New Lapsus

CASE REPORT

NON UNION 1/3 MIDDLE FEMUR FRACTURE SINISTRA AND OSTEOMYELITIS

Disusun untuk Memenuhi Sebagian Tugas Kepaniteraan Klinik

Bagian Ilmu Bedah di RSUD dr. H. Soewondo Kendal

Disusun oleh:

Ulfa Elsanata

01.211.6546

Pembimbing:

dr. Wisnu Murti, Sp.OT

ILMU BEDAH RSUD DR. H. SOEWONDO KENDAL

FAKULTAS KEDOKTERAN

UNIVERSITAS ISLAM SULTAN AGUNG

SEMARANG

2016

HALAMAN PENGESAHAN

Nama : Ulfa Elsanata

NIM : 01.211.6546

Fakultas : Kedokteran

Universitas : Universitas Islam Sultan Agung ( UNISSULA )

Tingkat : Program Pendidikan Profesi Dokter

Bagian : Ilmu Bedah

Judul : Non Union 1/3 Middle Femur Fracture Sinistra And Osteomyelitis

Semarang, April 2016

Mengetahui dan Menyetujui

Pembimbing Kepaniteraan Klinik

Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

CHAPTER I

INTRODUCTION

A fracture is a discontinuity of bone, catilage, ephiphyseal cartilage both total and

partial. The femur is the largest and strongest bone and has a good blood supply. Because

of this and its protective surrounding muscle, the shaft requires a large amount of force to

fracture. Once a fracture does occur, this same protective musculature usually is the cause

of displacement, which commonly occurs with femoral shaft fractures. 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.

Assessment of fracture healing (union) based on the union of clinical and radiology

union. Clinical assessment made by examining the fracture area by bending in the fracture

area, rotation and compression to determine the presence or feeling pain in patient. Union

radiology assessed by X-ray examination in the fracture line or callus and may be found of

the trabeculation that already connect the two fragments. At the advancednlevel include the

medulla or room in the fracture area. In the process of bone healing can occur undesirable

result, in which the bones have fused in line with expectation, either way the union nor the

time of unification. The healing process in question is malunion, nonunion and delayed

union.

As with many orthopedic injuries, neurovascular complications and pain

management are the most significant issues in patients who come to the hospital. The rich

blood supply, when disrupted, can result in significant bleeding. Open fractures have added

potential for infection

Osteomyelitis is inflammation of the bone caused by an infecting organism.

Although bone is normally resistant to bacterial colonization, events such as trauma,

surgery, the presence of foreign bodies, or the placement of prostheses may disrupt bony

integrity and lead to the onset of bone infection. Osteomyelitis can also result from

hematogenous spread after bacteremia.

CHAPTER II

CONTENS REVIEW

I. 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

body’s 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

II. 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 upper 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.

The Pipkin classification is the most widely used classification system, which is based

on the location of the femoral head fracture in relation to the femoral head fovea and the present

of any associated fractures. Type I femoral head fractures occur when the fracture is inferior to

the fovea centralis, whereas type II femoral head fractures extend superior to the fovea centralis.

Type III is any femoral head fracture that is associated with a concomitant femoral neck

fracture, and a type IV is associated with an acetabular fracture. Brumback et al. designed a

more comprehensive classification system with the attempt to eliminate the ambiguity of the

Pipkin classification and to provide treatment guidelines for each fracture type. Fractures are

divided into one of five categories and then are further delineated into subsets A and B. Many

orthopaedists, however, continue to use the traditional Pipkin classification system when

describing and reporting these fracture patterns.

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.

Picture 5. a A fracture-dislocation of the hip is evident on the routine trauma

anteroposterior (AP) pelvis radiograph. The dislocated femoral head is incongruent with the

acetabulum and is displaced superiorly overlapping the acetabular sourcil with an apparent

break in Shenton’s line. There is also an associated femoral neck fracture. b. A posterior

approach with a trochanteric-flip osteotomy provides excellent exposure for reduction and

internal fixation. c, d. Post-operative radiographs demonstrate anatomic reduction and fixation

of the femoral head and neck fractures, in addition to a congruent hip joint

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 patient’s

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 upper-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 upper 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 upper 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.

III. Fracture Healing Process

The healing process of a fracture starting fractures occur as the body's attempt to

repair the damage - the damage suffered. Healing of fractures is influenced by

several factors, local and systemic factors, while local factors:

a. location of the fracture

b. Types of bone fracture.

c. Reposition anatomical and immobilasi stable.

d. Contact between fragments.

e. The presence or absence of infection.

f. Levels of fracture.

The systemic factors are:

a. The general state of the patient

b. Age

c. malnutrition

d. Systemic disease.

Fracture healing process consists of several phases, as follows:

1. Phase Reactive

a. Phase hematoma and inflammation

b. Granulation tissue formation

2. Phase Reparatif

a. Phase formation of callus

b. Lamellar bone formation

3. Phase Remodelling

a. Bone remodeling to its original shape

In terms of classical histology, fracture healing fracture healing has been divided into

primary and secondary fracture.

Fracture Healing Process Primary

Healing occurs in this way internal remodeling that includes a direct attempt by the cortex to

rebuild itself when continuity interrupted. In order to be united fractures, bone on one side of

the cortex must be fused with the bone on the other side (direct contact) to establish a

mechanical continuity.

No association with callus formation. Remodeling of the internal occur haversian system

and unification edge fracture fragments of the broken bone

There 3 remodeling at the fracture site is:

1. Implementation of appropriate reduction

2. Fixation stable

3. The existence of an adequate blood supply

The use of dynamic compression plate in the osteotomy models have been shown to cause

primary bone healing. Remodeling active haversian seen at around week four fixation.

Secondary Fracture Healing Process.

Healing response in the secondary cover periostium and external soft tissues. The process of

fracture healing is broadly be divided into five phases, namely phase hematoma (swelling),

the proliferative phase, the phase of callus, ossification and remodeling.

1. Phase Inflammation:

Inflammatory phase lasts a few days and disappear with the reduced swelling and pain.

Bleeding in the injured tissue and hematoma formation at the site of fracture. The tip of the

bone fragments of devitalized because the breakdown of the blood supply hypoxia and

inflammation induced gene expression and promotes cell division and migration to the

fracture site to begin healing. Production or release of specific growth factors, cytokines, can

create conditions suitable for the micro:

(1) Stimulating the formation of osteoblasts and periosteal ossification intra membrane at the

site of the fracture,

(2) Stimulates cell division and migration to the fracture site, and

(3) Stimulates chondrocytes to differentiate in soft callus with accompanying endochondral

ossification.

Blood gathering phase initially suspected hematoma due to laceration local blood vessels

that are focused on a particular place. But on further development of hematoma is not only

caused by tearing of blood vessels but also instrumental factors that cause inflammation

localized swelling condition. The timing of this process begins when fractures occur until 2-

3 weeks.

2. Phase proliferation

Approximately 5 days hematoma will experience the organization, formed threads of fibrin

in the blood clot, forming a network for revascularization, and the invasion of fibroblasts

and osteoblasts. Fibroblasts and osteoblasts (the developing of osteocytes, endothelial cells,

and cell periosteum) will produce collagen and proteoglycan matrix of collagen in bone

fracture. Formed fibrous connective tissue and cartilage (osteoid). From periosteum, growth

looks circular. The callus cartilage is stimulated by micro minimal movement on the site of

fracture. But the excessive movement will damage the structure of the callus. Bones that are

actively growing shows electronegative potential. In this phase started in week 2-3 after

fracture and ended in week 4-8.

Phase 3. Establishment of Callus

An advanced phase of the phase hematoma and proliferation of bone tissue begins to form

the chondrocyte bone tissue starts to grow or commonly referred to as the cartilage tissue.

Actually, the cartilage is still subdivided into lamellar bone and wovenbone. Continued

network growth and cartilage growth cycle reaches the other side until the gap is plugged.

Fragments of bone fracture combined with fibrous tissue, cartilage, and bone mature fibers.

Callus shape and volume dibutuhkanuntuk linking effect is directly related to the amount of

damage and bone shifts. It can take three to four weeks to allow the bone fragments

belonging to the cartilage or fibrous tissue. Clinically bone fragments can no longer be

moved. Regulation of callus formation during fracture repair mediated by the expression of

growth factors. One of the most dominant factor of the many growth factors are

Transforming Growth Factor-Beta

1 (TGF-B1) which indicates involvement in regulating the differentiation of osteoblasts and

extra cellular matrix production. Other factors are: Vascular Endothelial Growth Factor

(VEGF), which plays an important role in the process of angiogenesis during fracture

healing.

The center of the soft callus is kartilogenous then along osteoblasts will differentiate to form

a chain network of osteocytes, are signs of bone cells and the ability to anticipate the

mechanical stress.

The rapid process of soft callus formation which then continues until the remodeling phase

is a critical period for the success of fracture healing.

Types of Callus

Known to some kind of callus which corresponds to the callus callus was formed primarily

as a result of the fracture occurs within 2 weeks Bridging (soft) callus occurs when the edges

of the bone fracture is not contiguous. Medullary (hard) will complete the bridging callus

Callus slowly. External callus is outermost regions under the periosteum fracture periosteal

callus formed between the periosteum and bone fractures. Interfragmentary callus was

formed callus and fracture fills the gap between the fractured bone. Medullary callus formed

in medullary bone around the fracture area.

4. Stadium Consolidation

With the activity of osteoclasts and osteoblasts continually, immature bone (woven bone)

converted into mature (lamellar bone). The bones become stronger so osteoklast can

penetrate tissue and debris in the area of the fracture followed by osteoblasts that will fill the

gap between the bone fragments with a new one.

This process goes slowly for a few months before the bone is strong enough to accept the

normal load.

5. Remodelling Stadium.

Fractures have been associated with strong bones sheath with a different shape with normal

bone. Within months or even years of a process of formation and bone resorption continuous

lamella thick will be formed on the side with high pressure. Medullary cavity diameter are

formed back and spine back to its original size. Finally, the bones will be returned close to

its original form, especially in children.

In these circumstances the bone has healed clinically and radiology.

IV. FRACTURE COMPLICATION

Early complications

Local:

Vascular injury causing haemorrhage, internal or external

Visceral injury causing damage to structures such as brain, lung or bladder

Damage to surrounding tissue, nerves or skin

Haemarthrosis

Compartment syndrome (or

Volkmann's ischaemia) Wound infection,

more common for open fractures

Systemic:

Fat embolism

Shock

Thromboembolism (pulmonary or venous)

Exacerbation of underlying diseases such

as diabetes or CAD Pneumonia

Compartment syndromes

Fractures of the limbs can cause severe ischaemia by damage to a major

artery or by increasing the osteofascial compartment pressure by swelling due to

bleeding or oedema.

↓capillary flow → muscle ischaemia. → more oedema → more pressure

→ ↓capillary flow. Thus rapid pressure build-up, leading to muscle and nerve

necrosis.

Compartment syndromes can also result from crush injuries (falling debris or simple

compression if patient unconscious for length of time) or an over-tight cast.

Any compartment, but tibia shaft # & forearm # greatest risk. Esp if age<35years

Presentation

Signs of ischaemia (5 P's: Pain, Paraesthesia, Pallor, Paralysis, Pulselessness)

diagnosis should be made before all these features are present. The presence of a

pulse

does not exclude the diagnosis.

Signs of raised intracompartmental pressure:

o Swollen arm or leg

o Tender muscle - calf or forearm pain on passive extension of digits

o Pain out of proportion to injury

o Redness, mottling and blisters

Watch for signs of renal failure (low-output

uraemia with acidosis)

When uncertain, measure intracompartmental pressure

directly.

Management

Remove/relieve external pressures

Prompt decompression of threatened compartments by open fasciotomy

Debride any muscle necrosis

Treat hypovolaemic shock and oliguria urgently

Renal dialysis may be necessary

Complications

Acute renal failure secondary to rhabdomyolysis

DIC

Volkmann's contracture (where infarcted muscle is replaced by inelastic fibrous

tissue

Fat embolism

This is a relatively uncommon disorder that occurs in the first few days following

trauma with a mortality rate of 10-20%. Various theories: Fat drops from bone marrow

following #, coalesce and form emboli in pulmonary capillary beds and brain, with a 2º

inflammatory cascade and platelet aggregation. Alternative theory suggests that FFAs are

released as chylomicrons following hormonal changes due to trauma or sepsis. Also seen

following severe burns, CPR, bone marrow transplant and liposuction.

Risk factors

Closed fractures

Multiple fractures

Pulmonary contusion

Long bone/pelvis/rib fractures

Presentation

Sudden onset dyspnoea

Hypoxia

Fever

Confusion, coma, convulsions

Transient red-brown petechial rash affecting upper body, especially axilla

Management

Supportive treatment

Corticosteroid drugs (used in treatment, more controversial

in prevention) Surgical stabilisation of fracture

Late Complications

Local:

o Delayed Union

o Non-union Malunion

o Joint stiffness

o Contractures

o Avascular necrosis

o Osteomielitis

Systemic:

o Gangrene, tetanus,

septicaemia

o Fear of mobilising

o Osteoarthritis

Problems with bone healing (non-union, delayed union and malunion)

Non-union = no signs of healing after >3-6 months (depending upon # site). Non-

union is one endpoint of delayed union. 1% of all #, but 19% in upper leg #. Malunion

occurs when the bone fragments join in an unsatisfactory position, usually due to

insufficient reduction.

Causes of

delayed

o union include: Severe

o soft tissue damage

o Inadequate blood

o supply Infection

o Insufficient splintage

o Excessive traction

For non-union: as above plus bone separation & interposition of

periosteum, muscle or cartilage

Presentation

Pain at fracture site

Non-use of extremity

Tenderness and swelling

Joint stiffness (prolonged >3 months)

Movement around the fracture site (pseudarthrosis)

X-Ray

Absence of callous (remodelled bone) or lack of progressive change in the callous

Closed medullary cavities suggest non-union.

May look avascular (known as atrophic non-union) or have

excessive bone formation on either side of the gap (known as hypertrophic

non-union).

Management

Early weight bearing and casting may be helpful. Surgical treatments include:

Debridement to establish a healthy infection-free vascularity at fracture site

Internal fixation to reducing and

stabilize fracture. Bone grafting to stimulate new

callous formation

V. OSTEOMYELITIS

The bony skeleton is divided into two parts: the axial skeleton and the

appendicular skeleton. The axial skeleton is the central core unit, consisting of the

skull, vertebrae, ribs, and sternum; the appendicular skeleton comprises the bones

of the extremities. The human skeleton consists of 213 bones, of which 126 are

part of the appendicular skeleton, 74 are part of the axial skeleton, and six are part

of the auditory ossicles.

Hematogenous osteomyelitis most commonly involves the vertebrae, but

infection may also occur in the metaphysis of the long bones, pelvis, and clavicle.

Vertebral osteomyelitis involves two adjacent vertebrae with the corresponding

intervertebral disk. (See the image below.) The lumbar spine is most commonly

affected, followed by the thoracic and cervical regions.

i. OSTEOMYELITIS PATHOPHYSIOLOGY

Bone is normally resistant to infection. However, when microorganisms

are introduced into bone hematogenously from surrounding structures or from

direct inoculation related to surgery or trauma, osteomyelitis can occur. Bone

infection may result from the treatment of trauma, which allows pathogens to

enter bone and proliferate in the traumatized tissue. When bone infection persists

for months, the resulting infection is referred to as chronic osteomyelitis and may

be polymicrobial. Although all bones are subject to infection, the upper extremity

is most commonly involved.

Some important factors in the pathogenesis of osteomyelitis include the

virulence of the infecting organism, underlying disease, immune status of the

host, and the type, location, and vascularity of the bone. Bacteria may possess

40

various factors that may contribute to the development of osteomyelitis. For

example, factors promoted by S aureus may promote bacterial adherence,

resistance to host defense mechanism, and proteolytic activity.

Hematogenous osteomyelitis

In adults, the vertebrae are the most common site of hematogenous

osteomyelitis, but infection may also occur in the long bones, pelvis, and clavicle.

Primary hematogenous osteomyelitis is more common in infants and

children, usually occurring in the long bone metaphysis. However, it may spread

to the medullary canal or into the joint. When infection extends into soft tissue,

sinus tracts may eventually form. Secondary hematogenous osteomyelitis is more

common and occurs when a childhood infection is reactivated. In adults, the

location is also usually metaphyseal.

S aureus is the most common pathogenic organism recovered from bone,

followed by Pseudomonas and Enterobacteriaceae. Less common organisms

involved include anaerobe gram-negative bacilli. Intravenous drug users may

acquire pseudomonal infections. Gastrointestinal or genitourinary infections may

lead to osteomyelitis involving gram-negative organisms. Dental extraction has

been associated with viridans streptococcal infections. In adults, infections often

recur and usually present with minimal constitutional symptoms and pain.

Acutely, patients may present with fever, chills, swelling, and erythema over the

affected area.

Contiguous-focus and posttraumatic osteomyelitis

The initiating factor in contiguous-focus osteomyelitis often consists of

direct inoculation of bacteria via trauma, surgical reduction and internal fixation

of fractures, prosthetic devices, spread from soft-tissue infection, spread from

41

adjacent septic arthritis, or nosocomial contamination. Infection usually results

approximately one month after inoculation.

Posttraumatic osteomyelitis more commonly affects adults and typically

occurs in the tibia. The most commonly isolated organism is S aureus. At the

same time, local soft-tissue vascularity may be compromised, leading to

interference with healing. Compared with hematogenous infection, posttraumatic

infection begins outside the bony cortex and works its way in toward the

medullary canal. Low-grade fever, drainage, and pain may be present. Loss of

bone stability, necrosis, and soft tissue damage may lead to a greater risk of

recurrence.

Septic arthritis may lead to osteomyelitis. Abnormalities at the joint

margins or centrally, which may arise from overgrowth and hypertrophy of the

synovial pannus and granulation tissue, may eventually extend into the

underlying bone, leading to erosions and osteomyelitis. One study demonstrated

that septic arthritis in elderly persons most commonly involves the knee and that,

despite most of the patients having a history of surgery, 38% developed

osteomyelitis. Septic arthritis is more common in neonates than in older children

and is often associated with metaphyseal osteomyelitis. Although rare,

gonococcal osteomyelitis may arise in a bone adjacent to a chronically infected

joint.

Patients with vascular compromise, as in diabetes mellitus, are

predisposed to osteomyelitis owing to an inadequate local tissue response.

Infection is most often caused by minor trauma to the feet with multiple

organisms isolated from bone, including Streptococcus species, Enterococcus

species, coagulase-positive and -negative staphylococci, gram-negative bacilli,

42

and anaerobic organisms. Foot ulcers allow bacteria to reach the bone. Patients

may not experience any resulting pain, because of peripheral neuropathy, and

may present with a perforating foot ulcer, cellulitis, or an ingrown toenail.

Physical examination may reveal decreased sensation, poor capillary

refill, and decreased dorsalis pedis and posterior tibial pulses. Treatment is aimed

at suppressing infection and improving vascularity. However, most patients

develop recurrent or new bone infections. Resection or amputation of the affected

tissue is sometimes necessary. Debridement, incision and drainage, and tendon

lengthening are attempted first.

ii. ETIOLOGY

Posttraumatic osteomyelitis accounts for as many as 47% of cases of

osteomyelitis. Other major causes of osteomyelitis include vascular insufficiency

(mostly occurring in persons with diabetes; 34%) and hematogenous seeding

(19%).

Motor vehicle accidents, sports injuries, and the use of orthopedic

hardware to manage trauma also contribute to the apparent increase in prevalence

of posttraumatic osteomyelitis. Osteomyelitis may complicate puncture wounds

of the foot, occurring in 1.8%-6.4% of patients following injury.

iii. PROGNOSIS

Inadequate therapy may lead to relapsing infection and progression to

chronic infection. Because of the avascularity of bone, chronic osteomyelitis is

curable only with radical resection or amputation. These chronic infections may

recur as acute exacerbations, which can be suppressed by debridement followed

by parenteral and oral antimicrobial therapy. Rare complications of bone

43

infection include pathologic fractures, secondary amyloidosis, and squamous cell

carcinoma at the sinus tract cutaneous orifice.

VI.

44

CHAPTER II

I. IDENTITY

a. Name : Mr. F

b. Age : 37 years old

c. Sex : male

d. Religion : Islam

e. Address : Kendal

f. Room : Kenanga

g. Register number : 487.401

h. Date of in patient : 18 March 2016

II. ANAMNESA

Autoanamnesa with the patient and held on March 22, 2016 in Kenanga

room and also supported by medical records.

Main complaints: Pain in the left medial thigh

Present status:

Patients come to orthopedic department hospitals in Kendal with

complaints of pain in the left thigh post ORIF 2 month ago, since 2 days ago.

Patients complain of pain in the left medial thigh because previous patient fall on

the bathroom. Patient fall it self and not treat to the doctor but to quack massage.

After several days, the patient felt no improvement, but getting worse. The patient

feels pain when he walk, patient difficulty in moving his left thigh. Patient no

fever, no problems with urination and defecation, and patient just pain and can’t

move his left thigh.

45

Medical condition history:

-History femur trauma(fracture) : yes about 2 month ago

- History of asthma and allergies: denied

- History of heart disease : denied

- History of hypertension : denied

- History of diabetes : denied

Family history:

- History of asthma and allergies: denied

- History of heart disease : denied

- History of hypertension : denied

- History of diabetes : denied

Socioeconomic status :

Patients working as an employee.

Impression: enough in socioeconomic.

III. Physical Examination

Held on March 22, 2016 at 7 a.m in Kenanga room of Kendal Hospital

General Condition : Looks weak

Awareness: Composmentis, GCS 15

Vital Signs

1. Blood pressure : 120/80 mmHg

2. Heart rate : 78 x / minute, regular

3. Temperature : 36,5oC

4. Breathing : 20 x / min

46

Status generalis

Skin : turgor (+)

Head : mesocephal, wound (-)

Eyes : anemis (-/-), icteric (-/-)

Ear : discharge (-/-)

Nose : deviation septum (-), discharge (-/-)

Mouth : sianosis (-)

Neck : simetris, trachea deviation (-)

Thorax :

Cor :

Inspection : ictus cordis (-)

Palpation: ictus cordis palpable at SIC V 2cm medial to line

midclavicularis, pulsus sternal (-), pulsus epigastrium(-)

Percussion : heart border

Bottom left : SIC 2 cm medial line midclavicularis

Top left : SIC II linea sternalis sinistra

Top right : SIC III linea 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 : vesiculer (+/+)

47

Abdomen

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

Auskultation : bowel (+), normal

Perkussion : tymphani (+)

Palpation : supel , pain (-), hepar lien are not papble

EXTREMITY SUPERIOR INFERIOR

Cold extremity -/- -/-

Oedem -/- -/-

Capillary refill <2” <2”

Lesion -/- -/+

Hematom +/- -/-

Backbone : inspection : kifosis and lordosis (-)

Palpation : pain (-)

IV. Localized status of left Thigh

Thigh

Look : deformity (+), hematom (-), wound (-), blood (-), oedem

(+),sikatric (+), striae (-)

Feel : painfulness when it given a palpation on left thigh, skin

temperature warm.

Move : motorik (+), muscle strenght (5/3), limited movement of

the left medial thigh.

48

Measurement

lower extremity

LLD

Dextra Sinistra

True lenght 76 75

Appearance

lenght

81 80

Anatomical

lenght

44 43

Active Passive

Extension (+)

minimum

(+) minimum

Flexion (+)

minimum

(+) minimum

endorotation Hard to

evaluate

(-)

exorotation (+)

minimum

(+) minimum

49

V. Laboratory Results

1. Blood laboratory

Examines Results Normal Results

Hb 14,6 gr% 13 – 18 gr%

Leucosite 7.500 cell/mm3 4.000 – 10.000 cell/mm3

Trombosite 360.000

cell/mm3

150.000 – 500.000

cell/mm3

Ht 47,1 % 39 – 54 %

PT 11,4 seconds 11,3-14,7 seconds

APTT 30,4 seconds 27,4 – 39,3 seconds

GDS 99 75-115 mg/dl

Ureum 20 10-50 mg/dl

Creatinin 1,19 0,5-1,1 mg/dl

50

2. Radiology

X- ray Femur Sinistra (AP- Lateral) Position

Open Reduction Internal Fixation 19-01-2016

51

Before surgery post ORIF 18-03-2016

After Open Reduction Internal Fixation 23-03-2016

52

VI. DIAGNOSE

Non union femur 1/3 middle sinistra and osteomyelitis

VI. PLANNING THERAPY

Medical

Infus RL 20 tpm

Inj. Cefazoline 2x1 gr

Inj. Ketorolac 3x 30mg

Inj. Ranitidin 2x1 amp

Non-Medical :

a. Ip. Operative

Can be perfomed by ORIF ( Open Reduction of Internal Fixation )

b. Ip. Monitoring

General situation, vital sign, the result of supporting examination

c. Education

Educate patient about weight bearing after operative treatment

Tell the patient to do some simple exercise after the treatment received

VII. PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad sanam : dubia ad bonam

Quo ad fungsionam : dubia ad bonam

CHAPTER IV

53

DISCUSSION

Anamnese :

Patients come to orthopedic department hospitals in Kendal with

complaints of pain in the left thigh post ORIF 2 month ago, since 2 days ago.

Patients complain of pain in the left medial thigh because previous patient fall on

the bathroom. Patient fall it self and not treat to the doctor but to quack massage.

After several days, the patient felt no improvement, but getting worse. The patient

feels pain when he walk, patient difficulty in moving his left thigh. Patient no

fever, no problems with urination and defecation, and patient just pain and can’t

move his left thigh.

Physical Examination

Left of Thigh

Look : deformity (+), hematom (-), wound (-), blood (-), oedem

(+),sikatric (+), striae (-)

Feel : painfulness when it given a palpation on left thigh, skin

temperature warm.

Move : motorik (+), muscle strenght (5/3), limited movement of

the left medial thigh.

Measurement

54

lower extremity

LLD

Dextra Sinistra

True lenght 76 75

Appearance

lenght

81 80

Anatomical

lenght

44 43

Active Passive

Extension (+)

minimum

(+) minimum

Flexion (+)

minimum

(+) minimum

endorotation Hard to

evaluate

(-)

exorotation (+)

minimum

(+) minimum

We need a supporting examination to find the right diagnosis. We did X-ray

examination of the femur sinistra with AP and Lateral position.

After we did the radiographic examination we can conclude that the true

diagnosis of this case is nonunion 1/3 middle os femur sinistra and osteomyelitis.

55

When we find the true diagnosis we can give the patient the right therapy. For this

patient we did surgical treatment, the treatment for this patient is ORIF.

PLANNING THERAPY

Theraphy ;

Infus RL 20 tpm

Inj. Cefazoline 2x1 gr

Inj. Ketorolac 3x 30mg

Inj. Ranitidin 2x1 amp

56

CHAPTER V

CONCLUSION

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.

Fracture healing process Primer Healing occurs in this way internal remodeling that

includes a direct attempt by the cortex to rebuild itself when continuity interrupted. In

order to be united fractures, bone on one side of the cortex must be fused with the

bone on the other side (direct contact) to establish a mechanical continuity.

No association with callus formation. Remodeling of the internal occur haversian

system and unification edge fracture fragments of the broken bone

There 3 requirements for Haversian remodeling at the fracture site is

1. Implementation of appropriate reduction

2. Fixation stable

3. The existence of an adequate blood supply

The use of dynamic compression plate in the osteotomy models have been shown to

cause primary bone healing. Remodeling active haversian seen at around week four

fixation.

Secondary Fracture Healing Process is Healing response in the secondary cover

periostium and external soft tissues. The process of fracture healing is broadly be

divided into five phases, namely phase hematoma (swelling), the proliferative phase,

the phase of callus, ossification and remodeling

57

In a minority of cases delayed union gradually transformed into non union -

which is clear that the fracture will never unite without intervention. Movement can

cause reduced pain at the broken bone fragments. The distance to the fracture into a

type of pseudoarthrosis.

Osteomyelitis Is an infection of the tissue that covers the bone marrow and bone

cortex may be exogenous (infections have come from outside the body) or

hematogenous (infection from the body). Pathogens can enter through an open

fracture wounds, penetrating wounds, or during surgery. Gunshot wounds, long bone

fractures, open fractures are visible bones, amputation injuries due to trauma and

fractures - fractures with compartment syndrome or vascular injuries have a greater

risk of osteomyelitis.

58

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