CHAPTER I

INTRODUCTION

Femoral fracture is the most common orthopedic injuries of children and required hospitalization. Epidemiological studies from Indiana in 2006 mentioned from almost 10.000 femoral fracture, 1076 (11%) occurred in children aged less than 2 years, 2119 (21%) in children aged 2 to 5 years, 3237 (33%) in children aged 6 up to 12 years, and 3528 (35%) in adolescents aged 13 to 18 years. 71% of incident femoral fracture occurred in males with two-thirds cause of the motorcycle accident. Incidence of fall drive greater occurred in young people and incidence of collision was more common in adults. 15% of femoral fractures occurred in children less than 2 years due to child abuse.1

Pediatric femoral fracture is one of the most prevalent kinds of fractures with an incident rate of 1.6% and about 4% of them are open fractures and most of these fractures (90%) are resulted from high energy trauma. Studies also show that these fractures are associated with more complications. Therefore, it is important to do special treatment as well as improved safety for children considering the complications due to a femoral fracture seriously can cause shock, a fat embolism and disruptions of growth if there is epiphysis plate injury. The following will discuss about the treatment of femoral fracture on children.1-2CHAPTER II

REVIEW OF LITERATUREA. FEMUR ANATOMY

Thefemur, the longest and strongest bone in the skeleton, is almost perfectly cylindrical in the greater part of its extent. In the erect posture it is not vertical, being separated above from its fellow by a considerable interval, which corresponds to the breadth of the pelvis, but inclining gradually downward and medialward, so as to approach its fellow toward its lower part, for the purpose of bringing the knee-joint near the line of gravity of the body. The degree of this inclination varies in different persons, and is greater in the female than in the male,on account of the greater breadth of the pelvis. The femur, like other long bones, is divisible into a bodyandtwo extremities.3

Picture 1. Right femur. Anterior surface.

The upper extremity presents for examination ahead,aneck,agreaterand alesser trochanter.

The Head (caput femoris).The head which is globular and forms rather more than a hemisphere, is directed upward, medialward, and a little forward, the greater part of its convexity being above and in front. Its surface is smooth, coated with cartilage in the fresh state, except over an ovoid depression, thefovea capitis femoris,which is situated a little below and behind the center of the head, and gives attachment to the ligamentum teres.4

Picture 2 . Upper extremity of right femur viewed from behind and above.

The Neck (collum femoris).The neck is a flattened pyramidal process of bone, connecting the head with the body, and forming with the latter a wide angle opening medialward. The angle is widest in infancy, and becomes lessened during growth, so that at puberty it forms a gentle curve from the axis of the body of the bone. In the adult, the neck forms an angle of about 125 with the body, but this varies in inverse proportion to the development of the pelvis and the stature. In the female, in consequence of the increased width of the pelvis, the neck of the femur forms more nearly a right angle with the body than it does in the male. The angle decreases during the period of growth, but after full growth has been attained it does not usually undergo any change, even in old age; it varies considerably in different persons of the same age. It is smaller in short than in long bones, and when the pelvis is wide. In addition to projecting upward and medialward from the body of the femur, the neck also projects somewhat forward; the amount of this forward projection is extremely variable, but on an average is from 12 to 14.3-4The Trochanters.The trochanters are prominent processes which afford leverage to the muscles that rotate the thigh on its axis. They are two in number, the greater and the lesser.

TheGreater Trochanter(trochanter major; great trochanter) is a large, irregular, quadrilateral eminence, situated at the junction of the neck with the upper part of the body. It is directed a little lateralward and backward, and, in the adult, is about 1 cm. lower than the head. It has two surfaces and four borders. Thelateral surface,quadrilateral in form, is broad, rough, convex, and marked by a diagonal impression, which extends from the postero-superior to the antero-inferior angle, and serves for the insertion of the tendon of the Glutus medius. Above the impression is a triangular surface, sometimes rough for part of the tendon of the same muscle, sometimes smooth for the interposition of a bursa between the tendon and the bone. Below and behind the diagonal impression is a smooth, triangular surface, over which the tendon of the Glutus maximus plays, a bursa being interposed. Themedial surface,of much less extent than the lateral, presents at its base a deep depression, thetrochanteric fossa(digital fossa), for the insertion of the tendon of the Obturator externus, and above and in front of this an impression for the insertion of the Obsturatorinternus and Gemelli. Thesuperior borderis free; it is thick and irregular, and marked near the center by an impression for the insertion of the Piriformis. Theinferior bordercorresponds to the line of junction of the base of the trochanter with the lateral surface of the body; it is marked by a rough, prominent, slightly curved ridge, which gives origin to the upper part of the Vastus lateralis. Theanterior borderis prominent and somewhat irregular; it affords insertion at its lateral part to the Glutus minimus. Theposterior borderis very prominent and appears as a free, rounded edge, which bounds the back part of the trochanteric fossa.TheLesser Trochanter(trochanter minor; small trochanter) is a conical eminence, which varies in size in different subjects; it projects from the lower and back part of the base of the neck. From its apex three well-marked borders extend; two of these are aboveamedial continuous with the lower border of the neck, alateralwith the intertrochanteric crest; the inferior borderis continuous with the middle division of the linea aspera. Thesummitof the trochanter is rough, and gives insertion to the tendon of the Psoas major.The Body or Shaft (corpus femoris).The body, almost cylindrical in form, is a little broader above than in the center, broadest and somewhat flattened from before backward below. It is slightly arched, so as to be convex in front, and concave behind, where it is strengthened by a prominent longitudinal ridge, thelinea aspera.It presents for examination three borders, separating three surfaces. Of the borders, one, the linea aspera, is posterior, one is medial, and the other, lateral.Thelinea asperais a prominent longitudinal ridge or crest, on the middle third of the bone, presenting a medial and a lateral lip, and a narrow rough, intermediate line. Above, the linea aspera is prolonged by three ridges. The lateral ridge is very rough, and runs almost vertically upward to the base of the greater trochanter. It is termed thegluteal tuberosity,and gives attachment to part of the Glutus maximus: its upper part is often elongated into a roughened crest, on which a more or less well-marked, rounded tubercle, thethird trochanter,is occasionally developed. The intermediate ridge orpectineal lineis continued to the base of the lesser trochanter and gives attachment to the Pectineus; the medial ridge is lost in the intertrochanteric line; between these two a portion of the Iliacus is inserted. Below, the linea aspera is prolonged into two ridges, enclosing between them a triangular area, thepopliteal surface,upon which the popliteal artery rests. Of these two ridges, the lateral is the more prominent, and descends to the summit of the lateral condyle. The medial is less marked, especially at its upper part, where it is crossed by the femoral artery. It ends below at the summit of the medial condyle, in a small tubercle, theadductor tubercle,which affords insertion to the tendon of the Adductor magnus.Theanterior surfaceincludes that portion of the shaft which is situated between the lateral and medial borders. It is smooth, convex, broader above and below than in the center. From the upper three-fourths of this surface the Vastus intermedius arises; the lower fourth is separated from the muscle by the interventionof the synovial membrane of the knee-joint and a bursa; from the upper part of it the Articularis genu takes origin. Thelateral surfaceincludes the portion between the lateral border and the linea aspera; it is continuous above with the corresponding surface of the greater trochanter, below with that of the lateral condyle: from its upper three-fourths the Vastus intermedius takes origin. Themedial surfaceincludes the portion between the medial border and the linea aspera; it is continuous above with the lower border of the neck, below with the medial side of the medial condyle: it is covered by the Vastus medialis.The Lower Extremity (distal extremity)

The lower extremity, larger than the upper, is somewhat cuboid in form, but its transverse diameter is greater than its antero-posterior; it consists of two oblong eminences known as thecondyles.In front, the condyles are but slightly prominent, and are separated from one another by a smooth shallow articular depression called thepatellar surface;behind, they project considerably, and the interval between them forms a deep notch, theintercondyloid fossa.Thelateral condyleis the more prominent and is the broader both in its antero-posterior and transverse diameters, themedial condyleis the longer and, when the femur is held with its body perpendicular, projects to a lower level. When, however, the femur is in its natural oblique position the lower surfaces of the two condyles lie practically in the same horizontal plane. The condyles are not quite parallel with one another; the long axis of the lateral is almost directly antero-posterior, but that of the medial runs backward and medialward. Their opposed surfaces are small, rough, and concave, and form the walls of the intercondyloid fossa. This fossa is limited above by a ridge, theintercondyloid line,and below by the central part of the posterior margin of the patellar surface. The posterior cruciate ligament of the knee-joint is attached to the lower and front part of the medial wall of the fossa and the anterior cruciate ligament to an impression on the upper and back part of its lateral wall. Each condyle is surmounted by an elevation, the epicondyle. Themedial epicondyleis a large convex eminence to which the tibial collateral ligament of the knee-joint is attached. At its upper part is the adductor tubercle, already referred to, and behind it is a rough impression which gives origin to the medial head of the Gastrocnemius. Thelateral epicondyle,smaller and less prominent than the medial, gives attachment to the fibular collateral ligament of the knee-joint. Directly below it is a small depression from which a smooth well-marked groove curves obliquely upward and backward to the posterior extremity of the condyle. This groove is separated from the articular surface of the condyle by a prominent lip across which a second, shallower groove runs vertically downward from the depression. In the fresh state these grooves are covered with cartilage. The Popliteus arises from the depression; its tendon lies in the oblique groove when the knee is flexed and in the verticalgroove when the knee is extended. Above and behind the lateral epicondyle is an area for the origin of the lateral head of the Gastrocnemius, above and to the medial side of which the Plantaris arises.

Picture 2a. Lower extremity of right femur viewed from below.

B. DEFINITION OF FRACTUREFracture is the breaking continuity of the bones tissues determined according to the type and extent usually caused by the forced movement or external pressure which comes greater than what is acceptable by bone.1,3,5To find out why and how the bone fractures occur, physical condition of bone and traumatic circumstances that can lead to bone fractures must be known in advance. Cortical bone has a structure that can withstand the compression and the pressure of shearing.

Most of fracture occurs due to failure of the bone hold the bending, twisting, and pulling of trauma that is directly or indirectly. Immediate trauma causing pressure directly on bone and fracture occurs in the area of pressure. A fracture that occurs usually tends to be comunitive and soft tissue are also damaged while the indirect trauma occurs when the trauma delivered to areas further away from the fractures, for example fell by hand extensions can cause fracture of clavicle. In these circumstances typically soft tissue remains intact.Pressure on the bones can be in form of : (1) rotating pressure that can causes oblique or spiral fracture, (2) bending pressure causing transversal fracture, (3) the pressure along the length of the bone that can lead to impaction fracture or dislocation, (4) vertical compression fracture can cause comunitive or split fracture, for example on the vertebrae, (5) direct trauma accompanied with resistance at a certain distance will cause an oblique fracture or Z fracture, (6) trauma due to the pull of the ligaments or tendons will draw some bones.6C. CLSSIFICATION OF FRACTUREFracture can be distinguished based on the connection with the surrounding bone tissue, bone fracture shape, and location of the physical bones.5Based on the connection of bone with surrounding bone tissue:1. Closed fracture : there is no connection between the bone fragments with the outside bone.

2. Open fracture : when there is a connection between the bone fragments with outside bone due to an injury of the skin.

D. FEMORAL FRACTUREFemoral fracture is the break of bone continuity groin can be caused by direct trauma (traffic accidents, falls from high place), muscle fatigue and certain conditions such as osteoporosis /degeneration of bone. There are 2 types of femur fracture : 31. Intracapsuler fracture : fracture that occurs in the joints, the pelvic and the capsule.

a. through the head of the femur (capital fracture)

b. Only below of the head femur

c. Through the neck of the femur2. Extracapsuler Fracture;a. Occur outside of the joint and capsule, through the larger trochanter femur / smaller/ on intertrochanter area.b. Occurs in the distal part of the femur to the neck but not more than 2 inches below the small trochanter.

E. ETIOLOGY OF FEMORAL FRACTURES Based on the causes of femoral fractures, can be divided into three based on major of trauma causes:1. High energy trauma or trauma due to considerable energy, the type of accidents that cause this type of fracture including vehicle accident trauma (accident motorcycle, car accidents, plane crashes, etc.); sports-especially those related to speed such as: skiing, bike racing, mountain climbing; falling, falling from a high place; and gunshot wounds.

2. Low energy trauma or trauma due to weak energy, because the structure of the femur is strong enough structures, there is a tendency trauma due to weak energy is mainly due to loss of bone strength, especially in people who experience a decrease in bone density due to osteoporosis; bone metastasis of cancer patients and people taking long-term corticosteroids are also at high risk of femur fractures for bone strength will be reduced.

3. Stress fracture or fracture due to pressure, the third cause of femur fractures is repeated stress or trauma. This kind of trauma resulting in different types of fractures as usually happens gradually. Repetitive stress trauma resulting in internal damage of the structure of bone architecture. This type of fracture often occurs on athletes or on the military people who undergo weight training. This type of fracture typically affects the area of the corpus femoris.F. PATHOPHYSIOLOGY OF FRACTUREChildren fracture is usually as a result of trauma from motor vehicle accidents, falls, or soft on child maltreatment. Soft tissue is usually still flexible, so that fractures occur more frequently than tissue injury (Muscari, 2001). Fractures can be also caused by the impulse directly on bone, underlying pathological condition such as rickets which lead to spontaneous fractures, strong and sudden muscle contraction, and another indirect encouragement (Betz and Sowden, 2004). Another causes are metastatic of neuroblastoma, embryo deficiency, osteomyelitis, an injury due to overdose and immobilization which leads to osteoporosis.These fractures occur when bone resistance against pressure transported by the pressure force. The most common fractures seen in children are:71. Bend Fracture

Characterized by bending at the point of the broken bones and cannot be corrected without intervention.

2. Buckle Fracture

Caused by compression of the bone failure characterized by bones that break through himself

3. Greenstick Fracture

An incomplete fractureFractures usually causes bone cells will be damaged and causes bleeding in the area of the fracture that cause multiple fractures of the soft tissue in the area are damaged. When a fracture occurs, it will activate the inflammatory response and causes the release of leukocytes agent, white blood cells, and mast cells to repair the fracture condition. The release of the inflammatory agent causes an increase in blood flow to the area of the fracture and causes vasodilatation of blood vessels in the area that causes the heat, redness and swelling. As the inflammatory response, fibrin will form a mesh for new cells and cause stimulated ostevlas and will form callus and later they will form true bone.G. CLASSIFICATION OF FEMORAL FRACTURES ON CHILDREN

1. Femoral Subtrochanter Fractures When there is a femur fracture in the area of subtrochanter, muscles come into the proximal fragment, especially partially illiopsoas and gluteus muscles that form the position of flexion, external rotation, and abduction.8-9

Picture 3. Photo of anteroposterior, proximal fragment flexion 90 degrees so it looks medullary cavity with a circular radiolucent pictureTo correct the alignment of the fracture, skeletal traction should be given continuously to pull the distal part into skeletal traction in line posititon. Position of skeletal traxy come into the distal metaphysis of the femur bone with a thigh flexion, external rotation, and abduction. Mostly subtrocanter femoral fractures occur on children who aged more than 10 years. At this age, they can use the locked intramedullary rod or ORIF with the nail plate.

Picture 4. Skeletal traction with pins inserted into

the distal femoral metaphysic.

Picture 5. subtrochanter femur fractures corrected with ORIF with screw and plate nail.2. Femur Neck Fractures

a. Frequency and Mechanism of InjuryThe femur neck on children is very strong unlike adults, just great trauma that can cause fracture. Femoral neck Fracture is a rare type of fracture but requires serious handling. Fracture around the hip joint due to a force such as high-energy trauma, or in rare circumstances often associated with pathological condition. Femoral neck fracture is also often associated with violence against children (child abuse). The incidence of femoral neck fractures on children is less than 1%. These fractures can occur on children of all ages, but the highest incidence at the age of 11 years and 12 years, with 60-70% occur in. In developing countries the most common cause is a traffic accident while in developed countries generally cause is falling from height such as trees and house roof. 30% of patients had injuries associated with chest, head, and abdomen. Injury on extremities such as femur fractures, tibia - fibula, and often pelvic. Another thing that often lead to fracture of the femur on children is child abuse.1,2,4b. classification

Fractures of the hip on children - children are classified by location and first morphology. Cromwell is the first who explained fractures of the femoral neck on children. Delbet publish standard classification of fractures of the proximal femur in 1907. This classification is not well known until Collona (1929) reported 12 cases using Delbet classification.Table 1. Classification of pelvic fractures on children (Delbet)Type ITrans epiphyseal separation (with or without dislocation of the femoral head from acetabulum)

Type IITranservical

Type IIICervikotrochantrik

Type IVIntertrokanter

Table 2. pediatric femoral neck fractures - the type and the importance characteristics Delbet type IncidenceCausesimportant characteristics

Type I8% High energy trauma

Child abuse The difficult Breech childbirth

50% of cases occur in the epiphyseal head dislocation

High risk of AVN (20-100%) when associating with epiphyseal dislocation

Differential diagnosis of septic arthritis, hip dislocation, loss of femoral head epiphysis.

Type II45%severe trauma Variation of the most widely 70-80% are displaced High risk of AVN (up to 50%). In displaced fractures, loss of reduction, malunion, non-union, varus deformity.

Type III35%Severe traumaAVN 20-25% depending on the placement at the time of injury.

Type IV12%traumaNon-Union and rarely AVN

Picture 6. Classification of proximal femur fractures on children, based on the classification of Colonna and Delbet.c. Assessment and Diagnosis

In addition, clinically diagnosis is often confusing. Usually children who are traumatized often get pain in the pelvic region and shortening, extremity rotated outwards. Children are usually fear of passive limb movement and cannot move actively. Diagnose is enforced using radiography, which is generally used on two planets photograph, if it is not painful. Sonography is also often used on condition that raises doubts e.g. pelvic pain on children. Fracture line or hematoma intracapsular can be detected using fracture ultrasound. With unknown fractures on the femur, the radiography cannot be used as supporting diagnostic. Computed tomography (CT) can be used to assess the degree of fracture and other intracapsular hematoma. A bone scan at 3 months post-injury also helps in detecting necrosis of the femoral head, which is a possible complication. Magnetic resonance imaging (MRI) detects previously avascular.In the state of femoral fractures, dorsalis pedis arterial pulsation are palpated. In femoral fracture should also be a secondary inspection because most patients only complain of pain so things that can danger life such as internal bleeding in the spleen rupture is often overlooked. Hence, the blood pressure is also important to be supervised.10d. ManagementFractures of the femoral neck on children are very unstable as like adults and cannot be done adequately handling both with closed reduction, external immobilization, or traction continuously.1 principles of management including: 11-12 Minimize the potential complications in avascular necrosis (AVN).

Avoid injury to the physical plate.

Reduction of fragments anatomically

Stabilization with pins or screws leads early protection to withstand the weight.Decompression of the hemarthrosis and stable internal fixation is an important aspect of the treatment for all fractures with the shift. Fractures were not shifting can be managed conservatively by using hip spica cast immobilization.

Based on studies conducted in 71 cases of the British Orthopedic Association reported in 1962, Ratliff said that the high incidence of non-union fractures occured in type II or type III treated conservatively. Canale and Bourland in 1974, reported that the observed fixation surgery showed better results.

According to Anil Arora (2006) treatment of traumatic fractures of the femoral neck on children is based on the type and number of shifts due to fractures, and skeletal maturity of children. Internal fixation for femoral neck fracture type I, type II, and type III, a smooth pin can be used on infants, screw cannula 4.0 mm on children; screw cannula 6.5 mm on adolescents. For type IV fracture fixation, in theory pediatric pelvic screws (pediatric hip screw) is better on children and adults pelvic screws for teenagers. Hip spica cast used a lot for postoperative immobilization, especially on children