difficult. Multiple observers were able to completely agree on the
Garden classification in only 22% of the cases. Hence, classifying femoral neck
fractures as nondisplaced (Garden grades I or II) or displaced (Garden grades III
or IV) is more accurate. See the illustration depicted below.

Trochanteric fracture
Trochanteric fracture is a fracture involving the greater and/or lesser trochanters
of the femur.
Classification
Fractures in these region can be classified as:
Intertrochanteric
Subtrochanteric
greater trochanteric avulsion fracture
lesser trochanteric avulsion fracture
Intertrochanteric fracture
Evan classified intertrochanteric fracture based on fragment fracture:
Type I: Fracture line extends upwards and outwards from the lesser trochanter
(stable). Type I fractures can be further subdivided as :

Type Ia: Undisplaced two-fragment fracture

Type Ib: Displaced two-fragment fracture
Type Ic: Three-fragment fracture without posterolateral support, owing to

displacement of greater trochanter fragment

Type Id: Three-fragment fracture without medial support, owing to

displaced lesser trochanter or femoral arch fragment

Type Ie: Four-fragment fracture without postero-lateral and medial support
(combination of Type III and Type IV)

Type II: Fracture line extends downwards and outwards from the lesser trochanter
(reversed obliquity/unstable). These fractures are unstable and have a tendency to
drift medially.

The Boyd and Griffin classification

is based on the involvement o

subtrochanteric region:

type I linear intertrochanteric

type II with comminution of trochanteric region
type III with comminution associated with subtrochanteric component
type IV oblique fracture of shaft with extension into subtrochanteric region

Subtrochonteric fracture
The Fielding classification of subtrochanteric fractures is based on the level
of the subtrochanteric region through which the fracture extends:

type I: at the level of the lesser trochanter (most common)

type II: within the region 2.5 cm below the lesser trochanter
type III: within the region 2.5 cm to 5 cm below the lesser trochanter (least
common)
The Zickel classification (modified

from

Fielding)

of

subtrochanteric

fractures takes into consideration the level and obliquity of the fracture line as
well as the presence or absence of comminution.
type I short oblique
o linear
o comminuted
type II long oblique
o linear
o comminuted
type III transverse
o high level
o low level
Treatment and prognosis
Subtrochanteric fractures generally have a good prognosis due to the good
supply of blood and adequate collateral circulation to this region of the femur with
low incidence of avascular necrosis and non-union. Postoperative infection,
however, is a potentially serious compilation.
Femur Shaft Fracture
Femoral shaft fractures in young people are frequently due to some type of
high-energy collision. The most common cause of femoral shaft fracture is a

motor vehicle or motorcycle crash. Being hit by a car as a pedestrian is another

common cause, as are falls from heights and gunshot wounds.
A lower-force incident, such as a fall from standing, may cause a femoral shaft
fracture in an older person who has weaker bones.
A femoral shaft fracture usually causes immediate, severe pain. You will not
be able to put weight on the injured leg, and it may look deformed shorter than
the other leg and no longer straight.
Femur fractures are classified depending on:

Picture 8. Femoral Shaft Fracture according OTA classification

Picture 9. Femoral Shaft Fracture according Winquist and Hansen classification

Management
Surgical Treatment
Timing of surgery.
If the skin around fracture has not been broken, the surgery should wait until
the condition of the patients are stable. Open fractures, however, expose the
fracture site to the environment. They urgently need to be cleansed and require
immediate surgery to prevent infection.
For the time between initial emergency care and surgery, the leg should be placed
either in a long-leg splint or in skeletal traction. This is to keep the broken bones
as aligned as possible and to maintain the length of your leg.
Skeletal traction is a pulley system of weights and counterweights that holds
the broken pieces of bone together. It keeps the leg straight and often helps to
relieve pain.
External fixation. In this type of operation, metal pins or screws are placed
into the bone above and below the fracture site. The pins and screws are attached
to a bar outside the skin. This device is a stabilizing frame that holds the bones in
the proper position so they can heal.
External fixation is usually a temporary treatment for femur fractures. Because
they are easily applied, external fixators are often put on when a patient has
multiple injuries and is not yet ready for a longer surgery to fix the fracture. An
external fixator provides good, temporary stability until the patient is healthy
enough for the final surgery. In some cases, an external fixator is left on until the
femur is fully healed, but this is not common.

External fixation is often used to hold the bones together temporarily when the
skin and muscles have been injured. Intramedullary nailing. Currently, the method
most surgeons use for treating femoral shaft fractures is intramedullary nailing.
During this procedure, a specially designed metal rod is inserted into the marrow
canal of the femur. The rod passes across the fracture to keep it in position.

An intramedullary nail can be inserted into the canal either at the hip or the
knee through a small incision. It is screwed to the bone at both ends. This keeps
the nail and the bone in proper position during healing.
Intramedullary nails are usually made of titanium. They come in various lengths
and diameters to fit most femur bones.

Intramedullary nailing provides strong, stable, full-length fixation. Plates

and screws. During this operation, the bone fragments are first repositioned
(reduced) into their normal alignment. They are held together with special screws
and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible,
such as for fractures that extend into either the hip or knee joints.

Picture 8. (Left) This x-ray shows a healed femur fracture treated with
intramedullary nailing. (Right) In this x-ray, the femur fracture has been treated
with plates and screws.
Recovery
Most femoral shaft fractures take 4 to 6 months to completely heal. Some
take even longer, especially if the fracture was open or broken into several pieces.

Weightbearing
Many doctors encourage leg motion early in the recovery period. It is very
important to follow the doctor's instructions for putting weight on injured leg to
avoid problems.
In some cases, doctors will allow patients to put as much weight as possible
on the leg right after surgery. However, the patient may not be able to put full
weight on leg until the fracture has started to heal. It is very important to follow
the doctor's instructions carefully. When the patient begin walking, they will most
likely need to use crutches or a walker for support.
Physical Therapy
With trauma-related femur fractures, physical therapy following stable
fixation of the fracture to improve hip and knee range of motion, strengthening
and gait training is recommended. Weight-bearing status is dependent upon
fracture pattern and surgical intervention. Ambulatory aids, such as crutches, are
used in the initial stages. The goal of the therapy program should be eventual full
weight-bearing and restoration of normal function. Pulmonary therapy is often
needed in patients sustaining major trauma requiring prolonged bed rest.
For femoral stress fractures, discontinue crutches once pain-free walking is
possible. Increase low-impact lower extremity aerobic training (e.g., swimming,
biking, elliptical trainer) as symptoms permit. Attempt to identify causative factors
of the femoral stress fractures (e.g., improper training techniques, footwear, diet).
One treatment algorithm that has been suggested consists of a graduated
four-phase program, each of which last three weeks in duration. Transfer to the
next phase is based on the result of fulcrum and hop tests carried out at the end of
each phase. If the tests were positive (i.e., a failed test), the patient was returned to
the beginning of that phase. In the first phase athletes walked with the help of
crutches and were instructed to be non-weight-bearing on the affected leg. In the
second phase normal walking was permitted, and swimming and exercising on the
unaffected extremities was allowed. In the third phase the patients performed
exercises with both upper and lower extremities using light weights. Patients were
also permitted to run in a straight line every other day and ride a stationary
bicycle. The distance that the subjects were allowed to run was gradually
increased. In the fourth phase the patient resumed normal training. In this study all
seven patients returned to normal activitywithin 12-18 weeks with no recurrences
noted at 48-96 month follow up.
Distal Femoral fracture

Distal femur fractures vary. The bone can break straight across (transverse
fracture) or into many pieces (comminuted fracture). Sometimes these fractures
extend into the knee joint and separate the surface of the bone into a few (or
many) parts. These types of fractures are called intra-articular. Because they
damage the cartilage surface of the bone, intra-articular fractures can be more
difficult to treat.

(Left) A

transverse

fracture

across

the

distal

femur

(Center)

An

intra-articular fracture that extends into the knee joint (Right) A comminuted
fracture that extends into the knee joint and upwards into the femoral shaft.
According to the common principles of the AO classification, type
A fractures are extra-articular and type B fractures are partial articular, which
means that parts of the articular surface remains in contact with the diaphysis.
Type C fractures are complete articular fractures with detachment of both
condyles from the diaphysis. The fracture types are further subdivided describing
the degree of fragmentation and other, more detailed characteristics. Further
subdivision of type B fractures includes Bl (sagittal, lateral condyle), B2 (sagittal,
medial condyle) and B3 (frontal, Hoffa type). Fracture type C is divided in C1
(articular simple, metaphyseal simple), C2 (articular simple, metaphyseal
multifragmentary) and C3 (multifragmentary).

Distal femur fractures can be closed meaning the skin is intact or can be
open. An open fracture is when a bone breaks in such a way that bone fragments
stick out through the skin or a wound penetrates down to the broken bone. Open

fractures often involve much more damage to the surrounding muscles, tendons,
and ligaments. They have a higher risk for complications and take a longer time to
heal.
When the distal femur breaks, both the hamstrings and quadriceps muscles tend to
contract and shorten. When this happens the bone fragments change position and
become difficult to line up with a cast.

Pisture 10. In this x-ray of the knee taken from the side, the muscles at the front
and back of the thigh have shortened and pulled the broken pieces of bone out of
alignment.
II.

COMPLICATION

Infection: In the case of a fractured femur that results in bone breaking the skin,
there is an increased risk of infection. This can be minimised with the appropriate
use of antibiotics.

Bone healing Problems: If the bones are not well aligned or there is irritation to
the bone due to infection, the healing process may be delayed and require further
surgery

Nerve damage: Nerve damage in femoral fractures is relatively rare but can lead
to persistent numbness or weakness in the lower leg.

Open fractures expose the bone to the outside environment. Even with good
surgical cleaning of the bone and muscle, the bone can become infected. Bone
infection is difficult to treat and often requires multiple surgeries and long-term
antibiotics.

CHAPTER II
PATIENTS STATUS
I.

II.

IDENTITY
a. Name
: Tn. A.S
b. Age
: 28 years old
c. Sex
: boy
d. Religion : islam
e. Job
: driver
f. Address : Jambearum RT 02/03, Patebon
g. Register Number : 226658
h. Date of in patient : 10 August 2015
ANAMNESA
Autoanamnesa and alloanamnesa with patients son held on december 2015 in
kenanga room III and also supported by medical records.
Main complaint : pain and swelling
Present status :
Patients come to IGD hospital in Kendal with complaints of pain in the upper
thigh sinistra due trauma. Previously patient could not standing again and
accompanied by persisten pain at rest and when the left foot was tried moved.
There are no nausea and vomiting. Beside of pain, the patients also headache.
Currently patients are unable to walk and just lay on the bed.
Medical condition history :
- History of asthma and allergies : denied
- History of heart disease
: denied
- History of hypertension
: denied
- History of diabetes
: denied
Family histori :
-

History of asthma and allergies : denied

History of heart disease
: denied
History of hypertension
: denied
History of diabetes
: denied

Socioeconomic status :

Patient is driver. The cost of treatment using money itself.

I

PHYSICAL EXAMINATION
GCS
: 15
Awareness : composmentis
Vital sign
BP : 140/80 mmHg
HR : 96x/menit
RR : 24x/menit
Temp : 36,30C
Generalic Status
1
2
3
4
5
6
7

Skin
Head
Eyes
Ear
Nose
Mouth
Neck

: turgor (+)
: mesocephal, wound (-)
: anemis (-/-), icteric (-/-)
: discharge (-/-)
: deviation septum (-), discharge (-/-)
: sianosis (-)
: simetris, trache deviation (-), enlargment of tyroid gland (-)

Thorax
COR
Inspeksi

: ictus cordis (-)

Palpation

: ictus cordis palpable at SIC V 2 cm medial to the line midclavicularis,

pulsus sternal (-), pulsus epigastrium (-)

Percussion

: heart border
Bottom left

: SIC V 2 cm medial line midclavicularis

Top left

: SIC II linea sternalis sinistra

Top rigt

: SIC II line sternalis dextra

Bottom right

: SIC III linea parasternalis sinistra

Auscultation : heart sound I-II reguler, gallop (-), murmur (-)

PULMO
Inspection

: normochest, simetris, retraction (-)

Palpation

: simetris, nothing widening between the ribs, retraction (-)

Percussion

: sonor (+/+)

Auscultation : vesikuler (+/+), wheezing (-/-), ronkhi (-/-)

ABDOMEN
Inspection

: flat, meteorismus (-), mass (-)

Auscultation : bowel (+) normal

Percussion

: tymphani (+)

Palpation

: supel, pain (-)

EXTREMITIES EXAMINATION
Extremity
Oedem
Cold extremities
Physiological reflex
Icteric

superior
-/-/+/+
-/-

inferior
-/+
-/+/+
-/-

BACK EXAMINATION
Inspection: kifosis (-), scoliosis (-)
Palpation : no painfulness
II

LOCALIST STATUS
Left Tight
Look
: eritem (-), wound (-), deformity (-), oedem (+)
Feel
: painfulness when it given a palpation on left tight ,numbness

III

(-), sensoric (+), NVD (-)

Move
: motoric test score 3
LLD
:

true length
apparent length
anatomic length
SUPPORTING EXAMINATION

right
84cm
87cm
46cm

Left
81cm
84cm
43cm

X Photo Rontgen Femur Sinistra ( AP ) Position

Laboratory (04-12-2015)
Hematology
Hb
Leukosit
Trombosit
Hematokrit
Protrombin time
APTT

IV
V

Result
14,0
11,90
306
44,3
13,4
33,2

Score
13,0-18,0
4,0-10,0
150-500
39,0-54,0
11,3-14,7
27,4-39,3

ASSESMENT
Clinical Diagnosis : Fracture of Os.Femur Sinistra 1/3 Proksimal
INITIAL PLAN
a Ip. Therapy
Infus RL 30 tpm

VI

Inj. Cefazolim 2x1gr

Inj. Ketorolax 3x 1 amp
ATS
b Ip. Operative
ORIF Femur
c Ip. Monitoring
General situation, vital sign, the result of supporting examination
d Education
Educate patient about weight bearing after operative treatment
Tell the patient to do some simple exercise after the treatment received
PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad sanam
: dubia ad bonam
Quo ad fungsionam
: dubia ad bonam

CHAPTER IV
DISCUSSION
Anamnese :
Patients come to IGD hospital in Kendal with complaints of pain in the upper thigh sinistra
due trauma. Previously patient could not standing again and accompanied by persisten pain at
rest and when the left foot was tried moved. There are no nausea and vomiting. Beside of
pain, the patients also headache. Currently patients are unable to walk and just lay on the bed.
Physical Examination

FEMUR
Look
Feel

: eritem (-), wound (-), deformity (-), oedem (+),

: painfulness when it given a palpation on left tight ,numbness (-),

sensoric +, NVD (-)

Move
: motoric test score , false movement (-)
LLD
:

true length
apparent length
anatomic length

right
84cm
87cm
46cm

Therapy

VII

Infus RL 30 tpm
Inj. Cefazolim 2x1gr
Inj. Ketorolax 3x 1 amp
ATS

SUPPORTING EXAMINATION
3 X Photo Rontgen Femur Sinistra ( AP ) Position

left
81cm
84cm
43cm

Laboratory (04-12-2015)
Hematology
Hb
Leukosit
Trombosit
Hematokrit
Protrombin time
APTT

VIII
IX

Result
14,0
11,90
306
44,3
13,4
33,2

ASSESMENT
Clinical Diagnosis : Mal Union Femur Sinistra
INITIAL PLAN
e Ip. Therapy
Infus RL 30 tpm
Inj. Cefazolim 2x1gr
Inj. Ketorolax 3x 1 amp
ATS
f Ip. Operative

Score
13,0-18,0
4,0-10,0
150-500
39,0-54,0
11,3-14,7
27,4-39,3

ORIF Femur
g Ip. Monitoring
General situation, vital sign, the result of supporting examination
h Education
Educate patient about weight bearing after operative treatment
Tell the patient to do some simple exercise after the treatment received
PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad sanam
: dubia ad bonam
Quo ad fungsionam
: dubia ad bonam

CHAPTER V
CONCLUSSION
The spectrum of femur fractures is wide and ranges from non-displaced femoral stress
fractures to fractures associated with severe comminution and significant soft-tissue injury.
Femur fractures are typically described by location (proximal, shaft, distal). These fractures
may then be categorized into three major groups; high-energy traumatic fractures, low energy
traumatic fractures through pathologic bone (pathologic fractures) and stress fractures due to
repetitive overload.

Traumatic femur fractures in the young individual are generally caused by high-energy forces
and are often associated with multisystem trauma. In the elderly population, femur fractures
are typically caused by a low energy mechanism such as a fall from standing height. Isolated
injuries can occur with repetitive stress.
Acute compartment syndrome is the most dangerous complication in closed femur fracture.
This is a painful condition that occurs when pressure within the muscles builds to dangerous
levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from
reaching nerve and muscle cells. Unless the pressure is relieved quickly, permanent disability
may result. This is a surgical emergency. During the procedure, the surgeon makes incisions
in your skin and the muscle coverings to relieve the pressure.

REFERENCES
1. Colin Woon, Ben Taylor , Femoral Head Fractures,
http://www.orthobullets.com/trauma/1036/femoral-head-fractures
2. Dr Bruno Di Muzio and A.Prof Frank Gaillard,et al. Femoral neck fracture.
http://radiopaedia.org/articles/femoral-neck-fracture
3. http://orthoanswer.org/hip/femurfractures/complications.html#sthash.dofEXd8e.dpuf
4. James F. Barwick, MD; Peter J. Nowotarski, MD, Peer-Reviewed by: Brett Crist,
MD; Stuart J. Fischer, MD; Stephen Kottmeier, MD, The Orthopaedic Trauma
Association