CASE WRITE UP : FRACTURE SHAFT OF FEMUR

CASE WRITE UP : FRACTURE SHAFT OF

FEMUR

PATIENT PROFILE :

Name: Mr C
Age: 42 years old
Sex: Male
Race: Malay
Address: Melaka
Occupation: Factory worker
Date of Admission: 1st June 2009
Date of Examination: 3rd June 2009

CHIEF COMPLAINTS :

Pain at the right thigh for 1 day.

Swelling at the right thigh for 1 day.

HISTORY OF PRESENTING ILLNESS :

Patient was apparently well since 2 day ago when he was involved in a motor
vehicle accident. He was riding his motorcycle with a helmet on, at a speed of 50
km/hour when suddenly a car in front of him applied the brakes. Patient then hit the car
at the back and fell with his bike and his right lower limb got stuck under his motorcycle.
Patient had bruises on the medial side of his right thigh and lacerations on the lateral

aspect of his right thigh and he was bleeding profusely. Patient noticed a deformity of his
right thigh of which he could see his bone protruding. Patient was then brought to the
A&E department by car and suturing was done for the laceration on the lateral aspect of
his right thigh. He was given analgesics for the pain and X-ray was taken.

Patient felt pain at his right thigh for 2 days which was maximally felt at the
proximal 2/3rd, sudden in onset, severe, continuous, and throbbing type, which
progressively worsened. There was no radiation of pain. The pain increases upon
movement of the limb. The pain is relieved upon rest.

Swelling was present throughout the whole right thigh. The swelling was seen
immediately after the accident with no progression.

Patient was also unable to bear his own weight and was unable to walk following
the accident.

There is no history of loss of consciousness, no vomiting, no headache, no

blurring of vision or breathlessness, bleeding from ears, nose, and throat, and no injuries
sustained to other parts of his body. There is no loss of sensation or any skin changes
distal to the site of swelling. There is no associated breathing difficulty or abdominal
pain following the accident.

PAST HISTORY :

Patient has no significant past history, no past history of allergy to any drugs.
No history of diabetes mellitus, hypertension, ischemic heart disease, asthma,
malignancies or tuberculosis.

PERSONAL HISTORY :

Patients sleep has been disturbed due to the pain. He has also lost his appetite since
admission to hospital. Patient is catheterized and has not passed stools since admission.

Patient has been smoking for the past twenty years and he smokes 10 sticks per day.
Patient does not consume alcohol and there is no history of drug abuse.

FAMILY HISTORY :

Patients father passed away due to old age of which patient is not aware of the cause.
Patient has two siblings who are alive and well.
There is no family history of diabetes mellitus, hypertension, ischemic heart disease or
tuberculosis.

SOCIAL HISTORY :

Patient stays in a terrace house which has 3 rooms with 2 toilet of both squatting and
sitting type and lives with 5 of his friends and is about 30 minutes drive away from the
hospital. Patient earns around RM 1200 per month.

Working Diagnosis :
1. Post traumatic, displaced, open fracture of the middle 1/3 rd of shaft of right femur
without any neurovascular deficit.
Reasons: Injury after direct impact on the right thigh, open wound, pain at proximal
2/3rd and swelling at the right thigh and inability to bear weight indicates fracture. There
is deformity at the right thigh. There is no loss of sensation or skin discolouration distal
to the swelling.

2. Post traumatic, displaced, open fracture of the upper 1/3rd of shaft of right femur without
any neurovascular deficit.
Reasons: Injury after direct impact on the right thigh, open wound, pain at proximal
2/3rd and swelling at the right thigh and inability to bear weight indicates fracture. There
is deformity at the right thigh. There is no loss of sensation or skin discolouration distal
to the swelling.

EXAMINATION

GENERAL EXAMINATION :

Patient is conscious, co-operative, moderately built and moderately nourished,

lying down in supine position. There is an iv cannula inserted on the dorsum of his left
hand. There is an upper tibial skeletal traction with a 5kg weight attached to it.
There is no pallor, icterus, cyanosis, finger clubbing, and no lymphadenopathy. There is
no spine tenderness. There is bruises on his medial side of right thigh and laceration on
the lateral side of his right thigh.

Vital signs :
Blood pressure: 126/86 mmHg
Pulse: 78 beats/ min
Respiratory Rate: 20/ min
Temperature: 37 C

SYSTEMIC EXAMINATION :

Cardiovascular Examination:
S1, S2 heard, no murmurs heard.

Respiratory Examination:
Vesicular breathing heard with no added sounds.

Abdominal Examination:
No abdominal tenderness, no organomegaly.

Bowel sounds heard.

Central nervous system:
Grossly intact.

LOCAL EXAMINATION :

Inspection :
Gait - Could not be assessed as patient was on traction.
Attitude - Patient was supine with right hip flexed 30 degrees and internally
rotated, right knee flexed twenty degrees and right ankle plantar flexed
twenty degrees.
Deformity - No deformity seen
Skin - There are abrasions on the upper part of medial aspect of his right thigh
measuring about 10cm 7cm which has been dressed. The right thigh
appears swollen. There are signs of inflammation. There are no sinuses or
ulcer or dilated veins.
Limb length discrepancy - There is no limb length discrepancy seen.

Palpation :
Temperature - There is a rise of temperature of his right thigh in comparison to
other parts of the body.
Tenderness - There is bony tenderness present on the upper 2/3 rd of his right
thigh.
There is no thickening and irregularity or any gap felt.
Swelling - There is diffuse swelling of the whole right thigh.
There is no abnormal mobility or crepitus.

Movements :
Patient could not move the right limb as he was on traction and due to tenderness.

Movements

Left

Right

Active

Passive

Active

Passive

Flexion

0 - 130

0 - 130

Restricted

Restricted

Extension

Restricted

Restricted

Abduction

0 - 40

0 - 40

Restricted

Restricted

Adduction

0 - 20

0 - 20

Restricted

Restricted

External
Rotation

0 - 45

0 - 45

Restricted

Restricted

Internal
Rotation

0 - 30

0 - 30

Restricted

Restricted

Flexion

0 - 130

0 - 130

Restricted

Restricted

Extension

Restricted

Restricted

Dorsiflexion

0 - 30

0 -30

0 - 20

0 -20

Plantar flexion

0 - 45

0 -45

0 - 20

0 -20

Inversion

0 - 40

0 - 40

Restricted

Restricted

Eversion

0 - 40

0 - 40

Restricted

Restricted

Hip joint

Knee joint

Ankle joint

Subtallar
joint

Movement of
toes

Full range

Full range

Full range

Full range

Measurements :

Measurements

Right

Left

108 cms

110cms

True length (Anterior

Superior iliac spine to
medial malleolus)

84cm

86cm

Femur length (Anterior

Superior iliac spine to
medial joint line)

50cm

52cm

Tibial length (Medial joint

line to medial malleolus)

34cm

34cm

Thigh circumference

48cm

46cm

Apparent length
(xiphisternum to medial
malleolus

Distal neurological status :

There is no distal neurological deficit. Active range of movements of toes and ankle
present and there is no loss of sensation of the lower limbs. Muscle power grade V.

Distal vascular status :

There is no distal vascular deficit. Dorsalis pedis artery and posterior tibial artery could
be felt and there is no distal limb coldness and capillary feeling time is less than 3
seconds on both lower limbs.

Differential Diagnosis :

Post traumatic, open fracture of the upper 1/3 rd of the shaft of the right femur
without any neurovascular deficit.
Reasons: Injury after direct impact on the right thigh, open wound on upper part of
medial aspect of thigh, pain at the upper 1/3rd of thigh, and shortening. Swelling and
bony tenderness at the upper 1/3rd of the femur indicates fracture of the right femur.
There is no loss of sensation or skin changes distal to the site of fracture.

Post traumatic, open fracture of the middle 1/3 rd of the shaft of the right femur
without any neurovascular deficit.
Reasons: Injury after direct impact on the right thigh, open wound on upper part of
medial aspect of thigh, pain at the middle 1/3 rd of thigh, and shortening. Swelling and
bony tenderness at the middle 1/3rd of the femur indicates fracture of the right femur.
There is no loss of sensation or skin changes distal to the site of fracture.

Investigations :

Full blood count, WBC, RBC, Hb, HCT, MCV, MCH, MCHC, platlet, lymphocyte, blood
sugar levels, blood urea and serum electrolytes.

Plain x-ray of skull, pelvis and right thigh with hip joint, both anterior-posterior and
lateral view was done. Plain x-ray of right thigh with hip joint showed fracture at the
upper 1/3rd of the shaft of right femur. Plain x-ray of skull and pelvis were normal.

Patient on tibial skeletal traction

This is the anterposterior view of the right femur showing a comminuted fracture of the upper 1/3 rd of right
shaft of femur.

FINAL DIAGNOSIS :

Post traumatic, displaced, comminuted, open fracture of the upper 1/3 rd of the
shaft of the right femur without any neurovascular deficit.