CASE REPORT

SURGICAL TREATMENT OF NEGLECTED

MALUNION OF SHAFT FEMUR

JASMINE STEPHANIE CHRISTIAN

NIM 1671021008

Dr. I Wayan Subawa, SpOT

PROGRAM PENDIDIKAN DOKTER SPESIALIS

ILMU BEDAH
RSUP SANGLAH
DENPASAR
2018
 CASE REPORT

1. IDENTITY
Name : Muhammad Zainul Hasan
Sex :Male
Age : 21 yo
CM : 17041889
Insurance : BPJS
Admitted : 11/12/2017
Ward : Angsoka 102.2

2. HISTORY
Present History :
 Pain on his left tight and limping when walk since 4 months ago after had traffic
accident (August 2017).
 Patient use crutches to walk.
Past History :
 After the accident his leg was broken but treated at bonesetter and never met a doctor.
 Then his left leg became shorter and pain when use to walk.

3. PHYSICAL EXAMINATION
Status Present :
BP:120/90 mmHg,
HR: 76x/m
RR :20 x/m
T :37.6 C

Status General :
Head : Cephal hematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : RP +/+ isokor, conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symmetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status

LOCAL STATUS :
Left Thigh Region
L : Swelling (-), deformity (+) shortening
F : Tenderness (+) over middle part of femur, dorsalis pedis artery (+) palpable, CRT
< 2”,
SaO2 99% sensation normal
M : Active ROM Hip limited due to pain
Active ROM Knee limited due to pain
Active ROM Ankle 35/45
Active ROM MT-IP 0/90

LLD D S
3 cm

FL 78 75

AL 73 70
Clinical Feature :

4. RADIOLOGY
 Left Thigh X-Ray AP/Lateral View

5. DIAGNOSIS
Neglected Malunion Left Femur
6. TREATMENT
P/ Osteocalsis + ORIF – PS + Bone Graft

DURANTE OP + RADIOLODY POST OP

Left Thigh X-Ray AP/Lateral View Post Op
 DISSCUSION

I . Introduction
Femoral shaft fractures occur in 10–37 / 100.000 patients per year, and mainly
male young patients are affected (median age 27 years) compared to the fracture of
the elderly in female patients (median age 80 years).Fracture of the femoral diaphysis
is a frequent injury whose well-conducted treatment provides good results. In
developing countries, neglected forms are not rare and present as non-union or
malunion. Generally speaking, a femoral shaft malunion includes either an angular
deformity of greater than 10 deg, a rotational malalignment of greater than 10 deg, or
shortening of more than 2 cm. The condition is usually caused by inadequate
treatment of fractures. Nevertheless, most patients are able to tolerate these
abnormalities very well and are usually asymptomatic.Since the inception of surgical
treatment of femoral shaft fractures with unlocked or locked reamed intramedullary
nailing, the malunion rate in treating femoral shaft fractureshas declined dramatically.
Most femoral shaft malunions are due to shortening only and are caused by treating a
nonunion while neglecting leg length problems. Although various methods of treating
pure femoral shaft shortening have been described, treatment of femoral shaft angular
or rotational deformity has rarely been reported.

II. Genesis / Epidemiology

Main trauma mechanism for femoral shaft fractures is a direct fall on the
affected limb (37). A direct impact trauma mechanism or high-energy trauma leads to
simple shaft fractures with related extensive soft tissue damage. Rotational or wedge
type shaft fractures are due to an indirect trauma mechanism with minor soft tissue
damage. Large segmental bone defects or comminuted shaft fractures are seen after
gunshots or explosive trauma exposure with significant soft tissue damage. Another
genesis of femur fractures is carcinogenic. Osteolytic or osteoblastic metastasis can
lead to pain and immobilisation due to a pathologic femur fracture.

III. Anatomy
The femoral bone is the largest and strongest in the human body. Its anatomical
shape includes a physiologic antecurvation and its femoral neck an anatomical
antetorsion of 125˚–130˚. Three main muscular groups surround the femoral bone, the
quadriceps muscle ventrally, the hamstring or ischiocrural muscles (long and short
head of the biceps muscle, semitendinosus and semimembranosus muscle) dorsally
and the adductor group on the medial side. Fracture displacement often follows a
predictable pattern caused by the pull of muscles attached to each fragment. The
femoral shaft is subjected to major muscular deforming forces :
 Abductors ( gluteus medius and gluteus minimus)
› they inserted on the greater trochanter and abduct the proximal femur
following subtrochanteric and proximal shaft fractures.
 Iliop psoas
› it flexes and externally rotates the proximal fragment by its attachment to
the lesser trochanter.
 Adductors
› They span most shaft fracture and exert a strong axial and varus load to the
bone by traction on the distal fragment.
 Gastrocnemius
› It acts on distal shaft fracture and supracondylar fracture by flexing the
distal fragment
 Fasia Lata
› It acts as attention band by resisting the medial angulating force of the
adductors.
The tight musculatule is devided into three distinct Fascial compartments :
 Anterior : this is composed of the quadriceps femoris, iliopsoas, sartorius, and
pectineus as well as the femoral artery , vein, nerve and the lateral femoral
cutaneous nerve.
 Medial : this contains the gracilis, adductor longus brevis, magnus, and adturator
externus muscle along with the obturator artery, vein , nerve and the frofunda
femoris artery.
 Posterior : this includes the biceps femoris semitendinosus and semimembranosus
a portion of the adductor magnus muscle, branches of the profunda femoris artery,
the sciatri nerve, and the posterior femoral cutaneus nerve.
 Because of the large volume of the three fascial compartement of the tight,
compartement syndromes are much less common than in the lower leg. The vascular
supply to the femoral shaft is devired mainly from the profunda femoral artery.
Especially in fractures at the junction of the middle and distal thirds of the femoral
shaft careful attention has to be placed as the femoral artery in the adductor canal can
be damaged. The one to two nutrient vessels usually enter the bone proximally and
posteriorly along the linea aspera. The periosteal vessels also enter the bone along the
liniea aspera and supply blood to the outer 1/3 of the cortex. The endosteal vessels
supply the inner 2/3 of the cortex.

IV. Malunion
Defined of malunion is a state that has suffered a broken bone union with fracture
fragments are in a abnormal position ( include shortening, rotational deformity and
angular deformity). Femoral malunion defined as shorthening by more than 2 cm or
angular or rotational deformity of more than 10◦. Malunion occured because the
reduction is not acurate or immobilization is not effective in the healing period.
malunion in a lower extremity which requires weight bearing not only can cause a
limp but also can induce joint degeneration , disturbances in gait and posture.
Classification of malunion depends or based on location which is on intraarticular,
metaphysial, or diaphysial, and based on complexity are simple or complex.
The object of surgery for malunion is to restore function. There is three indicated
for operarting femoral shaft malunion is :Overlaping > 5 cm, angulation >10-15◦ and
rotation > 45◦ with or without angulation (externally or internally). Operative
treatment for malunion of most fracture should not be considered until 6 to 12 month
after the fracture has occured. How to correct deformities and leg length discrepancies
from two indication :
• Absolute Indication

• Presence of disabling pain

• Severe functional disability
• Relative indication
• Cosmetic reason
• No respone to nonoperative treatment
When we considering surgical correction of the malunion, we have to think about :
 • Age of the patient
• Socio-economic factors
• The function of the joint
• The bone stock and the degree of osteoporosis
• The state of the soft tissue envelope

V. Evaluation
The evaluation of a patient with a malunion initially focuses on identifying if the
perceived problem is a deformity of functional or future pathomechanical significance.
Both require a complete history, initial treatment, as well as any complications of that
treatment. One should document the pain severity and frequency as well as any pain
medication taken on a daily basis. A through review of systems is necessary, including a
list of medications the patient uses, taking particular note of steroids, tobacco,
nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and antiseizure
medications. Complaints of pain in the extremity with nonunion or malunion should be
thoroughly considered and potential etiologies assessed. There are several potential
etiologies for pain after a fracture other than the non- or malunion of the bone. Local pain
factors can often be determined on physical exam by focusing on reproducing the
symptoms and additionally by selective injection of local anesthetic.
Physical examination should start with an evaluation of gait. Gross alignment in the
frontal and sagittal planes should be determined. Joint motion, including the rigidity of
the end point, as well as excessive mobility, is important to document. Ipsilateral joint
contractures should be carefully assessed and considered as part of the patient’s problem
list. Motion at the site of the nonunion should be noted and differentiated from local joint
motion. Rotational alignment should be determined compared with the normal side. Leg
length discrepancy should be evaluated with note of apparent and true limb lengths.
Radiographic evaluation should include anteroposterior and lateral views of the
involved extremity. Oblique radiographs of the involved side are also important for
planning purposes because most malunions occur out of the standard orthogonal planes.
Stress views are helpful in determining mobility of the nonunion. Special views, such as
tibial plateau views, may be necessary as well. Standing hip-knee-ankle views are
necessary to determinealignment with malunions. Anteroposterior and lateral views of
the contralateral uninvolved extremity are necessary for preoperative planning purposes.
Two dimensional computed tomographic (CT) scans are helpful when evaluating
rotational deformities, 5 degree of fracture consolidation, and leg length discrepancies.
However seductive 3-D CT scans may appear, a thorough study of the plain radiographs
is necessary for decision making when using plain and fluoroscopic images
intraoperatively.

VI. Treatment
Surgical management of nonunions and malunions requires a sound understanding
of the principles and biomechanics of internal fixation, the biology of fracture union,
and the limits of the specific implants employed. Due to the unique nature of each
patient’s problem, patients with a nonunion or malunion require an individualized
treatment plan with specific goals.
There is some of treatment type of implant choices for malunion surgery :
• Plates and screws
• Grants intrafragmentary compression and anatomical reduction
• Is mandatory to be covered adequately from soft tissues
• The implant of choice in case of perartritic & metaphysic area
• External fixation devices
• Useful to avoid soft tissue irritation
• Better to be used at the supramalleolar areas & tibial plafond
However, most nonunions and malunions require fixation in compression using
either a lag screw through the plate or an external fixator in the case of the
proximal or distal tibial. Internal fixation for malunion or nonunion has the
advantage of being definitive, biomechanically predictable, and cosmetic, and it
requires limited patient or surgeon aftercare. The disadvantage of open reduction
and internal fixation (ORIF) is that imprecise correction, if not recognized
intraoperatively, will require revision surgery. Successful internal fixation requires
a mechanically sound construct able to resist cyclic muscular contraction
generated during early functional activity. For internal fixation, this requires a
plate with sufficient length to resist torsional forces.

• Intramedullary devices
• The implant of choice in case of the diaphysis of the long bone
In the neglected fractures complicated by malunion, osteotomy is
indispensable and is performed in an open procedure. Such cases are described
 most particularly in developing countries. Mahaisavariya and Laupattarakasem
and Gahuakamble et al. respectively report 14 and four cases of femoral
diaphyseal malunion treated with intramedullary nailing. The difficulty
treating femoral diaphyseal malunion correcting limb shortening involves
carrying out the procedure in a single operation. Traction of the limb is
transmitted to the soft tissues and can lead to a number of neurovascular
complications.
The most common complications associated with malunion surgery are
under- or overcorrection (0 to 15%), nonunion (0 to 12%), nerve palsy (0 to
8%), infection (1 to 3%), delayed union (3 to 5%), and thromboembolism (2 to
4%).

New Techniques for Malunions and Nonunions : Bone Grafts and Bone Graft
Substitutes
The use of bone graft and bone graft substitutes to augment stability and
achieve union is integral to the treatment of nonunions and malunions. Although
autologous bone grafting is the gold standard to which all other grafts are compared,
there are circumstances where the appropriate use of allograft and bone graft
substitutes can spare the patient the potential risks and complications of obtaining
autograft. Any algorithm for bone graft use hinges on an understanding of when and
what type of graft is necessary. The biochemical and cellular environment of bone
defects in fresh fractures differs greatly from nonacute scenarios. In the treatment of
nonacute fractures, the surgeon must re-create the biochemical and cellular
environment of the fresh fracture to generate union. Bone graft can provide the
mesenchymal cells found in the periosteum of live bone and the bone growth factors
needed to generate them. Bone graft can also be used to improve structural stability in
large or diaphyseal defects. Both these circumstances necessitate that the mechanical
environment has been optimized by creating sound bony fixation.Assuming that
stability has been created, then the size and location of the defect as well as the
biological environment must be considered. Diaphyseal defects less than 6 cm in a
stable mechanical environment need both the scaffolding for osteoconduction and the
cellular and chemical components to generate healing. Therefore, cancellous autograft
is the best option. Cancellous allograft with bone marrow aspirate may yield similar
rates of union, but this has not been clearly demonstrated in human prospective
clinical studies. For diaphyseal defects greater than 6 cm, a cortical autograft or
allograft may be needed to provide structural stability. Vascularized cortical
autografts are advantageous over nonvascularized autografts or allografts because of
their more rapid and complete incorporation, as well as their ability to hypertrophy.
However, Finkemeier points out that cortical allografts are best utilized in areas of
excellent blood supply, such as the metaphyseal locations, or around the femur with
its heavy muscular coat. In bony areas with poor or disrupted flow the surgeon should
strongly considerusing vascularized autografts to achieve union.

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