FRACTURE

A Case Study

Prepared to the faculty of STI Education Services Group Inc. College of Nursing Lucena City

In partial fulfilment for the Requirements in the subject Nursing Care Management 104E Related Learning Experience

by Eric D. Umban BSN III April 2013

OBJECTIVES OF THE STUDY

General Objective The goal of the study aims to present the condition called fracture of the femur in relation to a patients clinical manifestation, treatment and general health status.

Specific Objective After doing the study, the student and readers will be able to: To raise the level of awareness of patient on health problems that he may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own. To help patient in motivating him to continue the health care provided by the health workers. To render nursing care and information to patient through the application of the nursing skills.

I.

INTRODUCTION

Fracture is any break in the continuity of bone. Fractures are named according to their severity, the shape or position of the fracture line, or even the physician who first described them. It is defined according to type and extent. In some cases, a bone may fracture without visibly breaking. Fractures occur when the bone is subjected to stress greater than it can absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even extreme muscle contraction. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, haemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by the fracture fragments. Among the common kinds of fractures are the following: Open (compound) fracture: The broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin. Comminuted fracture: The bone splinters at the site of impact, and smaller bone fragments lie between the two main fragments. Greenstick fracture: A partial fracture in which one side of the bone is broken and the other side bends; occurs only in children, whose bones are

not yet fully ossified and contain more organic material than inorganic material Impacted fracture: One end of the fractured bone is forcefully driven into the interior of the other. Potts fracture: A fracture of the distal end of the lateral leg, with one serious injury of the distal tibial articulation. Colles fracture: A fracture of the distal end of the lateral forearm in which the distal fragment is displaced posteriorly. Fractures may also be described according to anatomic placement of fragments, particularly if they are displaced or nondisplaced. Injuries to the skeletal structure may vary from a simple linear fracture to a severe crushing injury. The type and location of the fracture and the extent of damage to surrounding structures determine the therapeutic management. Maximum functional recovery is the goal of management. The most common fracture below the knee is one of the tibia and fibula that results from a direct blow, falls with the foot in a flexed position, or a violent twisting motion. Fractures of the tibia and fibula often occur in association with each other. The patient presents with pain, deformity, obvious hematoma, and considerable edema. Frequently, these fractures

are open and involve severe soft tissue damage because there is little subcutaneous tissue in the area. The signs and symptoms of a fracture include unnatural alignment, swelling, muscle spasm, tenderness, pain and impaired sensation and decreased mobility. The position of the bone segments is determined by the pull of attached muscles, gravity, and the direction and magnitude of the force that caused the fracture.

I.

OVERVIEW OF THE DISEASE

A. ANATOMY AND PHYSIOLOGY

Lower Limb Each lower limb has 30 bones in four locations: (1) the femur in the thigh; (2) the patella; (3) the tibia and fibula in the leg; (4) and the 7 tarsals in the tarsus, the 5 metatarsals in the metatarsus, and the 14 phalanges in the foot. The femur, or thigh bone, is the longest, heaviest and strongest bone in the body. Its proximal end articulates the acetabulum of the hip bone. Its distal end articulates with the tibia and patella.

The patella, or kneecap, is a small, triangular bone located anterior to the knee joint. It is a sesamoid bone that develops in the tendon of the quadriceps femoris muscle. The patella functions to increase the leverage of the tendon of the quadriceps femoris muscle, to maintain position of the tendon when the knee is bent, and to protect the knee joint. The tibia, or shin bone, is the larger, medial, weight-bearing bone of the leg. The tibia articulates at its proximal end with the femur and fibula, and its distal end with the fibula and the talus bone of the ankle. An interosseous bone connects the tibia and fibula. The fibula is parallel and lateral to the tibia, but it is considerably smaller than the tibia. The proximal end, the head of the fibula, articulates with the inferior surface of the lateral condyle of the tibia below the level of the knee joint to form the proximal tibiofibular joint. The distal end has a projection called the lateral malleolus that articulates with the talus bone of the ankle. The tarsus is the proximal region of the foot and consists of seven tarsal bones. They include the talus and calcaneus, the cuboid, the three cuneiform bones called the first, second, and third cuneiforms. The metatarsus is the intermediate region of the foot and consists of five metatarsal bones numbered I to V, from the medial to the lateral position.

The first metatarsal is thicker than the others because it bears more weight. The phalanges comprise the distal component of the foot and resemble those of the hand both in number and arrangement. They are numbered I to V being with the great toe, which is medial. B. DISEASE PROFILE Fracture of the Femur -it is any disruption or any damage in the continuity in the bone -any impairment in the bone integrity Causes: Trauma Direct blow Sudden twisting motion Severe muscle contraction Any disease that can be weakened the bone

Classification of the Fracture According the extent of break a. Complete fracture

Complete division of bone into two

b. Incomplete fracture Fracture does not divide into two

According to soft tissue Fracture a. Open/compound Break in the skin surface

b. Simple/close No break in the skin

According to cause a. Pathologic Fracture due to bone weakened by the disease

b. Fatigue or Stress Prolong or repeated use of the bone

c. Compression Loading force applied to a long axis of cancerous bone

According to pattern a. Transverse

Break that runs across the bone

b. Oblique Break that run slant/diagonal

c. Spiral Break goes around the bone

According to appearance a. Impacted Fragment driven or push in one another

b. Comminuted Splintered into three or more fragment

c. Depressed Broken bone driven inward

d. Longitudinal Break that run parallel in the bone

e. Fracture dislocation Fracture accompanied by out of the joint

Special type of fracture Greenstick No complete fracture

Avulsion Pulling away of a fragment bone of a ligament of tendon

Signs and symptoms Pain Tenderness Deformities Bleeding Crepitus Loss of function Shortening Increase temperature Principle and treatment 1. Reduction Close Open

2. Immobilization

3. Restoration

Stages of bone healing 1. Hematoma formation 2. Cellular proliferation 3. Callus formation 4. Ossification 5. Remodelling

Complication a. Hypovolemic shock Due to excessive bleeding

b. FES Released fat globules

c. Compartment syndrome

Condition

compromise

circulation

related

to

progressive

increased in the pressure in the confine area d. Nerve injury Due to bone fragment and edema

e. Ischemic necrosis Avascular necrosis and aseptic necrosis

f. Delayed union Fracture does not heal within 6 months of injury

g. Mal union Healing incorrect

Nursing management 1. Enhance comfort 2. Ensure adequate oxygen of tissue 3. Take measure toward restoring the function of the fractured bone 4. Maintain total body mobility while keeping the injured part at rest 5. Protect against infection in the absence of an intact first line of defence against infection 6. Provide adequate nutrition for healing 7. Promote urinary elimination 8. Prevent constipation 9. Prevent additional trauma to soft tissue

Emergency 1. Immobilize 2. Splint 3. Cover the wound with clean sterile dressing

Medical and Surgical management 1. Casting 2. Traction 3. Open reduction 4. Close reduction

C. Pathophysiology TRAUMA Injury to femur and fracture (transverse, oblique, spiral or comminuted)

Restricted/ loss of function or hematoma mass at site of injury Breakage in the skin Bleeding from damaged ends of the bone and bone from surrounding soft tissue Increase in the diameter of the thigh and continuous loss of the blood Hypertension (occasionally seen as response to acute/ anxiety) or hypertension (severe blood loss) Tachycardia (stress response, hypovolemia)

Fatigue, weakness on the affected part Unstable gait and mobility problem

II.

General Data

Biographical Data Name: Elpidio S. Cruz Age: 50 years old Gender: Male Address: 34 R. Santos Street Poblacion Pandi Bulacan Date of Admission: 2/17/13 Religion: Roman Catholic Nationality: Filipino Chief Complaint: Patient was admitted due to to severe pain on his Right knee Diagnosis: Open Reduction Internal Fixation of right femur + iliac bone grafting (4/2/13) Case Number: 757963 Birthday: 9/7/1962

History of Present Illness February 16, 2013, patient is going to a funeral when the accident happened. He is walking on the street when suddenly he stepped off his left foot and he fell down on the road, knee fell then he felt that there is something unnatural on his knee. Patient felt pain on his right knee and he

decided to go home and get some rest. On that night he feels uncomfortable and he is suffering for pain on his knee which he decided as 8/10 in pain scale. The day after the accident happened his wife decided to brought him on the hospital for check-up and the doctor said that his femur is broken and it needs some further surgical intervention. He was then admitted on that day because of his condition. Past Health History He said that he is not completely immunized. He has a polio since 1 years old at the right lower of his foot. He is having a cough and colds and only paracetamol is the medication that he takes.

Psychological History He is a NSO employee, a college graduate and he has a lot of friends. He always walks in their community as part of his exercise every morning. He does not smoke and he has no vices at all. Family Health History Patient told me that there is no history of any severe diseases. But he has a hypertension since he was admitted in the hospital.

III.

Physical History

General Appearance >awake and conscious >clothes were clean >ambulatory BP: 130/90 Temperature: 37.8C Pulse: 75bpm RR: 21bpm

Skin -brown -warm to touch -slightly moist and smooth -fair skin turgor

Head -symmetric -well rounded -no signs of tenderness -no swelling -hair was pliable and oily

Eyes and Vision -eyebrows were thinning but evenly distributed -eyelashes were evenly distributed -pale conjunctiva -PERRLA

Ears and Hearing -symmetrical -no discharge -no signs of tenderness Nose -symmetrical -no discharge -no signs of tenderness

Mouth

-pale lips -soft palate appeared smooth and pinkish -breath slightly odorous -no ulceration

Neck -symmetrical and head centred -able to move without difficulty -thyroid is palpable -lymph nodes are not palpable

Abdomen -globular abdomen -free of hair -7-30 per quadrant -no tenderness Chest/ Thorax -no bulging -apical pulse is not observable -no bounding abdominal pulsation noted on the epigastric area -regular heartbeat noted with 75bpm auscultated at the thoracic area

Musculoskeletal System Upper extremities

-symmetrical -no deformities -has full ability to perform gross and fine motor skill -no tenderness nor right knee -fair skin turgor

Lower extremities -atrophy of the right knee -left knee has no tenderness -left knee is freely movable without pain on range of motion -hemovac at the right knee -with elastic bandage at right knee -with pain and swelling on the right knee (7/10) -pale skin on the right knee and fair skin with the left knee -Capillary refill 3-4 seconds -left knee is cold to touch -with blood discharge on the right knee scanty in amount -with limited movement on the right leg

Genitourinary -with Foley catheter connected to urine bag draining into yellowish colour -200cc of urine output