Case DiscussionBY EXT.JIRAWATH ASSAWADARACHAI

Patient profile

Chief Complaint

ขบัรถจกัรยานยนตช์นรถยนต ์1 ช ัว่โมงกอ่นมารพ.

Initial management

Primary survey

A : spontaneous speech,no cervical tenderness

B : clear both lung,CCT negative

C : BP 115/68 mmHg , P 94 /min,PCT negative

D : E4V5M6,pupil 3 mm RTLBE

Secondary survey

History

A : ไม่มปีระวตัแิพย้า แพอ้าหาร

M : ไม่มยีาประจ า

P : no underlying disease

L : ทานขา้วลา่สดุตอน 12.00 น.

E : 1 ช ัว่โมง กอ่นมารพ. ผูป่้วยขีร่ถจกัรยานยนตผ่์านสีแ่ยกไปชนกบั

รถยนต ์สลบ หลงัมสีตไิม่มคีลืน่ไส ้อาเจยีน ไม่ปวดศรีษะ ไม่ปวด

คอ ไม่เจ็บหนา้อก ไม่ปวดทอ้ง ไม่มเีลอืดไหลออกจากจมูก/ห ูมี

อาการเจ็บทีต่น้ขาขวา ลกุขึน้เดนิไม่ได ้ยงัสามารถขยบัขอ้เทา้ได ้

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 fatigue

HEENT : not pale conjunctiva,anicteric sclera

Chest : normal breath sound,no adventitious sound

Heart : normal s1,s2,no murmur

Abdomen : soft,not tender

Neuro : 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

Compartments

1-anterior compartment of thigh

-sartorius

-quadriceps(rectus femoris,vastusmedialis/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-ray

well 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