Presented By :Presented By :Rosalya Mohd Wahid (C111 07 362)Rosalya Mohd Wahid (C111 07 362)

Sherla Wijoyo ( C111 07 095)Sherla Wijoyo ( C111 07 095)

Residen:Residen:Dr.A.Bau Tune M.Dr.A.Bau Tune M.

Supervisor :Supervisor :Prof. dr. Chairuddin Rasjad, MD., Ph.DProf. dr. Chairuddin Rasjad, MD., Ph.D

CASE PRESENTATION

CLOSED FRACTURE OF LEFT NECK FEMUR

PATIENT’S IDENTITYPATIENT’S IDENTITY NameName : : Mr. Arudin LadaaruMr. Arudin Ladaaru AgeAge : 39 years old : 39 years old Gender Gender : Male: Male AddressAddress : Anoa Street, Bau – Bau, : Anoa Street, Bau – Bau, Sulawesi TenggaraSulawesi Tenggara No.MRNo.MR : 008710: 008710 Date of admittance Date of admittance : 26: 26thth January 2012 January 2012

(19.00)(19.00)

HISTORY TAKINGHISTORY TAKING Chief complaint : Pain at left hipChief complaint : Pain at left hip History Taking :History Taking :

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

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• General Status : General Status :

ModerateModerate-illness/well-nourished/conscious-illness/well-nourished/conscious• Vital Sign :Vital Sign :

• Blood Pressure : 130/80 mmHgBlood Pressure : 130/80 mmHg• Heart rateHeart rate : 72 bpm, regular : 72 bpm, regular• Respiratory rate : 20 tpmRespiratory rate : 20 tpm• Body temperature : 36,7 Body temperature : 36,7 °°CC

REGIONAL STATUSREGIONAL STATUSHead ExaminationHead Examination

- Eyes- Eyes : anemic -/-, icterus -/- : anemic -/-, icterus -/-- Lip- Lip : cyanosis (-) : cyanosis (-)- Neck : lymphadenopathy (-)- Neck : lymphadenopathy (-)

Chest ExaminationChest Examination- Inspection : symmetric, normochest- Inspection : symmetric, normochest- Palpation : mass (-), tenderness (-), VF R=L- Palpation : mass (-), tenderness (-), VF R=L- Percussion : sonor- Percussion : sonor- Auscultation : breath sound : bronchovesicular- Auscultation : breath sound : bronchovesicular

additional sound : -/-additional sound : -/-

REGIONAL STATUSREGIONAL STATUSCardiac ExaminationCardiac Examination

- Inspection- Inspection : IC wasn’t visible: IC wasn’t visible- Palpation - Palpation : IC wasn’t palpable: IC wasn’t palpable- Percussion : normal heart size- Percussion : normal heart size- Auscultation : Regular of I/II heart sound, murmur (-)- Auscultation : Regular of I/II heart sound, murmur (-)

ORTHOPEDIC STATUSORTHOPEDIC STATUSLeft hip joint regionLeft hip joint region- Inspection Inspection

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

- Palpation Palpation Tenderness(-)Tenderness(-)

- ROM ROM Restricted because of painRestricted because of pain

- Neurovascular Distal (NVD) Neurovascular Distal (NVD) Dorsal pedis artery pulse is palpable, CRT < 2”Dorsal pedis artery pulse is palpable, CRT < 2”

LABORATORY EXAMINATIONDate of lab

testTypes of test Result

26th Jan 2012 Blood test PT : 13.7 sec (12-19 sec)APTT : 36.4 sec (27-42 sec)INR: 0.88 sec (0.85-1.15 sec)CT: 11 min (9-15 min)BT: 2.05 min (1-6 min)

27th Jan 2012 Routine blood test

WBC: 7 x103 mm3 ( 4,0 – 10,0 x 103)PLT: 264 x103 mm3 ( 150 – 400 x 103)RBC: 5.41 x106 mm3 ( 4,0 – 6,0 x 106)HGB: 14.0 gr/dl ( 12 – 16 )HCT: 47.8 % ( 37 – 48 )

RADIOLOGY EVALUATION

WORKING DIAGNOSISWORKING DIAGNOSIS Closed fracture of left neck femur

TREATMENTTREATMENT IVFD RL 20 dpmIVFD RL 20 dpm AnalgesicAnalgesic Operation : AMP (Austin-moore) hemiarthoplasty Operation : AMP (Austin-moore) hemiarthoplasty PhysiotherapyPhysiotherapy

RADIOLOGY

Post operation AMPBefore operation

Introduction Introduction Fracture is a break in the structural continuity of bone. If Fracture is a break in the structural continuity of bone. If

the overlying skin remains intact it is a closed fracture; 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 the skin or one of the body cavities is breached it is an open fracture, liable to contamination and infection.open fracture, liable to contamination and infection.

Type of fracture:Type of fracture:

Anatomy of femurAnatomy of femur Proximal: head, fovea and Proximal: head, fovea and

the neck, inter-trochanteric the neck, inter-trochanteric crest & line, lesser & greater crest & line, lesser & greater trochanter, gluteal tuberosity.trochanter, gluteal tuberosity.

Shaft: linea aspera, pectineal Shaft: linea aspera, pectineal line, supracondyline, supracondyllar linear line

Distal: popliteal fossa, medial Distal: popliteal fossa, medial & lateral condyle, & lateral condyle, epicondyles, intercondylar epicondyles, intercondylar fossa, adductor tuberclefossa, adductor tubercle

Angle between shaft and Angle between shaft and neck is 120-125neck is 120-12500..

Classification of neck femurClassification of neck femur Anatomic LocationAnatomic Location

SubcapitalSubcapital TranscervicalTranscervical BasicervicalBasicervical

PauwelPauwel This is based on the angle of fracture from the horizontalThis is based on the angle of fracture from the horizontal

Classification of neck femurClassification of neck femur GardenGarden

Based on the degree of valgus displacementBased on the degree of valgus displacement

EpidemiologyEpidemiology 80% occur in women, the incidence doubles every 5 to 6 years 80% occur in women, the incidence doubles every 5 to 6 years

in women age >30 years.in women age >30 years. The incidence in younger patients is very low and is associated The incidence in younger patients is very low and is associated

mainly with high-energy trauma.mainly with high-energy trauma. Risk factors:Risk factors:

female sexfemale sex white racewhite race increasing ageincreasing age poor healthpoor health tobacco and alcohol usetobacco and alcohol use previous fractureprevious fracture fall historyfall history low estrogen levellow estrogen level

Mechanism of InjuryMechanism of Injury Low-energy trauma (in older patients)Low-energy trauma (in older patients)

Direct: A fall onto the greater trochanter or forced Direct: A fall onto the greater trochanter or forced external rotation of the lower extremity impinges an external rotation of the lower extremity impinges an osteoporotic neck onto the posterior lip of the osteoporotic neck onto the posterior lip of the acetabulumacetabulum

Indirect: Muscle forces overwhelm the strength of the Indirect: Muscle forces overwhelm the strength of the femoral neck.femoral neck.

High-energy trauma: such as motor-vehicle accident or High-energy trauma: such as motor-vehicle accident or fall from a significant height.fall from a significant height.

Cyclical loading-stress fractures: These are seen in Cyclical loading-stress fractures: These are seen in athletes, ballet dancers; patients with osteoporosisathletes, ballet dancers; patients with osteoporosis

Clinical featuresClinical features Pain in the hipPain in the hip Displaced fracture patient lies with the limb in Displaced fracture patient lies with the limb in

lateral rotation and the leg looks shortlateral rotation and the leg looks short Femoral neck fractures in young adults result from road Femoral neck fractures in young adults result from road

traffic accidents or falls from heights and are often traffic accidents or falls from heights and are often associated with multiple injuriesassociated with multiple injuries

A good rule is that young adults with A good rule is that young adults with severe injuries severe injuries whether they complain of hip pain /not – should always whether they complain of hip pain /not – should always

be examined!!be examined!!

Radiographic evaluationRadiographic evaluation AP and lateral view of the pelvisAP and lateral view of the pelvis An internal rotation view of the injured hip An internal rotation view of the injured hip help clarify the fracture patternhelp clarify the fracture pattern Magnetic resonance imaging may be of Magnetic resonance imaging may be of

clinical utility in delineating nondisplaced or clinical utility in delineating nondisplaced or occult fractures that are not apparent on plain occult fractures that are not apparent on plain radiographsradiographs

Treatment Treatment Goals to:Goals to:

minimize patient discomfort minimize patient discomfort restore hip functionrestore hip function allow rapid mobilization by obtaining early anatomic allow rapid mobilization by obtaining early anatomic

reduction and stable internal fixation / prosthetic reduction and stable internal fixation / prosthetic replacementreplacement

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

Treatment Treatment Internal fixationInternal fixation Prosthetic Prosthetic

replacementreplacement

Hemiarthroplasty Hemiarthroplasty Advantages over ORIF:Advantages over ORIF:

It may allow faster full weight bearingIt may allow faster full weight bearing It eliminates nonunion, osteonecrosisIt eliminates nonunion, osteonecrosis

Disadvantages:Disadvantages: It is a more extensive procedure with greater blood loss.It is a more extensive procedure with greater blood loss. A risk of acetabular erosion exists in active individuals.A risk of acetabular erosion exists in active individuals.

Indications :Indications : Comminuted, displaced femoral neck fracture in the elderlyComminuted, displaced femoral neck fracture in the elderly Pathologic fracturePathologic fracture Poor medical conditionPoor medical condition Neurologic condition (dementia, ataxia, hemiplegia, parkinsonism)Neurologic condition (dementia, ataxia, hemiplegia, parkinsonism)

Contraindications:Contraindications: Active sepsisActive sepsis Active young personActive young person Preexisting acetabular disease (e.g., rheumatoid arthritis)Preexisting acetabular disease (e.g., rheumatoid arthritis)

Hemiarthroplasty Hemiarthroplasty

AustinmoorAustinmoore Raspe Rasp

ThompsoThompson n ProsthesiProsthesiss

Austin Austin Moore Moore ProthesisProthesis

Complication Complication NonunionNonunion OsteonecrosisOsteonecrosis Fixation failureFixation failure

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

Prominent hardware may occur secondary to Prominent hardware may occur secondary to fracture collapse and screw backoutfracture collapse and screw backout