kpj university college, nilai

Problem Based Learning 1

Human Anatomy & Physiology

Lecturer: Dr. Muneerah Jamil

11/11/2014

Cohort 2Intake September 2013

Year 1 / Semester 1

Group Members:

Mohd Alfam Shamin bin Ashraf Alisha2062141033

Vinith Prabu s/o Perabakaran2062141014

Nazim Muhamad Arif bin Abdullah2062141033

Putri Noor Syamimi binti Mohd Ridza2062141011

Siti Athirah binti Nordin2062141012

Anis Nadzirah binti Noor Azam2062141001

Table of ContentsINTRODUCTION

ABSTRACT..............................................................................................................................................3

FRACTURE DEFINITION..........................................................................................................................3

COMMON TYPES OF FRACTURES...........................................................................................................3

PLAN

COMPLICATIONS....................................................................................................................................5

EVALUATION..........................................................................................................................................6

History...............................................................................................................................................6

Physical Examination.........................................................................................................................6

Diagnostic Imaging............................................................................................................................7

MANAGEMENT

IMMOBILIZATION..................................................................................................................................8

What is fiberglass?.............................................................................................................................8

Why fiberglass cast is more preferable over plaster cast?................................................................9

Further Precautions...........................................................................................................................9

Primary (provisional) fracture immobilization with a cast.................................................................9

Duration of Recovery.......................................................................................................................10

THE REPAIR PROCESS OF BROKEN BONES...........................................................................................10

MEDICATION.......................................................................................................................................11

REFERENCES........................................................................................................................................13

2

INTRODUCTION

ABSTRACTA middle 40’s housewife had been admitted to the emergency room after being reported that she was unable to get up and walk after finding herself falling into an accident when she was pushed from her back during skating. She complained of having pain at her left lower leg with limited range of motion.

FRACTURES

DefinitionFracture is the act of breaking, or something that has broken, especially that in bone or cartilage. Fractures are named according to their severity, the shape or position of the fracture line, or even the physician who first described them. In this case, the affected area is known as a long bone fracture. Fractures of the "long bones" are one of the most common injuries associated with a variety of accidents. Long bones are long, cylindrical and hollow in the middle, and have a joint at each end. These bones can be injured (fractured) at any place along the course of the bone. The tibia, or shinbone, is the most common fractured long bone in the body. The long bones include the femur, humerus, tibia, and fibula. A tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle.

Common Types of Fractures

Types of fractures Description

3

Open (compound) fracture

An open fracture, also called a compound fracture, is an injury that occurs when there is a break in the skin around a broken bone. The broken ends of the bone protrude through the skin. Conversely, a closed (simple) fracture does not break the skin.

Comminuted fracture

A bone injury that results in more than 2 separate bone components is known as a comminuted fracture. The bone is splintered, crushed, or broken into pieces at the site of impact, and smaller bone fragments lie between the two main fragments.

Impacted fracture

An impacted fracture is a fracture in which the bone breaks into multiple fragments which are driven into each other. One of the fractured bones is forcefully driven into the interior of the other. This type of fracture is usually caused by something like a fall, especially if someone breaks a fall with the arms or legs.

4

Pott fracture

Fracture of the distal end of the lateral leg bone (fibula), with serious injury of the distal tibial articulation. A Pott's fracture often occurs in combination with other injuries such as an inversion injury, a dislocation of the ankle or other fractures of the foot, ankle or lower leg. Pott's fractures can vary in location, severity and type including displaced fractures, un-displaced fractures, bimalleolar fractures or compound fractures.

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 fully ossified and contain more organic material than inorganic material. In some cases, a greenstick fracture can be difficult to diagnose because there may not be much pain or swelling and the child is using the limb and has full motion. Mild greenstick fractures sometimes are thought to be sprains.

PLAN

COMPLICATIONSFractures, joint dislocations, ligament sprains, muscle strains, and tendon injuries are common injuries that vary greatly in severity and treatment. Limbs are most often affected, although any part of the body can be. Injuries may be open (in communication with a skin wound) or closed.

5

Complications may be serious. Some complications are potentially life threatening such as:

Rapid blood loss: Bleeding can be external or internal. Sometimes transfusion is required. Fat embolism or Nonthrombotic Pulmonary Embolism: This rarely happen, possibly

preventable, complication usually may occur when a long bone is fractured.

Complications may also threaten limb viability or cause permanent limb dysfunction. Such complications occur in only a small percentage of limb injuries. The greatest threats come from open injuries that predispose to infection and injuries that disrupt the vascular supply (causing ischemia), primarily by directly injuring arteries or occasionally veins. However, some closed injuries (eg, posterior knee dislocations, hip dislocations, displaced supracondylar humeral fractures) can also disrupt the vascular supply, causing ischemia. The following can threaten a limb:

Compartment syndrome: Tissue pressure increases in a closed fascial space, disrupting the vascular supply and reducing tissue perfusion. Crush injuries or markedly comminuted fractures are a common cause. Compartment syndrome can lead to rhabdomyolysis and thus infection, which threatens limb viability and, if untreated, survival.

Nerve or spinal cord injuries: A penetrating injury may sever a peripheral nerve. A blunt, closed injury may result in neuropraxia (bruised peripheral nerve) or axonotmesis (crushed nerve), which is more severe.

Dislocations: The bones in a joint are completely separated, sometimes disrupting the vascular supply and injuring nerves. Vascular and nerve injuries are more likely when reduction (realignment of fracture fragments or dislocated joints) is delayed. Partial dislocation, termed subluxation, can also result in significant sequelae.

Infection: Open injuries can become infected, potentially leading to osteomyelitis, which can be difficult to cure.

For this case, which seems to be a closed injury do not involve any blood vessels or nerves, including fractures, sprains, strains, and tendon tears, are least likely to result in serious complications.

EVALUATION

HistoryThe patient is a 45 years old housewife that had not been skating for at least 10 years but having a healthy lifestyle and known to have no medical history involving fractures nor serious medical illness throughout her life. She was admitted into the emergency room after reporting that she was unable to get up and walk after she was pushed from the back during skating.

Physical ExaminationA physical examination is an evaluation of the body and its functions using inspection, palpation by feeling with the hands, percussion by tapping with the fingers, and auscultation by listening. A complete health assessment also includes gathering information about a person’s medical history and lifestyle, doing laboratory tests, and screening for diseases.

6

Examination includes vascular and neurologic assessment, inspection for deformity, swelling, ecchymoses, and decreased or abnormal motion and palpation for tenderness, crepitation, and gross instability. Motor or sensory deficits suggest neurologic injury. Paresthesias or sensory deficits alone suggest neuropraxia; motor plus sensory deficits suggest axonotmesis.

Deformity suggests dislocation, subluxation (partial separation of bones in a joint), or fracture. Swelling commonly indicates a significant musculoskeletal injury but may require several hours to develop. If no swelling occurs within this time, fracture or severe ligament disruption is unlikely. Some fractures, swelling may be subtle but is rarely absent.

Nearly all injuries are tender, and for many patients, palpation anywhere around the injured area causes discomfort. However, a noticeable increase in tenderness in one localized area (point tenderness) suggests a fracture or sprain. Localized ligamentous tenderness and pain with stressing the joint are consistent with sprain.

Crepitation (a characteristic cracking or popping sound) may be a sign of fracture. Gross joint instability suggests dislocation or severe ligamentous disruption. Stability of an injured joint is evaluated by stress testing. However, if fracture is suspected, stress testing is deferred until x-rays exclude fracture.

7

There are two factors that might cause tibial fractures to occur; high energy collisions and lower energy injuries. The high-energy collisions, such as an automobile or motorcycle crash, are common causes of tibial shaft fractures. In cases like these, the bone can be broken into several pieces (comminuted fracture). Meanwhile, sports injuries, such as a fall while skiing or running into another player during soccer, are lower-energy injuries that can cause tibial shaft fractures. These fractures are typically caused by a twisting force and result in an oblique or spiral type of fracture.

The most common symptoms of a tibial shaft fracture are:

Pain Inability to walk or bear weight on the leg Deformity or instability of the leg Bone "tenting" the skin or protruding through a break in the skin Occasional loss of feeling in the foot

After physical examination from head to toe was done unto the patient, any abrasion or laceration must primarily be observed to prevent any infection. Abrasion is an injury caused by something that slightly rubs or scrapes against the skin compared to laceration that causes deep cut or tear in skin. However, there is no abrasion or laceration wound present to be observed on the superficial area of the patient’s left lower limb. It can be assumed that the part of her body that is affected is the left lower leg as the patient complain of having pain at her left lower leg with limited range of motion. The patient also said to experience pain when she walks with her left leg. As a result from the physical examination, there is a localized tenderness detected over the tibial shaft and along its medial border. Tenderness is known to be a discomfort when the affected area is touched. A tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle. Shaft of tibia is triangular in cross section. It consists of three surfaces. The medial border descends from anterior end of medial condyle to posterior margin of medial malleolus. The patient’s range of motion is limited. She has severe pain when walking with her left leg.

Diagnostic ImagingX-ray has a wavelength range between 0.01 to 10 nanometres, 3 x 1016Hz- 3 x 1019Hz range of frequency and about 12keV. This type of radiation is able to penetrate through most soft matters, such as muscle and tissue, however is stopped by bones and tendons. This therefore provides us with a good visual on the skeletal structure where we can determine whether there are any fractures or dislodged bones present. It is a more preferable option in diagnostic imaging as it is not a complex fracture and less radiation will be exposed to the patient compared to CT scan and MRI.

Tibial shaft (diaphyseal) fractures can be classifieds by:

Location; proximal, middle or distal third fracture pattern; transverse, spiral/oblique, comminuted/open involvement in fibula

Fractures of the tibial shaft can be result from a direct blow or rotational force. As from the previous physical examination, the suspected area of fracture might involve on the distal part of the tibia. Therefore, anteroposterior (AP) and lateral x-rays of the tibial shaft to include knee and ankle joints should be ordered. However, CT scan of the fracture will be needed if near knee or ankle. The image

8

of x-rays shows that the simple transverse fracture of tibia at the near end segment of the bone has not resulted in any angulations, rotation, shortening, distraction and impaction to the bone. The fracture is proximal to the talus, not entering the articular surface and considered as simple fracture as it is only has a single line. Also there is no pathological fracture arise from the abnormal bone such as osteoporosis since the patients has a healthy lifestyle.

MANAGEMENT

IMMOBILIZATIONAfter a bone is broken it needs rest and support to heal properly. Orthopedics use casts to support and protect injured bones. A cast in other word, is one of the preferred techniques to immobilize the bone of a limb that has been injured by fracture, dislocation or break. While cast can be uncomfortable and cumbersome, it is an effective and efficient method to treat fractures. Casts are custom-made to fit and support injured limbs. There are two main types of casts:

Fiberglass casts. Fiberglass is a type of plastic that can be shaped. Fiberglass casts are typically lighter and more durable than traditional plaster casts. Air circulates more freely inside a fiberglass cast. Also, X-rays penetrate fiberglass casts better than plaster casts. This is helpful if your child's doctor wants to use an X-ray to examine your child's bones while he or she is still wearing the cast. Fiberglass casts are available in different colors.

Plaster casts. Plaster casts are easier to mold for some uses than are fiberglass casts. Also, plaster casts are typically less expensive than fiberglass casts.

What is fiberglass?A fiberglass cast type is used which is a lighter, synthetic alternative to the more traditional plaster version. It is created by padding the extremity with cotton or waterproof padding material, followed by wrapping several layers of knitted fiberglass bandages impregnated with a water-soluble, quick-setting resin. It is lighter and more durable than plaster, so fiberglass has quickly become the preferred type of casting with many patients and medical care providers.

9

Why fiberglass cast is more preferable over plaster cast? Fiberglass has many advantages over a plastic cast. The first thing most patients notice is that the cast weighs less and is more comfortable. It is made of water-activated polyurethane resin combined with bandaging materials, so this material offers greater strength and less time for setting, as well. Casts made of this material require less maintenance than those made with plaster and often are used after the healing process already has begun.

The fiberglass bandages on the outside of the cast are waterproof, but typically, most of the padding materials inside the cast are not. Waterproof materials have been developed to replace this inside padding with a waterproof alternative. This offers an option that would allow patients the ability to bath or shower, wash hands, do chores and even swim while wearing a cast. The material also is reported to cut down on odor and itching by helping to wick moisture away from the skin under the cast.

Further Precautions Medical professionals advise patients wearing fiberglass casts to report any rough spots that snag clothing or chafe skin immediately to their medical care facility for repair. Cracks are easily repaired but are not very likely to occur. Experts also encourage patients to report any foul odor or damage to the padding of the cast.

This cast is appropriate for tibial shaft fractures just like in this case that are not badly displaced and are well aligned. Patients need to be in a cast that goes below the knee and below the ankle. The advantage of casting is that these fractures tend to heal well and casting avoids the potential risks of surgery such as infection. Patients with casts must be monitored to ensure adequate healing of the tibia and to ensure the bones maintain their alignment.

During the discharge the patient was also advice to inspect the skin around the edges of the cast for inflammation. Inflammation is defined as a localized reaction that produces redness, warmth, swelling, and pain as a result of infection, irritation, or injury. Inflammation can be external or internal. A broken bone can trigger an inflammatory response and dispatch cells and chemicals to the site to repair the damage.

Inflammation is categorized into two categories which is acute and chronic. Acute usually last for few days while chronic may last for weeks. Inflammation process begins with the vasoconstriction of small vessels in the injured area followed by rapid vasodilation of the arterioles and venules that supply the area. Inflammatory may leads to congestion in the area causing redness and warmth followed by increased capillary permeability which leads to swelling, pain, and impaired function.

Primary (provisional) fracture immobilization with a castUnless an indication for immediate surgery is identified, the following approach is recommended. Most low-energy closed tibial fractures can be aligned quite well by closed reduction in a dependent position and application of a long leg cast. Such a cast usually provides better immobilization than do splints made of plaster or fiberglass slabs or those that are available commercially. Radiographs of the fracture are then obtained, rotational alignment is reconfirmed by visual comparison, and unless a major problem with misalignment is noted, the reduction is accepted, at least temporarily. The patient is usually hospitalized with the leg elevated slightly above heart level and observed for

10

comfort and neurovascular status. Outpatient care is possible if comfort, monitoring, and gait training can be ensured. If the cast becomes too tight or the surgeon has serious concern about impending circulatory compromise, the plaster is loosened and the cast padding divided. If these measures do not maintain or restore satisfactory neurovascular status, arterial perfusion and compartmental pressure are checked, with further immediate surgical treatment as indicated. With a satisfactory reduction and no evidence of neurovascular compromise, it is expeditious to leave the provisional cast intact. If the reduction is not satisfactory or closed treatment is, for some other reason, less desirable, definitive fixation may be carried out electively after the initial swelling has begun to resolve, but without excessive delay.

Duration of Recovery Duration time taken for patient to return to daily activities varies with different types of fractures. Some tibial shaft fractures heal within 4 months, yet many may take 6 months or longer to heal. This is particularly true with open fractures and fractures in patients who are less healthy.

Early motion: Many doctors encourage leg motion early in the recovery period. For example, if soft tissue injury is present with a fracture, the knee, ankle, foot, and toes may be mobilized early in order to prevent stiffness.

Physical therapy: While you are wearing your cast or splint, you will likely lose muscle strength in the injured area. Exercises during the healing process and after your cast is removed are important. They will help you restore normal muscle strength, joint motion, and flexibility.

Weightbearing: When you begin walking, you will most likely need to use crutches or a walker.

Fracture pain usually stops long before the bone is solid enough to handle the stresses of everyday activities. If the bone is not healed and you put weight on it too soon, it could fail to heal. If that occurs, you may need a secondary surgical procedure, such as bone grafting or revision fixation.

THE REPAIR PROCESS OF BROKEN BONES

When a person subjects himself to physical blow, with strength that overcomes the bone itself, it will results a bone fracture. Bones are made up of connective tissue that is fortified by calcium and a combination of bone cells. They have a soft center where blood is formed, and its main function in the body is support the body, protect the internal organs and allow mobility.

11

Bones can fracture in several ways and healing that will follow will be dependent on the kind of fracture that the bones incurred. There are several stages bone healing process and all bones need to successfully undergo each stage in order to completely heal.

It's important to remember that your bones are constantly changing. Cells called osteoclasts constantly break down old bone so that osteoblasts can replace it with new bone tissue -- a process called bone remodeling. Another type of cell called a chondroblast forms new cartilage. These are three of the primary cells responsible for bone growth and not just the bone growth experienced during early stage of life. This constant bone remodeling gradually replaces old bone tissue with new tissue during the course of months.

Almost immediately after the break, the body begins to try and put itself back together again. The overall processes are divided into four phases:

1. When a bone breaks, the fissure also severs the blood vessels running down the length of the bone. Blood leaks out of these veins and quickly forms a clot called a fracture hematoma. This helps to stabilize the bone and keep both pieces lined up for mending. The clot also cuts off the flow of blood to the jagged bone edges. Without fresh blood, these bone cells quickly die. Swelling and inflammation follow due to the work of cells removing dead and damaged tissue. Tiny blood vessels grow into the fracture hematoma to fuel the healing process.

2. After several days, the fracture hematoma develops tougher tissue, transforming it into a soft callus. Cells called fibroblasts begin producing fibers of collagen, the major protein in bone and connective tissue. Chondroblasts then begin to produce a type of cartilage called fibro cartilage. This transforms the callus into a tougher fibro cartilaginous callus, which bridges the gap between the two pieces of bone. This callus generally lasts for about three weeks.

3. Next, osteoblasts move in and produce bone cells, transforming the callus into a bone callus. This hard shell lasts three to four months, and it provides necessary protection and stability for the bone to enter the final stage of healing.

4. At this point, the body establishes the position of the bone within the flesh, begins reabsorbing bits of dead bone, and creates a hard callus to bridge the gap between the two pieces of bone. However, this bulge of tissue needs a lot of work before the bone can take any strain. Osteoclasts and osteoblasts spend months remodeling bone by replacing the bone callus with harder compact bone. These cells also decrease the callus bulge, gradually returning the bone to its original shape. The bone's blood circulation improves and the influx of bone-strengthening nutrients, such as calcium and phosphorus, strengthen the bone.

MEDICATIONOther than that upon discharging, patient also complaint of having a severe pain at the site of injury thus the patient is will be prescribed with some medication to reduce the pain. Medication that is suggested to be prescribed to the patient is non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs work by reducing the production of prostaglandins. Prostaglandins are chemicals that promote inflammation, pain, and fever. They also protect the lining of the stomach and intestines from the damaging effects of acid, promote blood clotting by activating blood platelets, and promote normal

12

function of the kidneys. The enzymes that produce prostaglandins are called cyclooxygenases (COX). There are two types of COX enzymes, COX-1 and COX-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever; however, only COX-1 produces prostaglandins that activate platelets and protect the stomach and intestinal lining. NSAIDs block COX enzymes and reduce production of prostaglandins. Therefore, inflammation, pain, and fever are reduced. Since the prostaglandins that protect the stomach and promote blood clotting also are reduced, NSAIDs that block both COX-1 and COX-2 can cause ulcers in the stomach and intestines, and increase the risk of bleeding.

In this case Capsule Celebrex (celecoxib) is being prescribed with a dose of 200mg twice daily for 3 days to the patient to reduce the pain or any swelling if it is occurring.

13

REFERENCES

Introduction

Yoursurgery.com, (2014). http://www.yoursurgery.com. [online] Available at: http://www.yoursurgery.com/ProcedureDetails.cfm?BR=5&Proc=68 [Accessed 17 Nov. 2014].

Plan

Merckmanuals.com, (2014). Fractures: Fractures, Dislocations, and Sprains: Merck

Manual Professional. [online] Available at:

http://www.merckmanuals.com/professional/injuries_poisoning/fractures_dislocations

_and_sprains/fractures.html [Accessed 17 Nov. 2014].

Orthoinfo.aaos.org, (2014). Tibia (Shinbone) Shaft Fractures-OrthoInfo - AAOS.

[online] Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00522 [Accessed 17

Nov. 2014].

TheFreeDictionary.com, (2014). Physical exam. [online] Available at: http://medical-

dictionary.thefreedictionary.com/Physical+exam [Accessed 17 Nov. 2014].

Www2.aofoundation.org, (2014). AO Surgery Reference. [online] Available at:

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMA

fGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?

bone=Femur&segment=Shaft&soloState=lyteframe&contentUrl=srg/popup/

further_reading/PFxM2/15_Fx_Class.jsp#JumpLabelNr2 [Accessed 17 Nov. 2014].

Management

What is inflammation? What causes inflammation? - Medical News Today. 2014.

What is inflammation? What causes inflammation? - Medical News Today.

[ONLINE] Available at: http://www.medicalnewstoday.com/articles/248423.php.

[Accessed 13 November 2014].

Inflammatory response definition - Exercise and Fitness Center: Tips and Facts on

Working Out. 2014. Inflammatory response definition - Exercise and Fitness Center:

Tips and Facts on Working Out. [ONLINE] Available at:

14

http://www.medicinenet.com/script/main/art.asp?articlekey=19510. [Accessed 13

November 2014]

Novimmune -- Science: Inflammation. 2014. Novimmune -- Science: Inflammation.

[ONLINE] Available at: http://www.novimmune.com/science/inflammation.html.

[Accessed 13 November 2014].

Bonesfracture.com, (2014). Stages of Bone Healing after fracture. [online] Available

at: http://bonesfracture.com/stages-of-bone-healing-after-fracture/ [Accessed 17 Nov.

2014].

Jonathan Cluett, M. (2014). How Is a Cast Made for a Broken Bone?. [online] About.

Available at: http://orthopedics.about.com/od/castsfracturetreatments/f/casts.htm

[Accessed 17 Nov. 2014].

15