Ppt Lapsus

NON UNION 1/3 MIDDLE FEMUR FRACTURE SINISTRA AND OSTEOMYELITIS

Ulfa Elsanata01.211.6546

I. IDENTITY Name : Tn. F Age : 37 years old Sex : boy Religion : islam Address : Kendal Register number : 487.401 Date of in patient : 18 March 2016

II. ANAMNESIS Main complaint : 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.

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 statusenough in socioeconomic

III. PHYSICAL EXAMINATIONGCS : 15Awareness : composmentisVital sign 1. Blood pressure : 120/80 mmHg 2. Heart rate : 78 x / minute,

regular 3. Temperature : 36,5oC 4. Breathing : 20 x / min

Skin : Turgor (N) Head: Mesocephal, Wound (-) Eyes : Anemis -/-, Icteric -/- Ear : Discharge -/- Nose : Deviation septum -/-, discharge -/- Mouth : Bleeding (-) Neck : Simetris, Trachea deviation (-) Thorax : Normochest, simetris

COR Inspeksi : Ictus cordis (-) Palpasi : Ictus cordis palpable at SIC V, 2

cm medial to the linea mid clavicularis sinistra, pulsus the sternal (-), pulsus epigastrium (-)

Percussion : configuration of the heart normal

Auscultation: heart sound I-II regular, gallop (-), murmur (-)

Anterior PosteriorI: Statis: normochest(+/+), simetris (+/+), retraction (-/-). Dinamis: simetrisPa: statis: simetris (+), no widening between the ribs, retraction (-/-), sterm fremitus dx=sinPe: Sonor (+/+)Aus: vesicular (+/+), ronchi (-/-), wheezing (-/-)

I: Statis: normochest(+/+), simetris (+/+), retraction (-/-).Dinamis: simetrisPa: statis: simetris (+), no widening between the ribs, retraction (-/-), sterm fremitus dx=sinPe: Sonor (+/+)Aus: vesicular (+/+), ronchi (-/-), wheezing (-/-)

Pulmo

Abdomen Inspection : normal, massa (-) Auscultation : bowel (+) Normal Percussion : tympani (+) Palpation : Supel, pain (-), hepar and

spleen are not papble

Back : kifosis and lordosis (-)

ExtremityExtremity superior inferior

Oedem -/- -/+

Cold extremities

-/- -/-

Physiological reflex

+/+ +/+

Icteric -/- -/-

IV. LOCAL STATUS 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. LLD :

right lefttrue length 76cm 75cmapparent

length81cm 80cm

anatomic length

44cm 43cm

V. SUPPORTING EXAMINATION BEFORE ORIF PART 2 : X-RAY FEMUR SINISTRA19-01-2016 (post ORIF

1 ) 18-03-2016

Laboratory

VI. DIAGNOSE

NON UNION 1/3 MIDDLE FEMUR FRACTURE SINISTRA AND OSTEOMYELITIS

VII. INITIAL PLAN Ip. Therapy Infus RL 30 tpm Inj. Cefazolim 2x1gr Inj. Ketorolax 3x 1 amp Inj. Ranitidin 2x1 amp Ip. Operative ORIF Femur Ip. Monitoring General situation, vital sign, the result of

supporting examination

AFTER ORIF PART 2 ( 23-03-2016 )

CHAPTER VIII

CONTENS REVIEW

ANATOMI OF THE THIGH

MUSCLES COMPARTMENT OF THE FEMURANTERIOR COMPARTMENT

MUSCLE ORIGIN INSERTION NERVE

Sartorius ASIS Prox. med. tibia (pes anserius)

Femoral

Rectus femoralis

1.AIIS2.Sup. acetab. rim

Patella/tibia tubercle

Femoral

Vastus lateralis

Gtr. trochanter, lat. linea aspera

Lat. patella/tibia tubercle

Femoral

Vastus intermedius

Proximal femoral shaft

Patella/tibia tubercle

Femoral

Vastus medialis

Intertrochant. line, med. linea aspera

Medial patella/tibia tubercle

Femoral

MUSCLES COMPARTMENT OF THE FEMURMEDIAL COMPARTMENT


Obturator externus

Ischiopubic rami, obturator memb

Piriformis fossa Obturator

Adductor longus

Body of pubis (inferior)

Linea aspera (mid 1/3)

Obturator

Adductor brevis

Body and inferior pubic ramus

Pectineal line, linea aspera

Obturator

Adductor magnus

1.Pubic ramus2. Isxhial tub.

Linea aspera, add. tubercle

1.Obturator

2.Sciastic

Gracilis Body and inferior pubic ramus

Prox. med. tibia (pes anserius)

Obturator

Pectineus

Pectineal line of pubis

Pectineal line of femur

Femoral

MUSCLES COMPARTMENT OF THE FEMURPOSTERIOR COMPARTMENT


Semitendinosus

Ischial tubersity

Proximal medial tibia (pes anserius)

Sciastic (tibial)

Semimembranosus

Ischial tubersity

Posterior medial tibial condyle

Sciastic (tibial)

Biceps femoris : Long head

Ischial tubersity

Head of fibula Sciastic (tibial)

Biceps femoris :Short head

Linea aspera, supracondylar line

Fibula, lateral tibia

Sciastic (peroneal

)

II. FEMORAL SHAFT FRACTURE ACCORDING OTA CLASSIFICATION

FRACTURE HEALING

1. INFLAMMATORY PHASE: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. The timing of this process begins when fractures occur until 2-3 weeks.

2. PROLIFERATION PHASE

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.

3. REPAIRE PHASE (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.

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 osteoclast and osteoblast activity is continuous, 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 PHASEFractures 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.

COMPLICATION OF FRACTURE

General Local

Early Late

GENERAL COMPLICATION Crush syndrome Tetanus Gas gangrene Fat Embolism

EARLY COMPLICATION Local Visceral Injury Vascular Injury Nerve Injury Injury of tendon and joint Infection

• INFECTION Causes:

Open fracture (common) Use of operative method in the Tx op.

Wound becomes inflamed and starts draining seropurulent fluid.

Infection may be superficial, moderate (osteomyelitis), severe (gas gangrene).

Post-traumatic wound infx is most common cause of chronic osteomyelitis union will be slow and ↑ chance of refracturing.

Treatment: Antibiotic Excising all devitalised tissue If Sign of acute infx and pus formation :

tissue around the fracture should be opened & drained

LATE COMPLICATIONS

• Failure of implant• Delayed union• Non-union• Malunion• Joint stiffness• Avascular necrosis• Shortening of bone

FAILURE OF IMPLANTS Occur more frequently in heavy adult cattle and

buffaloes. The complications include excessive wear and

tear of plaster cast, bending of splints and bending and loosening of plates, screws and intramedullary pins.

The disparity in the size of large ruminants and the currently available internal fixation devices is the major cause of the implant failure.

Selection of devices of appropriate size and strength, their proper fixation and additional external support can reduce the incidence of implant failures to a great extent

DELAYED UNIONFracture takes more than the usual time to unite.

Delayed union means waiting delayed, ie fractures united within 3-6 months. there were no new bone growth, even if

there is very little, callus (cartilage) in the vicinity of the fault is very less.

Causes Inadequate blood supply Severe soft tissue damageImproper fixationExcessive tractionInfectionMetabolic disturbances ( hyperparathyroidism)

Clinical features Fracture tenderness (Esp when subjected to stress)

X-Ray Visible fracture line Very little callus formation or periosteal reaction

Severe soft tissue damage Infection Excessive

traction

Treatment Conservative

- To eliminate any possible cause - Immobilization - Exercise Operative - Indication : Union is delayed > 6 mths No signs of callus formation

- Internal fixation & bone grafting

NON-UNION Condition when the fracture will never unite without intervention non-union means not fused or no unification, non union is an advanced

case of delayed union. So, if the fracture is not integrated within 6-8 months of so-called non-union.

Healing has stopped.Fracture gap is filled by fibrous tissue (pseudoarthrosis)

Causes Improper Treatment of delayed union Too large a gap Interposition of periosteum, muscle or cartilage between the

fragments

Clinical features Painless movement at the fracture site

X-Ray Fracture is clearly visible Fracture ends are rounded, smooth and sclerotic Atrophic non-union : - Bone looks inactive

(Bone ends are often tapered / rounded) - Relatively avascular Hypertrophic non-union : - Excessive bone formation

` - on the side of the gap - Unable to bridge the gap

Hypertrophic non-union Atrophic non-union

Treatment Hypertrophic non-union (Esp long bone) → Rigid fixation (internal / external)

sometimes need bone grafting Atrophic non-union

→ Fixation & bone grafting

MALUNION

Condition when the fragments join in an unsatisfactory position (unaccepted angulation, rotation or shortening)

Causes Failure to reduce a fracture adequately Failure to hold reduction while healing proceeds Gradual collapse of comminuted or osteoporotic bone. injury to the epiphyseal area in young animals

Clinical features Deformity & shortening of the limb Limitation of movements

Treatment Angulation in a long bone (> 15 degrees)

→ Osteotomy & internal fixation Marked rotational deformity

→ Osteotomy & internal fixation

JOINT STIFFNESS Common complication of fracture Tx following

immobilization

Common site : knee, elbow, shoulder, small joints of the hand

Causes Oedema & fibrosis of the capsule, ligaments, muscle around the

joint Adhesion of the soft tissue to each other or to the underlying bone

(intra & peri-articular adhesions) Synovial adhesions d/t haemarthrosis

Treatment Prevention :

- Exercise- If joint has to be splinted → Make sure in correct position

Joint stiffness has occurred:- Prolonged physiotherapy- Intra-articular adhesions → Gentle manipulation under anaesthesia followed by continuous passive motion- Adherent or contracted tissues → Released by operation

AVASCULAR NECROSIS Circumscribed bone necrosis

Causes Interruption of the arterial blood flow It is a common complication when the fracture

involves the articular end of a bone fractured fragment is devoid of soft tissue

attachments and depends entirely on intramedullary circulation for nutrition.

excessive periosteal stripping during surgical intervention

Clinical features Joint pain, stiffness, swelling

X-Ray The adjoining normal bone, however, shows the

signs of demineralization due to hyperaemia. The adjacent normal bone appears to be

mottled while the avascular bone retains its original appearance.

However, gradually the avascular bone loses its original appearance and ultimately collapses into an irregular mass

end result will be non-union, and osteoarthritis

Treatment early and rigid fixation can prevent avascular

necrosis. If extensive soft tissue damage, excision of

avascular fragments is indicated. Excision arthroplasty can minimize the changes

and disorganization of the adjacent joint surfaces and maintains the functional activity by formation of false joint in cases of fractures of the femoral head and neck

SHORTENING OF THE BONECause Loss of bone following comminuted and multiple

fracture Overriding of fracture fragment Injury to epiphyseal plate

Treatment Prevented by using proper reduction and fixation

techniques In bone loss use of bone graft

DEFINITION OF OSTEOMYELITIS The root words osteon (bone) and myelo (marrow)

are combined with itis (inflammation)

Osteomyelitis is an infectious process that involves bone and its medullary cavity which leads to a subsequent Inflammatory process.

Greene,W. Netter’s Orthopaedic 1st ed

CLASSIFICATION Based on onset

Acute Chronic

Source of infectionHematogenous ContagenousDirect Infection

Apley’s System Of Orthopaedics And Fractures 8th Edition

Port D’ entry

Contagenou

s

Hematogeno

usDirect infecti

on

ACUTE OSTEOMYELITIS• Acute haematogenous osteomyelitis is

mainly a disease of children

• Etiology: Staph. aureus, gram-negative bacili, group B streptococcus


Infection in the metaphysis may spread towards the surface, to form a subperiosteal abscess

Some of the bone may die, and is encased in periosteal new bone as a sequestrum

The encasing involucrum is sometimes perforated by sinuses


`• Vascular congestion• Exudation of the fluid• Infiltrating by PMNInflammation•Pus form within the bone and forces it way along the Volkman canal to the surface where it produce subperiosteal abcessSuppuration

• Bone death sequstraBone Necrosis

• New bone forms from the deep layers of the periosteum involucrum

Reactive new bone formation

• In some cases, remodelling may restore the normal contour; •In others, the bone is left permanently deformed

Resolution or chronic

Pathology


SIGN & SYMPTOMS Signs and symptoms can vary significantly. The patient, usually a child, presents with

severe pain, malaise and a fever In infants, elderly patients, or

immunocompromised patients, clinical findings may be minimal.

Pain and local tenderness are common findings.


LABORATORY The most certain way to confirm the clinical

diagnosis is to aspirate pus from the metaphyseal subperiosteal abscess or the adjacent joint.

The WBC and CRP values are usually high. Blood culture is positive in only about half

the cases of proven infection.


IMAGING PLAIN X-RAY

Standard radiographs generally are negative, but may show soft-tissue swelling.

Skeletal changes, such as periosteal reaction or bone destruction, generally are not seen on plain films until 10 to 12 days into the infection

The first x-ray, 2 days after symptoms began, is normal – it always is; metaphyseal mottling and periosteal changes were not obvious until the second film, taken 14 days later; eventually much of the shaft was involved.Apley’s System Of Orthopaedics And Fractures 9th Edition

Soft tissue swelling (early), bone demineralization (10-14 days), sequestra (dead bone with surrounding granulation tissue), and involucrum (periosteal new bone) later.

MRI : extremely sensitive, even in the early phase of bone infection, and can help to differentiate between soft-tissue infection and osteomyelitis.

Radioscintigraphy Sensitive but not specific.

Apley’s System Of Orthopaedics And Fractures 9h Edition

MANAGEMENT Supportive treatment for pain and dehydration Splintage of the affected part Antibiotic therapy Surgical drainage


COMPLICATION Suppurative arthritis Pathological fracture Chronic osteomyelitis


CHRONIC OSTEOMYELITIS Chronic osteomyelitis represents a

continuation of unresolved acute infection

Now days, it more frequently follows an open fracture or operation.

Usual organisms are staphylococcus aureus, Escherichia coli, Streptococcus pyogens, Proteus and Pseudomonas.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

STAGING FOR ADULT CHRONIC OSTEOMYELITIS BY CIERNY ET AL. (2003)


PATHOLOGY Bone is destroyed or devitalized in a discrete

area at the focus of infection.

Cavities containing pus and pieces of dead bone (sequestra) are surrounded by vascular tissue, and beyond that by areas of sclerosis the result of chronic reactive new bone formation.

The histological picture is one of chronic inflammatory cell infiltration around areas of acellular bone or microscopic sequestra.


DIAGNOSIS

BIOPSY “Gold

Standard”

IMAGING

LABORATORY

CLINICAL


CLINICAL FEATURES Pain, pyrexia, redness and tenderness have

recurred, or with a discharging sinus.

There may be a sero-purulent discharge and excoriation of the surrounding skin.


LABORATORY ESR and white blood cell count may be

increased Organisms cultured from discharging sinuses

should be tested repeatedly for antibiotic sensitivity.


IMAGING X-ray examination

Bone resorption with thickening and sclerosis of surrounding bone

However, there are marked variation: there may be no more than localized loss of trabecculation, or a area osteoporosis, periosteal thickening, sequestra show up as unnaturally dense fragments.


Radioscintigraphy Sensitive but not specific.

CT and MRIShow the extent of bone destruction and reactive edema, hidden abscess and sequestra


MANAGEMENT Antibiotics Operation :

Debridement Dealing with the dead space Soft tissue cover


COMPLICATION A pathologic fracture Non union or segmental bone loss


DISCUSSION Diagnose of femoral middle fractures obtained

by history, physical examination, such as look (see), feel (palpable), and move (driven), as well as the necessary investigations, such as X-ray photographs.

• 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.

autoanamnesis

• 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.

physical examinati

on

• X-ray looked from femur sinistra there are non union 1/3 middle os. Femur sinistra and osteomyelitis

X-ray

CHAPTER VCONCLUSSION

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.

http://www.medscape.com/resource/fracture

http://emedicine.medscape.com/article/86808-overview

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, both local and systemic factors.

The process of fracture healing is broadly be divided into five phases, namely phase hematoma (swelling), the proliferative phase, the phase of callus, consolidationand remodeling.

Late ComplicationsLocal:Delayed Union Non-union MalunionJoint stiffnessContracturesAvascular necrosisOsteomielitis

THANK YOU

Ppt Lapsus

Documents

Transcript of Ppt Lapsus