CASE PRESENTATION

CLOSED FRACTURE OF LEFT NECK FEMUR

Presented By : Rosalya Mohd Wahid (C111 07 362) Sherla Wijoyo ( C111 07 095) Residen: Dr.A.Bau Tune M. Supervisor : Prof. dr. Chairuddin Rasjad, MD., Ph.D

PATIENTS IDENTITY

Name Age Gender Address

: Mr. Arudin Ladaaru : 39 years old : Male : Anoa Street, Bau Bau, Sulawesi Tenggara No.MR : 008710 Date of admittance : 26th January 2012 (19.00)

HISTORY TAKING

Chief complaint : Pain at left hip History Taking : A 39 years old male was admitted to the hospital because he felt pain at his left hip. He had suffered it since 1 month ago, because of motorcycle accident. History of unconsciousness (-). History of queasy and vomiting (-). History of take other medicine before(-).

PHYSICAL EXAMINATION

General Status : Moderate-illness/well-nourished/conscious Vital Sign :

Blood Pressure
Heart rate

: 130/80 mmHg
: 72 bpm, regular

Respiratory rate

: 20 tpm

Body temperature : 36,7 C

REGIONAL STATUS
Head Examination - Eyes : anemic -/-, icterus -/- Lip : cyanosis (-) - Neck : lymphadenopathy (-) Chest Examination - Inspection : symmetric, normochest - Palpation : mass (-), tenderness (-), VF R=L - Percussion : sonor - Auscultation : breath sound : bronchovesicular additional sound : -/-

REGIONAL STATUS
Cardiac Examination - Inspection : IC wasnt visible - Palpation : IC wasnt palpable - Percussion : normal heart size - Auscultation : Regular of I/II heart sound, murmur (-)

ORTHOPEDIC STATUS
Left hip joint region
-

Inspection
The skin appearance is same with its surrounding, edema (-), hiperemis (-), hematom (-)

Palpation
Tenderness(-)

ROM
Restricted because of pain

Neurovascular Distal (NVD)

Dorsal pedis artery pulse is palpable, CRT < 2

LABORATORY EXAMINATION
Date of lab test
26th Jan 2012

Types of test
Blood test PT : 13.7 sec APTT : 36.4 sec INR: 0.88 sec CT: 11 min BT: 2.05 min

Result
(12-19 sec) (27-42 sec) (0.85-1.15 sec) (9-15 min) (1-6 min) ( 4,0 10,0 x 103) ( 150 400 x 103) ( 4,0 6,0 x 106) ( 12 16 ) ( 37 48 )

27th Jan 2012

Routine blood test

WBC: 7 x103 mm3 PLT: 264 x103 mm3 RBC: 5.41 x106 mm3 HGB: 14.0 gr/dl HCT: 47.8 %

RADIOLOGY EVALUATION

WORKING DIAGNOSIS
Closed fracture of left neck femur

TREATMENT

IVFD RL 20 dpm Analgesic Operation : AMP (Austin-moore) hemiarthoplasty Physiotherapy

RADIOLOGY

Before operation

Post operation AMP

Introduction

Fracture is a break in the structural continuity of bone. If the overlying skin remains intact it is a closed fracture; if the skin or one of the body cavities is breached it is an open fracture, liable to contamination and infection. Type of fracture:

Anatomy of femur

Proximal: head, fovea and the neck, inter-trochanteric crest & line, lesser & greater trochanter, gluteal tuberosity. Shaft: linea aspera, pectineal line, supracondylar line Distal: popliteal fossa, medial & lateral condyle, epicondyles, intercondylar fossa, adductor tubercle Angle between shaft and neck is 120-1250.

Classification of neck femur

Anatomic Location Subcapital Transcervical Basicervical Pauwel This is based on the angle of fracture from the horizontal

Classification of neck femur

Garden Based on the degree of valgus displacement

Epidemiology

80% occur in women, the incidence doubles every 5 to 6 years in women age >30 years. The incidence in younger patients is very low and is associated mainly with high-energy trauma. Risk factors:

female sex white race increasing age poor health tobacco and alcohol use previous fracture fall history low estrogen level

Mechanism of Injury

Low-energy trauma (in older patients) Direct: A fall onto the greater trochanter or forced external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the acetabulum Indirect: Muscle forces overwhelm the strength of the femoral neck. High-energy trauma: such as motor-vehicle accident or fall from a significant height. Cyclical loading-stress fractures: These are seen in athletes, ballet dancers; patients with osteoporosis

Clinical features

Pain in the hip Displaced fracture patient lies with the limb in lateral rotation and the leg looks short Femoral neck fractures in young adults result from road traffic accidents or falls from heights and are often associated with multiple injuries A good rule is that young adults with severe injuries whether they complain of hip pain /not should always be examined!!

Radiographic evaluation

AP and lateral view of the pelvis An internal rotation view of the injured hip help clarify the fracture pattern Magnetic resonance imaging may be of clinical utility in delineating nondisplaced or occult fractures that are not apparent on plain radiographs

Treatment

Goals to:

minimize patient discomfort restore hip function allow rapid mobilization by obtaining early anatomic reduction and stable internal fixation / prosthetic replacement

Nonoperative treatment for traumatic fractures is indicated only for patients who are at extreme medical risk for surgery

Treatment

Internal fixation

Prosthetic replacement

Hemiarthroplasty

Advantages over ORIF: It may allow faster full weight bearing It eliminates nonunion, osteonecrosis Disadvantages: It is a more extensive procedure with greater blood loss. A risk of acetabular erosion exists in active individuals. Indications : Comminuted, displaced femoral neck fracture in the elderly Pathologic fracture Poor medical condition Neurologic condition (dementia, ataxia, hemiplegia, parkinsonism) Contraindications: Active sepsis Active young person Preexisting acetabular disease (e.g., rheumatoid arthritis)

Hemiarthroplasty

Austin Moore Prothesis

Thompson Prosthesis

Austinmoore Rasp

Complication

Nonunion Osteonecrosis Fixation failure

related to osteoporotic bone or technical problems (malreduction, poor implant insertion)

Prominent hardware may occur secondary to fracture collapse and screw backout