Closed Fracture 1/3 Distal of The Left Radius and Left Ulna Closed Fracture 1/3 Distal of The

Right Radius Closed Comminuted Fracture 1/3 Middle of the Left Femur
Presented by :

Hasmia
Advisor dr. Benny

dr. Jacky

Supervisor dr. M.Ruksal Saleh, Ph.D, Sp.OT

Patient Identity
Name Age Sex Admittance Address Occupation RM number

: Mr. E : 16 years old : Male : 3rd July 2012 : Parigi, Maros : Student : 55 51 42

History Taking
Chief complaint : wound at the left light Anamnesis : suffered since + 4 hours before admitted to Wahidin Sudirohosodo hospital due to traffic accident. Injury mechanism : He was riding a motocycle, and then hit the tree. History of unconsciousness (-), nausea (-), vomit (-) History of prior treatment at Soppeng Hospital

Primary Survey
A : Patent B : RR = 20 x/min, simetris, spontaneous, thoracoabdominal type. C : PR= 88 x/min regular, strong. D : GCS 15 (E4V5M6), pupil isochors 2,5mm/2,5 mm, light reflex +/+ E : T = 36,5 0 C (axillar)

Secondary Survey
Right Antebrachii region : I : Deformity (+), swelling (+), hematoma (), wound (-) P : Tenderness (+) ROM : Active and passive motion at elbow and wrist joints are limited due to pain. NVD : Sensibility is good , radial artery pulse is palpable, capillary refill time is <2

Left Antebrachii region : I : Deformity (+), swelling (+), hematoma (+), wound (-) P : Tenderness (+) ROM: Active and passive motion at elbow and wrist joints are limited due to pain. NVD: Sensibility is good , radial artery pulse is palpable, capillary refill time is <2

Femoral region : I : Deformity (+), swelling (+), hematoma (-), wound (-) P : Tenderness (+) ROM: Active and passive motion at hip and knee joints are limited due to pain. NVD: Sensibility is good , dorsalis pedis arterypulse is palpable, capillary refill time is <2

Leg Length Discrepancy

R ALL TLL 78 cm 76 cm L 77 cm 75 cm

LLD

1 cm

The Right Forearm

The Left Forearm

The Lower Limb

WBC 8,92 x 103 /uL RBC 5,14 x 106 /uL HGB 14,9 g/dL PLT 236 x 103 /uL Ureum 16 mg/dl Creatinin 0,7 mg/dl SGOT 20 u/l SGPT 27 u/l CT 800 BT 200 PT 12,7 control 13,6 APTT 22,2 control 26,3

Radiological Findings
X-Ray AP/Lat of The Right Antebrachiu m

X-Ray AP/Lat of The Left Antebrachium

X-Ray AP/Lat of Left Femur

Closed Fracture 1/3 Distal of the Left Radius and Left Ulna Closed Fracture 1/3 Distal of The Right Radius Closed Comminuted Fracture 1/3 Middle of The Left Femur

Management
IVFD

RL Analgesic Immobilization Plan for ORIF

Resume
A 13 years old with Deformity (+) edema (+) and tenderness at the antebrachii region, limited active and passive motion of elbow and wrist joint due to pain. Deformity (+) edema (+) and tenderness at the femoral region and limited active and passive motion of hip joint and knee joint due to pain. Sensibility is good, dorsalis pedis artery palpable, Capillary refill time < 2. Radiological finding with distal fracture of left radius and left ulna, distal fracture of right radius, and comminuted fracture of left femur shaft.

The diagnosis are Closed Fracture 1/3 distal of the Left Radius and Left Ulna, Closed Fracture 1/3 distal of the right Radius, and Closed comminuted fracture 1/3 middle of the Left Femur.

Fracture in Pediatrics

Distal Forearm Fracture in Children

Introduction
Fractures of the forearm is common in children, accounting for 30% to 40% of all fractures in children. Most forearm fractures occur in children older than 5 years. The location of the fracture advances distally with increasing age of the child, probably because of the anatomic changes in the metaphyseal-diaphyseal junction that occur with maturity The distal forearm is the site of 70% to 80% of fractures of the radius and ulna.

BONE ANATOMY IN CHILDREN

Bone in Children: Less mineralized. Have more vascular channels than the bones of adults. Periosteal is thick Elastis of ligament There are Growth plate (physis)

ANATOMY OF RADIUS ULNA

MECHANISM OF INJURY

Indirect: The mechanism is a fall onto an outstretched hand. Forearm rotation determines the direction of angulation:
Pronation: flexion injury (dorsal angulation) Supination: extension injury (volar angulation)

Direct: Direct trauma to the radial or ulnar shaft.

Classification of The Distal Forearm Fractures

Buckle or torus fracture Greenstick fracture Metaphyseal fracture Physeal fracture Galleazzi fracture

Greenstick Fracture

Buckle or Torus Fracture

CLINICAL EVALUATION

Wrist deformity and displacement of the hand in relation to the wrist. The wrist is typically swollen with ecchymosis, tenderness, and painful range of motion.

DIAGNOSIS
Anamnesis Physical examination X- ray, with AP and lateral view

NonOperatif
Simple

Operative
External

Closed reduction Immobilization long arm casting

Fixation

ORIF

MANAGEMENT

COMPLICATIONS
Malunion Re-fracture Growth arrest Peripheral nerve injury Compartement syndrome Non-union, cross union Reflex sympathetic dystrophy.

Femur Shaft Fracture in Children

Introduction
Fracture of the femur are quite common and are usually due to direct violence or a fall from high. Between 1 and 4 years of age, 30 % of femoral shaft fracture are attributed to abuse. In the adolescent age group, high velocity motor vehicle accidents are more often the mechanism of injury and account for up to 90% of all femoral shaft fractures.

ANATOMY OF FEMUR

Muscles Compartment of the Femur

ANTERIOR COMPARTMENT
MUSCLE Sartorius Rectus femoralis Vastus lateralis Vastus intermedius Vastus medialis ORIGIN ASIS 1.AIIS 2.Sup. acetab. rim Gtr. trochanter, lat. linea aspera Proximal femoral shaft Intertrochant. line, med. linea aspera INSERTION Prox. med. tibia (pes anserius) Patella/tibia tubercle Lat. patella/tibia tubercle Patella/tibia tubercle Medial patella/tibia tubercle NERVE Femoral Femoral

Femoral Femoral Femoral

Muscles Compartment of the Femur

MEDIAL COMPARTMENT
MUSCLE Obturator externus Adductor longus Adductor brevis Adductor magnus Gracilis Pectineus ORIGIN Ischiopubic rami, obturator memb Body of pubis (inferior) Body and inferior pubic ramus 1.Pubic ramus 2. Isxhial tub. Body and inferior pubic ramus Pectineal line of pubis INSERTION Piriformis fossa Linea aspera (mid 1/3) Pectineal line, linea aspera Linea aspera, add. tubercle Prox. med. tibia (pes anserius) Pectineal line of femur NERVE Obturator Obturator Obturator 1.Obturator 2.Sciastic Obturator Femoral

Muscles Compartment of the Femur

POSTERIOR COMPARTMENT
MUSCLE Semitendinosus ORIGIN Ischial tubersity Ischial tubersity Ischial tubersity Linea aspera, supracondylar line INSERTION Proximal medial tibia (pes anserius) Posterior medial tibial condyle Head of fibula Fibula, lateral tibia NERVE Sciastic (tibial) Sciastic (tibial) Sciastic (tibial) Sciastic (peroneal)

Semimembrano sus Biceps femoris : Long head Biceps femoris :Short head

Classification of Fracture
Descriptive Open versus closed Level of fracture: proximal, middle, distal third Fracture pattern: transverse, spiral, or oblique Comminuted, segmental or butterfly fragment Angulation or rotation deformity Displacement : shortening or translation

Stable 0 I II

: No comminution : Minimal comminution : Comminuted > 50% of cortices intact

Unstable III IV

: Comminuted < 50% of cortices intact : Complete comminution, no intact cortex

Winquist & Hansen Classification

Mechanism of Injury
Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse are causes. Indirect trauma: Rotational injury. Pathologic fractures: Causes include osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors.

Clinical Evaluation
Patients

with a history of high-energy injury should undergo full trauma evaluation as indicated. The presence of a femoral shaft fracture results in an inability to ambulate, with extreme pain, variable swelling, and variable gross deformity.

A careful neurovascular examination is essential.

Radiologic Evaluation

Anteroposterior (AP) and lateral views of the femur should be obtained. Radiographs of the hip and knee should be obtained to rule out associated injuries

Treatment
Guideline Age 0 to 6 Months : Pavlik Harness 7 Months to 5 Years : Closed Reduction with Spica Cast Application, Skin or Skeletal Traction, Flexible Intramedullary Rods. 6 to 10 Years : Open Reduction with Flexible Rods. 11 Years to Skeletal Maturity : Flexible Intramedullary Rodding, Submuscular Plate Fixation, Rigid Intramedullary

Complication
Common Limb Length Inequality Unacceptable Angulation Rotational Deformities Non-union and Delayed Union Rare Compartment Syndrome Infection Inflamation Vascular Injury