Case DiscussionBY EXT.JIRAWATH ASSAWADARACHAI

Patient profile

ผปวยหญงไทย อาย 14 ป ภมลำาเนา จ.นครราชสมา นบถอศาสนาพทธ

Chief Complaint

ขบรถจกรยานยนตชนรถยนต 1 ชวโมงกอนมารพ.

Initial management

Primary surveyA : spontaneous speech,no cervical tendernessB : clear both lung,CCT negativeC : BP 115/68 mmHg , P 94 /min,PCT negativeD : E4V5M6,pupil 3 mm RTLBE

Secondary survey

HistoryA : ไมมประวตแพยา แพอาหารM : ไมมยาประจำาP : no underlying diseaseL : ทานขาวลาสดตอน 1200. น.

E : 1 ชวโมง กอนมารพ . ผปวยขรถจกรยานยนตผานสแยกไปชนกบรถยนต สลบ หลงมสตไมมคลนไส อาเจยน ไมปวดศรษะ ไมปวดคอ ไมเจบหนาอก ไมปวดทอง ไมมเลอดไหลออกจากจมก/ห มอาการเจบทตนขาขวา ลกขนเดนไมได ยงสามารถขยบขอเทาได

Physical examination

V/S : T 37 C,BP 115/68 mmHg,P 94/min,RR 20/min,BW 45 kg

GA : A Thai girl,good consciousness,look fatigueHEENT : not pale conjunctiva,anicteric scleraChest : normal breath sound,no adventitious soundHeart : normal s1,s2,no murmurAbdomen : soft,not tenderNeuro : E4V5M6,pupil 3 mm RTLBE,motor power grade

V all extremities,sensory grossly intact

Extremities : Rt.leg > ext.rotation,tender at rt.thigh,abrasion wound at rt.thigh 2*3 cm,shortening rt.leg,popliteal & post.tibial a. & dorsalis pedis 2+,sensory intact

Investigation

Film Rt.femur AP/Lat Film pelvis AP Film Rt.knee AP/Lat

Femur AP

Femur Lat

Pelvis AP

Knee AP

Knee Lat

Femur AP(After skeletal traction)

Femur Lat(After skeletal traction)

Management

Tramol 50 mg IV stat On skeletal traction 5 kg at rt.leg Wating for surgery > ORIF with plate & screw

Femoral Shaft Fractures

Anatomy

It is the largest and the strongest bone of the body

The femur consists of a shaft (body) and two ends superior and inferior

The superior end of femur consists of head, neck, two trochanters(greater and lesser).

The inferior end consists of two large condyle: medial and lateral

Blood supply of shaft of femur Metaphyseal vessels Single nutrient artery in

diaphysis enters linea aspra Medullary arteries supply 2/3rd

of endosteal blood supply Nutrient artery communicates

with medullary arteries in intermedullary canal

Nerve

Muscle

Muscle of the thigh are arranged in three Compartments1-anterior compartment of thigh-sartorius -quadriceps(rectus femoris,vastus medialis/lateralis/intermedius)2-medial compartment of thigh-gracilis-adductor longus/brevis/magnus

3-posterior compartment of thigh -hamstring(biceps femoris,semitendinosus,semimembranosus)

Femoral Shaft Fractures

Common injury due to major violent trauma-1 femur fracture/ 10,000 people-More common in people < 25 yo or >65 yo-Motor vehicle, motorcycle and gunshot wound accidents

are most frequent causes

Mechanism of injury

High energy trauma-Motor vehicle accident-Gun shot injury-Fall from height Pathologic fractures-especially in elderly ,commonly occur following a trivial

fall

Classification of Femoral shaft Fracture

Type 0 - No commination

* Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture

* Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact

* Type 3 - Larger butterfly leaving less than 50% of the cortex in contact

* Type 4 - Segmental commination

Clinical

Non weight-bearing Pain Deformity Leg position

-Ext.rotation,shortening

Associated injuries

Hemodynamic instability Ipsilateral Fx neck of femur Hip dislocation Tibial shaft fx Vascular injury Nerve injury

X-raywell confirm the diagnosis and establish the sites ,line ,extent and displacement

Immediate management

ATLS resuscitation Analgesia X-ray Skeletal traction

Skeletal traction

-Keep length,immobilize -Wating for surgery

Operative management

IM nail Plate fixation External fixation

IM nail

Advatage-small wound-less damage soft tissue-rapid recovery-decrease rate of infection

Weak point-Fx site not complete closed

IM nail is gold standard

Plate fixation

Indication-Ipsilateral fx neck of femur

Advantage-Rigid internal fixation

Weak point-Higher infection and implant failure rates

External fixation

Use temporarily before change to IM nail or plate

Indication-Dirty open fracture-Vascular injury

COMPLICATION

Nerve injuries Malunion Nonunion Heterotropic ossification Vascular injuries

Thank you