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FRACTURE

MIDSHAFT OF FEMUR

INTRODUCTION
A # may be a complete break in the continuity
of a bone or it may be an incomplete break or
crack.

SIGNS & SYMPTOMS


- The most common signs & symptoms are :
Pain around the injured area.
Swelling around the injured area.
Loss of function around the injured area.
Bruising around the injured area.
Deformity of the limb.

CLASSIFICATION
1. Open / compound #.
when there is a wound of the skin surface
leading down to the site of #.

when a direct communication exists


between the body surface & the fractured
bone ends
2. Closed / simple #.

when there is no communication between


the site of # & the exterior of the body.

is free from that risk.

PATTERNS OF FRACTURE

DR MANAGEMENT
1. Conservative management
Close manipulative reduction (CMR)
followed by POP
b) Traction
skin traction
skeletal traction
2. Surgical management
) Dynamic hip screw (DHS)
) K-Nail/intramedullary nail (IMN)
) Interlocking nail (ILN)
) Screw & plate
a)

PT MANAGEMENT
a)

b)
c)
d)

e)
f)

g)

Active free exs / mechanical resisted /


manual resisted exs.
Static gluteus.
Static quads of the immobilized limb.
Active free exs / manual resisted exs
for non immobilized joints of the
affected limb.
breathing exercise & coughing.
Isometric muscle contraction for the
immobilized limb.
Teach crutch walking & maneuvering
up & down steps curbs & slopes.

a)

b)

c)
d)

Swelling : Massage, exercise &


elevation.
Exercise : Assisted active to free active
exercise.
Ensure full support at the # site.
Ambulation : PWB/NWB ambulation
depends on the type of surgery.

CASE STUDY
PATIENTS PARTICULAR :
Unit : Orthopedic
Name : Ms. N
Age : 14 years old
Sex : Female
No R/N : D.O.Admitted : 13th Mac 2015
D.O.Ass : 18th Mac 2015
Diagnosis : Closed # Rt. midshaft femur.
Doc. Management :
Post K-nail done on 17/3/15 for Rt femur.

SUBJECTIVE ASSESSMENT
pt c/o :
pain over anterior aspect of Rt thigh.
Pain VAS : 6/10 (rest)
Pain nature : deep aching
Pain area : anterior aspect
of Rt. Thigh
(refer to body chart)

Aggravating : movement of the Rt. Thigh (VAS


8/10)
Ease : rest (VAS 6/10) , took about 5 minutes for
pain to reduce
24 hour behaviour:
Am
Pm
On movement / activity
Night
Irritability : medium

Present Hx:
admitted in ward on 13/3/15 due to alleged
MVA (MB vs Car) at 6.00pm on 13/3/15.
Past Hx:
Nil
PMHx/PSHx :
Nil
Medication :
Nil
Family history :

NIL

Social Hx :
Form 2 students.
non smoker & non alcoholic
stay with parents.
single storey house.
toilet : sitting
Ix/MRI/x-ray :
x-ray : on 13/3/15 :
closed # midshaft Rt. Femur
On 17/3/15 :
Post K-nail Rt. femur

OBJECTIVE ASSESSMENT
General observation :
pt on POD 1
Malay woman, middle body size, 16 yrs old
pt lying on his bed
pt alert & co-operative
abrasion wound at lat. aspect of Lt arm.
Local observation :
no muscle wasting
swelling at Rt. thigh & calf muscle.
Redness at operation site of Rt. thigh

Palpation :
slightly in local temperature at operation
site.
tenderness around the operation site.

Measurement ROM :
generally both UL : AFROM
generally Lt. LL : AFROM
for Rt. LL ( in supine lying position)
Hip flex w kn. bending
Hip abduction
Hip adduction
Knee flexion
Knee extension
Ankle plantarflexion
Ankle dorsiflexion

Active

Passive
-

unable to
do d/t pain

FROM
FROM

Muscle power : (in sup. lying pos.)


Left
Iliopsoas
Gluteal medius
Adductor muscle
Hamstring
Quadriceps
Tibialis anterior
Gastrocnemius

5/5

Right
unable
to do
d/t pain
3/5

Limb girth/muscle bulk : (in cm)


From sup border of patella
- Vastus medialis (5cm)
- Quadricep( 10cm)
- Hamstring (15cm)

Left
46.5
50.5
55.5

Right
50.5
54.5
60.0

Diff
3.5
4.0
4.5

Left
39.5

Right
40.0

Diff
0.5

Rt > Lt swelling
From head of fibula
Calf muscle (10cm)
Rt > Lt swelling

Leg length : (in cm)


Left

Right

Diff

93

92

100

99

TRUE LIMB LENGTH

- ASIS to med. malleolus


APPARENT LIMB LENGTH

- Umbilicus to med.
malleolus
Normal

ANALYSIS
Problem listing :
pain due to # & operation.
swelling LL due to inflammation.
limited ROM of hip & knee joint due to pain.
muscle weakness due to pain.
Short term goals :
to maintain clear airway.
to reduce swelling.
to increase ROM at affected side ( hip &
knee joint)

to maintain ROM at unaffected side (Lt. LL) &


both UL
to improve muscle strength of Rt. LL
to encourage pt. ambulation.
Long term goals :
to regain functional ability ADL.

PLAN OF TREATMENT
Deep breathing exercise.
Active free exercise.
Stretching exercise.
Strengthening exercise.
Circulatory exercise
Ambulate pt.

Intervention :
1) Deep breathing exercise.
- pt in lying position.
- do 5x/hrly/day
2) Incentive spirometer
-sit up in bed
-10x/hourly
3) Active free exercise for both UL & Lt. LL.
- pt. in lying position.
- for UL sh.flex through elevation, sh.abd.
& add., elb.flex & ext, hand grip.
- for Lt LL hip & knee flex, SLR, hip abd &
add.
- do 5x/hrly/day

4) Circulatory exercise for both feet.


- pt in lying position.
- do ank.dorsiflex & plantarflex actively &
movement of toes.
-10 rep/3 set/hourly/day
5) Static quads exercise(SQE) for Lt. knee.
- pt in lying position.
- ask pt to press down knee & hold 10 sec.
- do hold 10 sec./5x/hrly/day.
6) Encourage pt to do DBE, active free exercise for
both UL & Lt. LL, circulatory exercise, SQE.
* do every exercise 5x /hrly/day.

Evaluation :

pt able to do all exercise given.

Review :

reassess pain scale,ROM,muscle


power,limb girth.

PROGRESSION NOTE :
19/03/2015
S
O
same as initial assessment
A
P
Intervention : Cont. the same treatment
1) Deep breathing exercise.
- do 5x/hrly/day.
2) Incentive spirometer
- do 10x/hourly
3) Active free exercise for both UL & Lt. LL.
- do 5x/hrly/day.

4) Circulatory exercise for both feet.


- do 5x/hrly/day.
5)Static quads exercise for both knee.
- do hold 10 sec/5x/hrly/day.
6) Encourage pt to do DBE, active free
exercise for both UL & Lt LL, circulatory
exercise, SQE
7) Ambulate pt.
-transfer from bed to wheelchair.