CASE

PRESENTATION
CLOSED FRACTURE
MS

MIDSHAFT RT FEMUR
AND OPEN FRACTURE
OF RT PATELLA
NAME:NURDINA AFINI BT
IZAMUDIN

ANATOMY OF FEMUR
Femur is the only bone of the human thigh.
It is both the longest and the strongest bone in the
human body, extending from the hip to the knee.
Important features are head, medial and lateral
condyles, patellar surface, medial and lateral
epicondyles, and greater and lesser trochanters.
The head is where the bone forms the hip joint with
the innominate bone.
The condyles are the points of articulation with the
tibia, which is a lower leg bone.
The patellar surface is the groove where the bone
articulates with the patella, or knee cap.
The epicondyles and trochanters are all important
attachment sites for various muscles.

The human femur can resist forces of 1,800 to 2,500

pounds, so it is not easily fractured.
A break in this bone can only result from a large
amount of force, such as can occur during a car
accident or a fall from an extreme height.
Such an injury can take three to six months to heal.

ANATOMY OF PATELLA
-The patella is a small bone located in front of knee
joint where the thighbone (femur) and shinbone
(tibia) meet.
- It protects knee and connects the muscles in the
front of thigh to tibia.
-The ends of the femur and the undersides of the
patella are covered with a slippery substance called
articular cartilage. This helps the bones glide smoothly
along each other when move leg.

-Tendons connect the knee bones to the leg muscles that move
the knee joint.
-Ligaments join the knee bones and provide stability to the
knee:
I. The anterior cruciate ligament prevents the femur from
sliding backward on the tibia (or the tibia sliding forward
on the femur).
II. The posterior cruciate ligament prevents the femur from
sliding forward on the tibia (or the tibia from sliding
backward on the femur).
III. The medial and lateral collateral ligaments prevent the
femur from sliding side to side.
- Two C-shaped pieces of cartilage called the medial and lateral
menisci act as shock absorbers between the femur and tibia.
-Numerous bursae, or fluid-filled sacs, help the knee move
smoothly.

FEMORAL SHAFT FRACTURES

Femur fractures vary greatly, depending on the
force that causes the break. The pieces of bone may
line up correctly or be out of alignment (displaced),
and the fracture may be closed (skin intact) or open
(the bone has punctured the skin).
Doctors describe fractures to each other using
classification systems. Femur fractures are classified
depending on:
The location of the fracture (the femoral shaft is
divided into thirds: distal, middle, proximal)
The pattern of the fracture (for example, the bone
can break in different directions, such as cross-wise,
length-wise, or in the middle)
Whether the skin and muscle above the bone is
torn by the injury

-The most common types of femoral shaft fractures include:

Transverse fracture.In this type of fracture, the break is a
straight horizontal line going across the femoral shaft.
Oblique fracture.This type of fracture has an angled line
across the shaft.
Spiral fracture.The fracture line encircles the shaft like
the stripes on a candy cane. A twisting force to the thigh
causes this type of fracture.
Comminuted fracture.In this type of fracture, the bone
has broken into three or more pieces. In most cases, the
number of bone fragments corresponds with the amount of
force required to break the bone.
Open fracture.If a bone breaks in such a way that bone
fragments stick out through the skin or a wound penetrates
down to the broken bone, the fracture is called an open or
compound fracture. Open fractures often involve much more
damage to the surrounding muscles, tendons, and ligaments.
They have a higher risk for complications especially
infections and take a longer time to heal.

AETIOLOGY
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 lower-force incident, such as a fall from
standing, may cause a femoral shaft fracture
in an older person who has weaker bones.

SIGN AND SYMPTOMS

A femoral shaft fracture usually causes
immediate, severe pain. Not be able to put
weight on the injured leg, and it may look
deformed shorter than the other leg and no
longer straight.

DR. MX
-Imaging Tests

1)X-rays.The most common way to evaluate a fracture is

with x-rays, which provide clear images of bone. X-rays can
show whether a bone is intact or broken. They can also
show the type of fracture and where it is located within the
femur.
2)Computed tomography (CT) scan.If doctor still needs
more information after reviewing x-rays, he or she may
order a CT scan. A CT scan shows a cross-sectional image
of limb. It can provide doctor with valuable information
about the severity of the fracture. For example, sometimes
the fracture lines can be very thin and hard to see on an xray. A CT scan can help doctor see the lines more clearly.

TREATMENT
Nonsurgical Treatment
Most femoral shaft fractures require surgery to heal. It is unusual
for femoral shaft fractures to be treated without surgery. Very
young children are sometimes treated with a cast..
Surgical Treatment
Timing of surgery.If the skin around fracture has not been
broken, doctor will wait until stable before doing surgery. 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, doctor
will place leg either in a long-leg splint or in skeletal traction. This
is to keep broken bones as aligned as possible and to maintain
the length of leg.

External fixation is often

used to hold the bones
together temporarily
when the skin and
muscles have been
injured.

Intramedullary nailing
provides strong, stable,
full-length fixation.

(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.

COMPLICATION
Infection
Injury to nerves and blood vessels
Blood clots
Fat embolism (bone marrow enters the blood
stream and can travel to the lungs; this can also
happen from the fracture itself without surgery)
Malalignment or the inability to correctly
position the broken bone fragments
Delayed union or nonunion (when the fracture
heals slower than usual or not at all)
Hardware irritation (sometimes the end of the
nail or the screw can irritate the overlying
muscles and tendons)

PATELLAR FRACTURE
Patellar fractures account for about 1% of all
fractures. They are most common in people who
are 20 to 50 years old. Men are twice as likely as
women to fracture the kneecap.
Patellar fractures vary. The kneecap can crack
just slightly, or can be broken into many
pieces.
A break in the kneecap can happen at the top,
center, or lower part of the bone. Sometimes,
fractures occur in more than one area of the
kneecap.

This x-ray of the knee taken

from the side shows a patella
that has been fractured in
three places.

Stable fracture.This type of

fracture is nondisplaced. The broken
ends of the bones meet up correctly
and are aligned. In a stable fracture,
the bones usually stay in place during
healing.

Displaced fracture.When a bone

Comminuted fracture.This type of
breaks and is displaced, the broken
break is very unstable. The bone
ends are separated and do not line
shatters into three or more pieces.
up. This type of fracture often
requires surgery to put the pieces
Open
fracture.In this type of fracture, the skin
back
together.
has been broken and exposes the bone. These
injuries often involve much more damage to the
surrounding muscles, tendons, and ligaments.
Open fractures have a higher risk for
complications and take a longer time to heal.

Open fracture.In this type

of fracture, the skin has
been broken and exposes
the bone. These injuries
often involve much more
damage to the surrounding
muscles, tendons, and
ligaments. Open fractures
have a higher risk for
complications and take a
longer time to heal.

AETIOLOGY
Patellar fractures are most commonly caused by
a direct blow, such as from a fall or motor vehicle
collision.
The patella can also be fractured indirectly. For
example, thigh muscles can contract so violently
that it pulls the patella apart.

SIGN AND SYMPTOMS

The major sign and symptoms of a patellar fracture
include pain and swelling in the front of the knee.
Additional symptoms include:
Bruising
Inability to straighten the knee
Inability to walk

DR. MX.
Tests
X-rays are the most common and widely available
diagnostic imaging technique. They create images of
dense structures, like bone, so are particularly useful
in showing fractures. X-rays are important for showing
front and side views of the fracture.
Although rare, a person may be born with extra bones
in the patella that have not grown together. This is
called bipartite patella and may be mistaken for a
fracture. X-rays help to identify bipartite patella. Many
people have bipartite patella in both knees, so doctor
may take an x-ray of other knee, as well.

Treatment
Nonsurgical Treatment
If the pieces of broken bone have not been
displaced by the force of the injury, may not need
surgery.
Casts or splints may be used to keep knee
straight.
This will keep the broken ends in proper position
while they heal.
Not be able to put any weight on leg until the
bone is completely healed.
This may take 6 to 8 weeks, and perhaps longer.
Most people use crutches during this period.

Surgical Treatment
If the patella has been (displaced), most likely need
surgery. Fractured patellar bones that are not close
together often have difficulty healing or may not heal.
The thigh muscles that attach to the top of the patella
are very strong and can pull the broken pieces out of
place during healing.
Timing of surgery.If the skin around fracture has not
been broken, doctor may recommend waiting until
any abrasions have healed before having surgery.
Open fractures, however, expose the fracture site to
the environment. They urgently need to be cleansed
and require immediate surgery.
Procedure.The type of procedure performed often
depends on the type of fracture .

Transverse fracture.These two-part fractures are most often fixed

in place using pins and wires and a "figure-of-eight" configuration
tension band. The figure-of-eight band presses the two pieces
together.
This procedure is best for treating fractures that are located near
the center of the patella. Fracture pieces at the ends of the
kneecap are too small for this procedure. Breaks that are in many
pieces can be overcompressed by the tension band.
Another approach to a transverse fracture is to secure the bones
using small screws, wires, and pins. In many cases, these wires
and pins will need to be removed about a year or two after the
surgery.

Comminuted fracture.In some cases, either the top or the

bottom of the patella can be broken into several small pieces.
This type of fracture happens when the kneecap is pulled
apart from the injury, then crushed from falling on it.
Because the bone fragments are too small to be fixed back
into place, they will be removed. Doctor will attach the loose
tendon to the remaining patellar bone.
If the kneecap is broken in many pieces at its center (and they
are separated), your doctor may use a combination of wires
and screws to fix it. Removing small portions of the kneecap
may also have good results. Complete removal of the kneecap
is a last resort in treating a comminuted fracture.

PTs MX.
Because pt. will most likely lose muscle
strength in the injured area, exercises during the
healing process are important. Physical therapy
will help to restore normal muscle strength, joint
motion, and flexibility.
A physical therapist will most likely begin
teaching specific exercises while pt are still in
the hospital. The therapist will also help pt learn
how to use crutches or a walker.

DEMOGRAPHIC DATA
NAME: Mr. XX
AGE: 31 Y/O
RACE: MALAY
GENDER: MALE
DATE OF AX: 23 NOVEMBER 2014
DATE OF REFERRED: 16 NOVEMBER 2014
DR. DIAGNOSIS: CLOSED FRACTURE
MIDSHAFT RT FEMUR AND OPEN FRACTURE
RT PATELLA
DR MX.: OPERATIVE AND REFER PHYSIO

SUBJECTIVE AX.
PROBLEM:
Pt. c/o unable to bend his Rt. kn.
Pt. c/o pain when move his Rt. LL
PAIN SCALE:
Current: 8/10
Agg: 8/10 ( when move Rt. LL, bend Rt. Kn, put
Rt. Kn without support)
Ease: 5/10 ( on painkiller)
Nature: Dull aching pain and needling pain
24 H: Pain all the time
Irritibility: High

CURRENT Hx: h/o MVA 0n 17/6/2014(motor vs

car).Pt. was admitted at Hospital Kemaman for a
day and then transfer to HSNZ and admitted ward
for two weeks. Dr. diagnosis same as above. Done
ILN of rt. femur, post screw fixation at rt. Kn. And
wound debriment for rt. Foot. 2/12 later, h/o high
fever for 1/52 d/t infection in blood and went to see
doctor.Since after high fever, pt. unable to move
his Rt. LL and bend Rt. Kn. d/t pain. Later, Dr. refer
him to physio for further mx.
PAST Hx: NIL
PMHx: NIL
DRUG Hx: Painkiller
Ix: on 23/11/2014. result: bone still malunion
according to x-ray result.

SOCIAL Hx:
Occ: clerk at school
Nature of work: sitt and use a lot of hand movt.
Smoker: not smoking
Dominant hand: Rt.
Life style: maximally dependence to his wife
Type of house: Single storey house with 5 steps
Toilet: Sitting
FUNCTIONAL ACTIVITY:
1) pt still depends on wheelchair and need help from
his wife.

OBJECTIVE AX
GENERAL OBSERVATION: An endomorph body size of
Malay male come to department accompanied with his
wife by using wheelchair.
Alert and obey command

LOCAL OBSERVATION:
Swelling of Rt. LL
On gauze at Rt. Kn.
Scar at Rt. Kn.
Dry skin at Rt. Calf and foot
On bandage at Rt. Foot.
Rt. Hip external rotation position.

PALPATION:
No increase in warmth at Rt. Ankle and foot.
Tenderness at Rt. Kn.
ROM: KIV d/t pt. refuse to touch his rt. LL because of
untolerable with pain.

MS. POWER
Jt.

Muscle

Hip.

Flexor

Kn. (in sitt)

Flexor

Rt.

Lt.

1/5
3/5

Extensor
Ank.

d/flexor
p/flexor

3/5

Reduce ms. power of Rt and Lt. hip flexor .

4/5

MS. GIRTH:
From suprapatella (cm)

Rt. (cm)

Lt. (cm)

Diff. (cm)

63

59

10

67

65

15

70

68

44

42

From infrapatella (cm)

15

Swelling of Rt. LL

FIGURE OF 8
Rt (cm)

Lt (cm)

diff (cm)

61

60

Swelling of Rt. foot

ANALYSIS
PTS IMPRESSION
1) Pain at rt. Kn d/t pt. condition
2) Swelling at Rt. LL d/t prolong immobilised
3) Reduce functional activty d/t pain
STG
4) To reduce pain at. Rt. Kn. within 1/52 by doing exs.
5) To reduce swelling at Rt. LL within 1/52
6) To improve ms. Power of bil. LL. Within 1/52
LTG
7) To regain maximal functional activity
8) To improve quality of life

PLAN OF TX
Stretching exs.
Mobilising exs
Strenghtening exs.
Circulatory exs.
Positioning
Ambulation
Gait training exs.
HEP
Pt. edu.

INTERVENTION
1) Positioning
Pt. half ly., correct rt. hip from external rot. to
internal rot.
2) Strengthening exs.
-Pt. half ly., lt. hip SLR, hold 5 sec., 50 reps.
-Pt. half ly., rt. Kn SQE,hold 15 sec.,50 reps.
-Pt. sitt with rt. LL supported, Lt. kn. Ext. exs.,
sandbag(3 lb), hold 10 sec., 50 reps.
-Pt. sitt., hand push up exs., hold 5 sec., 20 reps.
-Sitt to stand exs. (NWB), walking frame, hold 5
sec., reps.
3) Circulatory exs., 10 reps.

4) HEP
Advice pt to do all exs. home regularly 3 times per day.
5)Pt. edu.
-Encourage pt. to elevate his rt. LL more than heart
level when lying on bed and sleeping.
-Encourage pt to slowly move his rt. LL.
-Educate pt. correct his rt. LL position to prevent hip
external rotation.

EVALUATION
-Pt. refuse to touch him because of pain.
-Pt. give cooperation to do all exs.
-Pt. able to sitt on wheelchair with rt. Kn. unsupported.
REVIEW
-To review ROM

Follow up
Date:
S:
Pt. claim slightly reduce pain on rt. Kn. VAS (6/10)a
and reduce the intake of painkiller from everyday to 3
days per once.
Pt. c/o same problem.

O:
GO: An endomorph body size of Malay male come to
department accompanied with his wife by using
wheelchair.
Alert and obey command
LO:
Swelling of Rt. LL
Unmatured scar at Rt. Kn.
Dry skin at Rt. Calf and foot
On bandage at Rt. Foot.
Rt. Hip external rotation position.

PALPATION
No increase in warmth at Rt. Ankle and foot.
Tenderness at Rt. Kn.

ROM
Jt.

Movement

Rt.

Lt.

Hip.

Flex.

KIV d/t pt unbale

to lift up his Rt. LL

AFROM

Kn. (in sitt)

Flex.

A:0-40 degree
P:0-45 degree

AFROM

Ext.

LACK 40 degree

AFROM

d/flex.

A:30-45 degree
P:30-55 degree

A:30-60 degree
P:30-70 degree

p/flex.

A:30-20 degree
P:30-15 degree

A:30-10 degree
P:30-5 degree

Ank.

Reduce ROM of Rt. kn. Jt. and ank. jt.

MS. POWER
Jt.

Muscle

Hip.

Flexor

Kn. (in sitt)

Flexor

Rt.

Lt.

1/5
3/5

Extensor
Ank.

d/flexor
p/flexor

3/5

Reduce ms. power of Rt and Lt. hip flexor .

4/5

MS. GIRTH
From suprapatella (cm)

Rt. (cm)

Lt. (cm)

Diff. (cm)

60

59

10

68

64

15

71

69

44

42

From infrapatella (cm)

15

Swelling of Rt. LL

FIGURE OF 8
Rt (cm)

Lt (cm)

diff (cm)

63.5

61

1.5

Swelling of Rt. foot

ANALYSIS
PTS IMPRESSION
1) Pain at Rt. Kn d/t condition.
2) Reduce ROM of Rt. kn. and ank. jt. d/t jt.
stiffness.
3) Reduce of ms. power of bil. LL d/t lack of ms.
activity.
4) Swelling at Rt. LL d/t prolong immobilised
5) Reduce functional activty d/t pain

PLAN OF TX.
1) Positioning
Pt. half ly., correct rt. hip from external rot. to
internal rot.
2) Passive stretching exs.
Pt. half ly.,stretch Rt hip internal rot.,hold 15
sec.,20 reps
3) Strengthening exs.
-Pt. half ly., lt. hip SLR, hold 8 sec., 50 reps.
-Pt. half ly., rt. Kn SQE,hold 20 sec.,50 reps.
-Pt. sitt with rt. LL supported, Lt. kn. Ext. exs.,
sandbag(3 lb), hold 10 sec., 50 reps.
-Pt. sitt., hand push up exs., hold 8 sec., 20 reps.

-Pt. half ly., isometric exs., Rt.hip flex.,hold 10 sec.,30

reps.
-Pt. sitt., isometric exs., Rt. Kn. flex. and ext., hold 10
sec., 30 reps each.
-Sitt to stand exs. (NWB), walking frame, hold 5 sec.
10 reps.
4) Ambulation using walking frame for 50 meter, 3
cycle.
5) HEP
Advice pt to do all exs. home regularly 3 times per day.
6)Pt. edu.
-Encourage pt. to try walk by using walking frame.

REFERENCES
http://orthoinfo.aaos.org/
http://www.webmd.com/