CLOSED FRACTURE LEFT INTERTROCHANTER OF FEMUR

PRESENTED BY :Ummu Asma' binti Mohd RosliC 111 10 877

ADVISOR :dr. Satria Prawira Putradr. Ery Wildan

SUPERVISOR : dr. M. Ruksal Saleh , Ph.D, Sp.OT(K)

Orthopaedic and Traumatology DepartmentMedical Faculty of Hasanuddin University

Makassar 2015

CASE REPORT

PATIENT'S IDENTITY• Name : Mrs. AT

• Number Register : 045034

• Sex : Female

• Age : 69 years old

• Date of Admission : August 22nd , 2015

HISTORY TAKING• Chief complaint : Pain at left thigh

• Anamnesis : Suffered since 3 days before admitted to the Hasanuddin University hospital after fell in toilet.

• Mechanism of Trauma : Patient cannot walk properly due to Parkinson's disease. she suffered

this disease since 2 years ago, and controlled with Sinemet, 3 times daily.

she walk with her walking stick. she accompanied by her maid everyday. because her maid was not

around that day, she tried to go to toilet by herself, and fell onto toilet floor on her left thigh. because her children was not around, she stay at home for 3 days before admitted to RSUH.

No prior treatment

GENERAL STATUS

General condition : wellnourished,compos mentis (GCS 15)

Vital signs : BP = 130/80 mmHg; HR = 86x/minutes, reguler, palpable RR = 16x/minute T =36,5

NRS : 4/10

LOCAL REGIONLeft Thigh Region

Look There is deformity, there is swelling, no hematom

Feel There is tenderness

Move Active and passive movement of the hip joint cannot be evaluated

NVD • Sensibility is good. • Pulsation of the dorsal pedis artery are palpable.• Capillary refill time <2”

CLINICAL PHOTOS

LATERAL VIEW

ANTERIOR VIEW

LEG LENGHT DISCREPANCY

R LALL 90 cm 88 cmTLL 83 cm 81 cmLLD 2 cm

LABORATORY FINDING

◦ WBC : 10.227 x 103 mm3◦ RBC : 4.63 x 106 /mm3◦ HGB : 13.3 g/dL◦ HCT : 38.6 %◦ PLT : 246 x 103 /mm3

PHOTOOF FEMUR

AP/ LATERAL

FRACTURE

PELVIS PHOTO FRACTURE

DIAGNOSIS

CLOSED FRACTURE LEFT INTERTROCHANTER OF FEMUR

MANAGEMENT• IVFD RINGER LACTATE 20

DROP/MINUTES• ANALGESIC

• PLAN FOR ORIF DYNAMIC HIP SCREW

DISCUSSION

Intertrochanteric fracture

fracture of proximal femur located between greater

and lessertrochanter, external to

capsule of hip joint

Richard's S. Snell. Clinical Anatomy by Region. 9th edition

ARTERIES

NERVES

Netter Concise Orthopedic, 2nd edition, 2002

• women: men= 8 :1• age : 66-76 yo• unstable gait• direct impact to

greater trochanteric area(low energy fall)

PATIENT'S EVALUATIONTHEORITICALLY

mrs AT69 yohistory of Parkinson diseasefell on her left thigh on toilet floor directly

PATIENT'S

Koval, Kenneth j.; Zuckerman, joseph d. handbook of fractures, 4th edition

CLINICAL MANIFESTATION• pain in motion• shortening of

extremity• deformity of

rotation in resting position

• angulation• associated

injury

• NRS : 4/10• left leg shortened

LLD = 2 cm

• external rotation

• varus• no other injury

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

Solomon. L. et al. Injury’s of the Knee and Leg in Apley’s System of Orthopaedics and Fractures 9th Edition.

EVANS-JANSEN

OTA

classificationdegree of stability

degree of communition

BOYD AND GRIFFIN

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

OTA/AO classification

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

EVANS-JANSEN

Associated Diseases of Mrs. AT

• Parkinson's Disease - loss of dopaminergic neuron, altered calcium metabolism : poor bone density

• Osteoporosis - menopause, decrease estrogen, reduction BMD : pathologic fracture

mitochondria,calcium and cell death, BBA 1787(5) :335-44

Mrs. AT has history of Parkinson's Disease and taking Sinemet

What is Sinemet??

Levodopa (100 mg) + carbodopa (25 mg)

levodopa : metabolic precursor of dopaminecarbodopa : decrease peripheral conversion to

dopamine

Parkinsonism, Drugs that acts in the central system, Basic and ClinicalPharmacology, 11th ed

do not affect bone healing and do not lead to decrease of BMD

From radiologic exam, there is demineralisation of Mrs. AT's bone

Diagnosis : Osteoporosis senilis

woman69 yo

screening for osteoporosis

BMD (bone mineral density) measure calcium and other minerals

T-SCORE

NORMAL >-1,0

OSTEOPENIA -1.0-(-0,25)

OSTEOPOROSIS <-2,5

SEVERE OSTEOPOROSIS <-2.5 + HISTORY OF FRACTURE

WHO classification

X-RayPEHistory Taking

•CLOSED FRACTURE LEFT

INTERTROCHANTER OF FEMUR

•OSTEOPOROSIS•PARKINSON'S

DISEASE

EVIDENCES LEADING TO DIAGNOSIS

• ADMINISTER INTRAVENOUS FLUID• ANALGESIC

INITIAL TREATMENT

OPERATIVE TREATMENTOpen ReductionInternal Fixation

1. unstable fracture- reverse oblique2. to get the patient up and walking

as soon as possible 3. reduce the complications

associated with prolonged recumbency.

WHY?

dynamic hip screw

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

Gamma Nail

Implant of choice for Mrs. AT

unstable pathologicfracture

Lavini F et al.: The Treatment of Stable and Unstable Proximal Femoral Fractures with a New Trochanteric Nail: Results of a Multicentre Study with the Veronail. Strategies Trauma Limb Reconstr 2008 April; 3(1): 15–22.

protects the biological healing potential of the fracture site

minimises the classic complications of screw cut out, collapse and gait disturbance

The elasticity within the nail favours fracture healing (0% non-union rate)

may prevent secondary deformities

contraindication for operative treatment

non-ambulatory or chronic dementia patients with pain that is controllable with analgesics and rest

terminal disease with less than 6 weeks of life expected, unresolvable medical comorbidites that preclude surgical

treatment active infectious diseases that preclude insertion of a

surgical implant

Mrs. AT does not has any C/O for operation

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

Treatment for Associated Diseases• Parkinson's Disease : continue her drugs,

refer to Neurologist• Osteoporosis Senilis :

-Keep out of drugs lead to decrease BMD : steroid,anticoagulant,antipsychotic,anticancer-Morning sunlight : rich vit D (20-30 mins)-Biphosphonate-Hormone therapy (estrogen agonist or progesterone)

How to Manage Postmenopausal Osteoporosis? Acta Clin Belg 66(6) :443-7

Rehabilitation for Mrs. AT(Pathologic Fracture)

• Isometric exercise (0-3 days): contracts muscle by press heel on bed repeatedlypatient still in pain,continue this exercise

• Isotonic exercise (4-7 days) : passive movement of extremity (ROM) - only if the pain already diminished

• Isokinetic exercise (7 days-healed) :active movement of extremity - pain diminished and until joint can be used normally

Robert et al. Rockwood and Green.Fractures in Adult. 7th edition

COMPLICATION

IMPLANT MALFUNCTION

MALUNION

INFECTION

PNEUMONIA

BEDSORES

EMBOLISM

PROGNOSIS

• Quo at vitam : dubia• Quo at sanationam : dubia• Quo at functionam : dubia