fracture introduction
TRANSCRIPT
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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
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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
Af ter do ing the study, the student and readers wi ll 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.
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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
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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
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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.
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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.
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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.
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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
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- 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
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- 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
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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
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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
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- 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
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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
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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)
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Fatigue, weakness on the affected part
Unstable gait and mobility problem
II. General Data
Biographical Data
Name: Elpidio S. Cruz Case Number: 757963
Age: 50 years old Birthday: 9/7/1962
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)
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
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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 thenadmitted 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. Buthe has a hypertension since he was admitted in the hospital.
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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
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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
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-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
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-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