Professional Documents
Culture Documents
Laporan Kasus
Laporan Kasus
I. IDENTITY
Name : Ny. Sumarni
Age : 64 years
Sex : Female
Religion : Muslim
Address : Pare-pare
Marriage status : Married
RM : 035061
Admission date : March 11th 2017
II. ANAMNESIS
Chief complaint: Pain at left femur
Patients come to the hospital emergency room A. Makkasau with complaints of
pain in the left thigh about 3 hours ago before admission to hospital, the patient
complained of pain in her left hip and difficult to move. A history of fallen sitting by the
roadside as blurred vision 2 months ago. A history of fainting (-), headache (-),
vomiting (-).
Past History: allergic history was unknown, hypertension and Diabetes Mellitus was
denied
Social economic history : BPJS
Look :
Deformity (+), Flexed Hip (+), Adduction and Internal Rotation (+) Swelling (-),
Hematoma (-), Wound (-)
Feel :
Tenderness (+)
Move:
Active and passive movement of left femur was limited due to pain
NVD :
Sensibility is good, CRT < 2 seconds, pulsation of posterior tibial artery and
dorsalis pedis artery is palpable
V. LABORATORY
Tanggal pemeriksaan 8 Maret 2017
Items Result Unit N Value
Hematology:
WBC 5.80 103/ul 4-12
Eosinofil .213 % 2-4
Basofil .093 % 0-1
Netrofil 3.56 71.5 % 50-70
Limfosit 1.48 23.9 % 25-50
Monosit .457 3.16 % 1-6
RBC 3.97 106/ul 3,8-5,2
Hemoglobin 11.3 g/dl 12,8-16,8
Hematokrit 33.8 % 35-47
MCV 85.2 Fl 80-100
MCH 28.5 Pg 26-34
MCHC 33.5 g/dl 32-36
PLT 151. 103/ul 150-450
Imuno-Serologi:
Negative
HBsAg Negatif
(Kualitatif)
Hemostasis:
Minutes < 1500
CT 1000
100 300
BT 130 minutes
VI. RADIOGRAPHY
X-Ray Pelvic AP on March 13 th 2017
RESUME
Patient, female, 64 years old, was admitted to hospital on March 11th 2017 with pain
in the pelvis of the left since two months ago and was advancing about 3 hours before
hospital admission. History fallen sitting by the roadside as blurred vision two months
ago. Patients being treated in hospitals Andi Makkasau and planned to surgical operation
but patients feel no pain anymore so the patient refuses surgical. A month after leaving
the hospital Andi Makkasau, patients go to the masseur to massage the pelvic. Patients
feel the disease is not cured so that the patient contact the call center 112 to take him back
to the hospital Andi Makkasau.
In physical examination of left hip joint there are deformity, Flexed Hip (+),
Adduction and Internal Rotation (+), Tenderness (+). Range of motion; active and passive
movement of left hip joint was limited due to pain, Sensibility is good, CRT < 2 seconds,
pulsation of posterior tibial artery and dorsalispedis artery is palpable.
Radiologic examination of pelvic AP shentons line is disrupted and the joint space
is asymmetric.
VII. DIAGNOSE
Closed Fracture Left Neck Femur
VIII. MANAGING
1. Non operatif
Immobilitation : Splint
Elevation of the legs, watch sign compartment syndrome
Patiient education about pain experienced by the patients mouth
2. Medikamentosa
- IVFD Ringer Lactate
- Analgesic
Bab II
Literature Review
Colum fracture femur is a fracture occurs in volumes the femur. Damage to the
base of the bone continuity that can be caused by direct trauma, indirect trauma, muscle
fatigue, certain conditions such as degeneration of the bones / osteoporosis.
In this case, the author will discuss some of the system include: (1) the skeletal
system, (2) the joint system, (3) the muscular system, (4) the nervous system.
Os. Femur
A long bone in the body which is divided into Caput Corpus and collum with the distal
end and proksimal.Tulang is jointed with the acetabulum in the structure of the pelvic
joints and jointed with the tibia bone in the knee joint (Syaifudin, B.AC 1995) .Tulang
thigh or upper limbs is longest and largest bone in the body including one-quarter of the
length of the thigh tubuh.Tulang consists of three parts, namely proximalis epiphysis,
diaphysis and distal epiphysis.
Proximal epiphysis
The tip makes 2/3 ball circle called caput femoris which has facies articularis for middle
acetabulum are jointed with basin called the fovea capitis. Caput continued ourselves as
femoral neck were then rounded lateral side called throcantor major medial direction too
small rounded called trochantor minor. Viewed from the front, both major and minor
spheres are connected by a line called the linea intertrochanterica (linea spiralis). Viewed
from the rear, the two spheres are connected by a ridge called the crista
intertrochanterica. Seen from the back anyway, then the medial side of the basin are
major trochantor called trochanteric fossa.
Diaphysis
A long section called transverse corpus.Penampang is a triangle with the base facing
forward. Having a plateau that is facies medial, lateral facies, facies anterior. The
boundary between the medial and lateral facies appear on the back of a line called the
linea aspera, starting from the proximal part to the presence of a rough protrusions called
gluteal tuberosity. Linea is divided into two seedlings, namely medial and labium laterale
labium, labium medial itself is a continuation of the linea intertrochanrterica. Linea
aspera distal section forming a triangle is called Planum popliseum. From minor
trochantor there is a line called the linea pectinea. At the rear there is a foramen nutricium
plateau, also called the lateral medial labium supracondylaris lateral / medial.
Distal Epiphysis
A pair of dots called condylus medial and proximal lateralis.Disebelah condylus these
bumps are again each a small spheres called epicondylus medial and lateral epicondylus.
This is the end of the trip Epicondylus linea aspera distal portion viewed from the front
there is a wide plain of the joints called facies patelaris for jointed with os. patella.
Proximalnya Intercondyloidea that section there is a line called the linea
intercondyloidea.
Muscular System
The muscles that will be discussed only with the condition of the patient's postoperative
femoral fracture medial 1/3 dextra with mounting plate and screw are the muscles that
function in all directions like a hip region for flexion-extension, abduction-adduction and
external rotation-internal rotation.
For more terperincinya authors include the muscles associated with these conditions, are
as follows:
3 Quadricep
Femoralis
SIAS Tendon m. Flexi arc N.
a. Rectus quadriceps coxae femoralis
femoris pada patela,
vialigamentum
patellae ke
dalam
tuberositas
tibia
Extansi lutut
b. Vastus Ujung atas
c. Vastus menstabilkan
Ujung atas
medialis patela
dan batang N.
d. Vastus
Permukaan
intermediu
anterior dan N.
s lateral batang femoralis
femur
The nervous system in the upper leg (thigh) is divided into four, namely:
Bloodstream system
The circulatory system of the upper leg (thigh) Here will be discussed throughout the
circulatory system of the upper leg or thigh ie arteries and veins.
Arteries
Arteries carry blood from the heart to the body cavity and arteries always bring fresh
blood containing oxygen, except pulmonale arteries that carry dirty blood oxygenation
require. The arteries in the legs, among others, namely:
Femoral Artery
Femoral artery enters the thigh through the rear of the inguinal ligament and is a
continuation of the external illiace artery, which is located mid between SIAS (illiaca
spina anterior superior) and femoral pubis.Arteria sympiphis the main blood supplier part
of the leg, walking downhill almost bump into the femoral adductor tuberculum and ends
Reviewed by magnus muscle hole enters the popliteal spatica as popliteal artery.
Obturator Artery
An internal illiaca arterial branches, he goes down and forward on the lateral wall of the
pelvis and accompanying obturator nerves through the obturator canal, which is the top of
the foramen obturatum.
Popliteal Artery
Popliteal artery running through the canal adduktorius entered into a branched fossa
posterior tibial artery is located in the popliteal fossa from lateral to medial fossa is the
tibial nerve, popliteal vein, the popliteal artery.
Veins
Femoral Vein
The femoral vein into the thigh through the hole in the adductor magnus muscle as a
continuation of the popliteal vein, he climbed the thigh early on the lateral side of the
artery. Then the posterior of it, and ended up on the side medialnya.Ia left thigh in the
space of the medial femoral sheath and walked behind the inguinal ligament into vena
iliaca externa.
Deep venous femoral
Femoris accommodate deep venous branches that can be likened to the branches of the
artery, it flows into the femoral vein.vena obturator Accommodate the obturator vein
branches that can be likened to the branches of the artery, which pours its contents into
the vein internal illiaca.
Saphenous vein
Transporting the journey of blood from the medial end venosum arcus dorsalis pedis and
runs up right in the medial malleolus, venosum dorsalin this vein runs behind the knees,
bent forward through the medial side of the thigh. He is shooting went through the
bottom n. saphensus the deep fascia and join the femoral vein.
Fractures of the neck of the femur including intracapsular fracture which occurs in the
proximal femur, which included the femoral neck is starting from the distal surface of the
femoral head to the proximal part of the intertrokanter.
On physical examination, fracture neck of femur with a shift would cause a deformity
that occurs shortening and external rotation while the fractures without deformity shift is not
clearly visible. Regardless of how many shifts occurring fracture, most patients will complain
of pain when it gets imposition, tenderness in the groin and hip pain when actuated.
Standard radiographs for femoral neck fractures are the hip and pelvic anteroposterior
radiograph and cross-table lateral. Classification of femoral neck fractures according to
Garden's are as follows:
a. Grade I: Fracture Incomplete (abduction and impacted)
d. Grade IV: Fracture to shift the entire fragment without passage segments that
intersect
Pauwel's classification for femoral neck fractures are often digunakan.Klasifikasi is based
on the angle formed by the fracture line and the horizontal plane in an upright position.
a. Type I: the fracture lines form an angle of 30 to the horizontal plane in an
upright position.
b. Type II: fracture lines form an angle of 30-50 to the horizontal plane in an
upright position.
c. Type III: fracture lines form an angle> 50 to the horizontal plane in an upright
position.
Another frequently used classification is Russel Taylor. This classification is based on the
involvement of piriformis fossa.
1. History
Biographical data, past medical history, current medical history, family medical
history, psychosocial history (interaction with family), pattern of daily hygiene,
activity, blood circulation, Neurosensori (numbness, kesemuran, tense), Pain /
comfort.
2. Physical Examinatio
inspection:
Swelling, bruising and deformity (abnormal protrusion, angulation, rotation,
shortening) may be obvious, but the important thing is whether the skin was intact;
ripped skin and wounds that have a relationship with the fracture, an injury
terbuka.Pemeriksaan motion of your joints are actively included in the routine
examination of fractures.
Palpation:
There is local tenderness, but it should also examine the distal part of the fracture to
feel the pulse and to test sensation. Vascular injury is an emergency that requires
surgery
Motion:
On or pasif. Krepitus and abnormal movement can be found, but it is more important
to ask whether the patient can move the distal section joints injury.
3. Investigations Collum Femur Fractures
Radiological (x-ray), the area suspected fractures, must follow the role of two,
consisting of:
1. Includes two images are anteroposterior (AP) and lateral.
2. Load the two joints between the fracture is proximal and distal parts.
3. Load the two extremities (especially in children) both injured and not affected by
the injury (to compare with normal)
4. Do it twice, ie before the procedure and after the action.
X-rays
In the AP projection is sometimes not clearly found a fracture in the cases
impacted, for additional examination is necessary axial projection. Shifting assessed
through shadow form abnormal bone and trabecular level of mismatch line at the end of
the femoral head and the femoral neck. This assessment is important because an impacted
fracture or shift (stage I and II Garden) can be improved after internal fixation, while
fractures were shifted often have non union and avascular necrosis.
Plain radiographs have traditionally been used as the first step in the examination
of the hip bone fracture. The main purpose of the film x-ray to rule out any obvious
fractures and to determine the location and extent of the fracture. The presence of
periosteal bone formation, sclerosis, callus, or a fracture line may indicate a voltage
fraktur.Radiografi may indicate a fracture line on the neck of the femur, which is the
location for this type of fraktur.Fraktur be distinguished from compression fractures,
which according to the Devas and Fullerton and Snowdy, usually located in the inferior
part of the femoral neck. If the movie is not visible in the standard x-ray, bone scan or
Magnetic Resonance Imaging (MRI) should be performed.
Bone Scanning
Bone scanning can help determine the presence of a fracture, tumor, or
infeksi.Bone scan is the most sensitive indicator of bone trauma, but they have little
specificity. Shin et al. reported that bone scanning has a positive predictive value of 68%.
Bone scanning is limited by the relative spatial resolution of the anatomy of the hip. In
the past, bone scanning is considered unreliable before 48-72 hours after a fracture, but a
study conducted by Hold et al found sensitivity of 93%, regardless of the time of the
injury.
Laboratory examination
Highlights include:
1. Blood routine,
2. The blood clotting factor,
3. Blood groups (especially if it will do the surgery),
4. urinalysis,
5. Creatinine (muscle trauma can increase the load creatinine for kidney clearance).
Reduction method:
1. Reduction covered, in most cases, closed reduction is done by returning the bone
fragments into position (edges are interconnected) with "Manipulation and Traction
manual". Before the reduction and immobilization, the patient's consent must be
requested, in accordance with the analgesic and anesthetic given if necessary.
Ektremitas maintained in the desired position while the cast, splint or other device
fitted by a doctor. Tools will maintain the reduction and immobilization of extremity
to stabilize the bone healing. X-rays should be performed to determine whether the
bone fragments have been in correct alignment.
2. Traction
Traction can be used to obtain the effect of reduction and immobilization. Weighing
traction adapted to muscle spasms that occur. Generally traction is done by placing
the burden to strap on ekstermitas patients. Area attractions also adjusted such that the
direction of the long axis aligned with the pull of a broken bone.
3. Reduction open
In certain fractures require open reduction. With the surgical approach, reduced bone
fragments. The internal fixation devices in the form of pins, wires, screws, palt, nail
or metal rod can be used to retain the bone fragments in his position until a solid bone
healing occurs.
Immobilization
Early complications
General Compilation:
a. Shock: hypovolemic or traumatic shock due to bleeding (blood loss either external or
invisible) and external fluid loss kejaringan damaged.
b. Fat embolism syndrome: In the event of fracture of fat globules can get into the blood
vessel due to the pressure higher than the bone marrow or the capillary pressure due
to catecholamines released by a stress reaction patients will mobilize fatty acid and
eases the fat globules in the bloodstream
c. Compartment syndrome: a problem that occurs when muscle tissue perfusion in less
than that required for the life of the network. This could be due to a decrease in the
size of the muscle compartment due to fascia that wraps muscles are too tight, use a
cast or bandage which ensnare or browse increase muscle compartment for edema or
bleeding in connection with various problems (eg, ischemia, injury crushed).
d. Venous Thrombosis: Blood clots in the veins, especially in the lower limbs caused by
blood flow becomes slow or static the bloodstream, whereas vascular endothelial
abnormalities rarely a factor. Venous thrombus composed largely of fibrin and
erythrocytes and platelets contain only a little time. In general, the reaction resembles
a blood clot in the tube.
e. Pulmonary embolism: blockage of the pulmonary artery (pulmonary artery) by an
embolus, which occurs suddenly. An embolism can be a blood clot (thrombus), but
can also be fat, amniotic fluid, bone marrow, tumor fragments or air bubbles, which
will follow the blood flow until eventually clog arteries. Clogged arteries are usually
not able to provide adequate amounts of blood to the lung tissue exposed to tissue
death could have been avoided. But if the blocked vessel is very large or the person
has a previous lung disorder, then the amount of blood may be insufficient to prevent
the death of the lungs. Most cases are caused by a blood clot from a vein, especially
the veins in the legs or pelvis. Less common causes are air bubbles, fat, amniotic
fluid, or clumps of parasites or tumor cells.
f. Avascular necrosis: results in 30% of patients with fractures that accompanied the
shift and 10% in fracture without shifting. If the fracture is more to the proximal
localization, then it is likely to occur avascular necrosis becomes larger.