Transcript CASEPRESENTATION ON FEMORAL SHAFT FRACTURE

PREPARED BY
DHANYA VIJAYAN
OPERATING ROOM
GENERAL APPEARANCE
 Patient is conscious and coherent.
 Looks weak and fatigue.
 Unable to mobilize his left lower extremity.
VITAL SIGNS
 BP
:124/86mm of Hg
 PR
:82bpm
 RR
:20cpm
 Temp :98.6F
 SPO2 :98%
SKIN
•Skin is warm .
•Has swelling on rt leg.
•Noted abrasions on rt arm and lower limbs
HEAD
•Hair is equally disrtibuted.
•Absence of dandruff
EYES
•Able to move both eyes
•On inspection of eyes ,the rt eye is reddish and the
eyelid has dark discouloration .
EARS
• Patients pinna is same colour as fascial.
• Able to hear sounds clearly .
• No discharges.
MOUTH
• Lips are pink but dry.
• Teeth is propely aligned with no dentures.
NECK
•No tenderness of node
THORAX
•The Thorax Is Symmetric On Inspection
CARDIO VASCULAR
•Absence Of Chest Pain .
•Heart sounds are clear.
•Upon auscultation his Bp is 132/78mmof hg.
GENITO URINARY
•With foley catheter fr.16
.
GASTRO INTESTINAL
.
•No Tender Ness Of Abdomen and its soft .
•Had enema once and he was kept on NPO for 8hrs.
.
MUSCULOSKELETAL
•Unable To Mobilize His Lt Lower Limb.
•Has Pain During Examination.
•Cannot Perform ADL.
•Tenderness at site of fracture.
•Visible deformity.
•Lower extremity appear shortened.
•Crepitus noted with movement.
NEUROLOGIC
•Patient Is Mentally Alert And Oriented With
Circumstances.
•Able To Follow Commands.
•No neurovascular deficit.
PAST MEDICAL AND SURGICAL HISTORY
 H/O Adenotonsilectomy 10yrs back
PRESENT MEDICAL HISTORY
 Patient was brought in E.R on 17/12/12 by RED
CRESCENT due to R.T.A.After further investigations he
was diagnosed with fracture on femoral shaft rt side.
PRESENT SURGICAL HISTORY
 He underwent intramedullary nailing of lt femur on
18/12/12.
INVESTIGATIONS DONE FOR THE PATIENT
X-Ray Pelvic And Femur
CT lower extremity
CT lumbar and thoracic spine
Blood investigations like
o CBC
o PT INR
o SERUM ELECTROLYTES
o RH TYPING
MEDICATIONS
 Inj .Risek 40mg od
 Inj:Augmentin1.2gm Bd
 Inj.Amikacin 500mg bd
 Inj.Perfelgan 1 gm.
TEST on 17/12/12
CBC
HB
HCT
RBC
PLT
RESULT
REFERENCE
RANGE
12.1g/dl
35.8g/dl
4.81
13.7-17.5g/dl
40.1-51.0g\dl
4.63-6.08 *10^6/ul
198
163-337/ul
sodium
138
135-150 mmol/l
pottassium
PT
4.0
3.5-5.0mm0l/l
13.4
10.0-17.0sec
APTT
INR
RH typing
29.2
26.1-36.3sec
1.3
2.4theraputic
Ab+ve
TOPIC PRESENTATION
The femur is the anatomical name given to the thigh bone .It is the
largest and strongest bone of the body. The long, straight part of the
femur is called the femoral shaft.
When there is a break anywhere along this length of bone, it is called a
femoral shaft fracture.
The most common types of femoral shaft fractures include:

Transverse fracture.
In this type of fracture, the break is a straight horizontal line
going across the femoral shaft.

b.Oblique fracture.
This type of fracture has an angled line across the shaft.
C.Spiral
fracture.
The fracture line encircles the shaft like the stripes on a candy cane.
A twisting force to the thigh causes this type of fracture.
d.Open or compound fracture
If a bone breaks in such a way that bone fragments stick out through the
skin or a wound penetrates down to the broken bone, the fracture is
called an open or compound fracture.
They have a higher risk for complications — especially infections— and take a
longer time to heal.
e.Comminuted fracture
In this type of fracture, the bone has broken into three or more pieces.
open fracture
The femur is the longest and strongest bone in the skeleton, is almost perfectly
cylindrical in the greater part of its extent It is divisible into a body and two
extremities
.
THE UPPER EXTREMITY (PROXIMAL EXTREMITY),
presents a head, a neck, a greater and a lesser
trochanter
The Head (caput femoris).
is globular and forms
rather more than a hemisphere and fits in to the
acetabulam (a cup shaped socket in the pelvis) .
THE NECK (COLLUM FEMORIS).—The neck is a
flattened pyramidal process of bone, connecting
the head with the body
The Greater 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.
The Lesser Trochanter (trochanter minor; small trochanter) is a conical
eminence it projects from the lower and back part of the base of the neck.
Running obliquely downward and medialward from the tubercle is the intertrochanteric
line (spiral line of the femur)
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 strengthened by a prominent longitudinal ridge,
the linea aspera.
The distal extremity of the femur (or lower
extremity) is larger than the proximal extremity
It consists of two oblong eminences known as the
condyles
Anteriorly, the condyles are slightly prominent and are
separated by a smooth shallow called the patellar
surface.
posteriorely they project considerably and a deep
notch, the Intercondylar fossa of femur, is present
between them.
The lateral condyle is the more prominent and is the broader both
in its antero-posterior and transverse.
oThe lateral condyle is the more prominent and
is the broader both in its antero-posterior and
transverse.
oEach condyle is surmounted by an elevation,
the epicondyle
oThe medial epicondyle is a large convex eminence to which the
tibial collateral ligament of the knee-joint is attached.
oThe lateral epicondyle, smaller and less
prominent than the medial, gives attachment to
the fibular collateral ligament of the knee-joint.
oThe articular surface of the lower end of the femur occupies the
anterior, inferior, and posterior surfaces of the condyles. Its front
part is named the patellar surface and articulates with the
patella.
THE FEMORAL ARTERY PASSES roundthe
medial aspect of the femur to enter the
popiliteal space where it becomes the
POPILITEAL ARTERY .it supplies blood to the
structures of the thigh.
Branches from the femoral artery
 DEEP ARTERY OF THE THIGH
(ARTERIAPROFUNDA FEMORIS) is the largest
and main branch of the femoral artery and
branches off the femoral artery about 2 to 5
cm below the inguinal ligament.
 MEDIAL CIRCUMFLEX ARTERY AND LATERAL
CIRCUMFLEX ARTERY may arise from the deep
artery or directly from the femoral artery.
Great saphenous vein joins the femoral vein
about 3 cm below the inguinal ligament
Deep vein of the thigh (profunda femoris
vein) joins the femoral vein about 8cm below
the inguinal ligament.
 The muscles in the front of the thigh are the
SARTORIUS and the QUADRICEPS FEMORIS.
T he quadriceps is actually a powerful muscle
made of 4 parts – the rectus femoris,
vastus lateralis, vastus medialis and
vastus intermedius. While the sartorius
flexes both the hip and knee joints, the
quadriceps femoris is an extensor of the knee
joint.
 The muscles in the inner aspect of the
thigh are the PECTINEUS, GRACILIS,
ADDUCTOR LONGUS, ADDUCTOR MAGNUS,
ADDUCTOR BREVIS, OBTURATOR EXTERNUS The
adductor muscles also help rotate the thigh
in an inward direction while the iliopsoas
flexes the hip joint .
 The back of the thigh holds the powerful
hamstring muscles, the biceps femoris,
semitendinosus and semimembranosus. ND
THE ILIOPSOAS. The hamstrings are all
flexors of the knee joint.
THE IMPORTANT NERVES OF THE THIGH ARE THE
FEMORAL AND THE SCIATIC NERVES
The femoral triangle is an anatomical
region of the upper inner human thigh.
It is bounded by
:
(superiorly) the inguinal ligament
•(medially) the medial border of the
adductor longus muscle
laterally) the medial border of the
sartorius muscle
(
The three compartments of the femoral sheath (From lateral to
medial):
•femoral artery and its branches
•femoral veins and its tributaries
•femoral canal, Which contains lymphatic vessels and some lymph
nodes (Specifically, the deep inguinal lymph nodes
 DUE TO A FALL (USUALLY FROM A HEIGHT AND OFTEN
ON TO HARD SURFACE)
 DUE TO DIRECT BLOW TO FEMUR SUCH AS RTA
 OSTEO POROSIS OR MALIGNAN
Common Symptoms Are
BLEEDING
DEFORMITY OF THE LEG
INABILITY TO MOVE THE AFFECTED LEG
MUSCLE SPASMS
NUMBNESS Or TINGLING
SEVERE PAIN
SWELLING
SERIOUS SYMPTOMS THAT MIGHT INDICATE A LIFE
THREATENING CONDITION ARE.
CONTUSION OR LOC EVEN FOR A BRIEF MOMENT
HEAVY UNCONTROLLABLE BLEEDING
INAVBILITY TO MOVE LEG
HYPOTENSION
PROTRUDING FRAGMENTS OF BONE THROUGH THE sKIN
 Nonsurgical Treatment
Most femoral shaft fractures require surgery to heal. It is unusual for femoral
shaft fractures to be treated without surgery. Very young children are
sometimes treated with a cast.
Surgical Treatment
For the time between initial emergency care and surgery, doctor will place leg
either in a long-leg splint or in skeletal traction. This is to keep broken bones
as aligned as possible and to maintain the length of leg.
(SKELETAL TRACTION IS A PULLEY SYSTEM OF WEIGHTS AND COUNTERWEIGHTS THAT HOLDS
THE BROKEN PIECES OF BONE TOGETHER. IT KEEPS LEG STRAIGHT AND OFTEN HELPS TO
.)
RELIEVE PAIN
 EXTERNAL FIXATION
External fixation is usually a temporary treatment for femur fractures. This device is
stabilizing frame that holds the bones in the proper position so they can heal.
Extensive comminution and open fractures were considered to be relative indications
for the use of femoral external fixation as a definitive treatment for femoral shaft
fractures.
INTRAMEDULLARY NAILING.
It is the most common treatment for
femoral shaft fractures in adults,An
intramedullary nail can be inserted
into the canal either at the hip or the
knee through a small incision. It is
screwed to the bone at both ends.
This keeps the nail and the bone in
proper position during healing. to
determine how
PLATE AND SCREWS
PLATE AND SCREWS
The use of plate fixation for the
routine treatment of femoral shaft
fractures has decreased with the
increased use of intramedullary nails.
The main disadvantages associated
with plate fixation when compared
with intramedullary nailing are the
need for an extensive surgical
approach with its associated blood
loss, infectious complications, and
soft tissue insult.
Because the plate is a load-bearing
implant, implant failure is expected if
union does not occur.
IM NAILING
Complications from Femoral Shaft Fractures
 The ends of broken bones are often sharp and can cut or tear surrounding blood
vessels or nerves.
 Acute compartment syndrome may develop.
 (This is a painful condition that occurs when pressure within the muscles builds to
dangerous levels. This pressure can decrease blood flow, which prevents nourishment
and oxygen from reaching nerve and muscle cells. Unless the pressure is relieved
quickly, permanent disability may result. This is a surgical emergency.)
 Open fractures expose the bone to the outside environment. Even with good
surgical cleaning of the bone and muscle, the bone can become infected. Bone
infection is difficult to treat and often requires multiple surgeries .
Complications from Surgery.
 Infection.
 Injury to nerves and blood vessels.
 Blood clots.
 Fat embolism (bone marrow enters the blood stream and can travel to the lungs; this can also
happen from the fracture itself without surgery).
 Malalignment or the inability to correctly position the broken bone fragments.
 Delayed union or nonunion (when the fracture heals slower than usual or not at all).
 Hardware irritation (sometimes the end of the nail or the screw can irritate the overlying
muscles and tendons.)
NURSING INTERVENTIONS
1.Provide emergency care if requires (hemostasis, respiratory care, prevention of
shock).
2. Provide fracture fixation to prevent following injury of tissues.
3. Observe signs of fat embolism (especially during first 48 hours after the fracture).
4. Monitor fluids input and output continuously, insert IV catheter, urinary catheter.
5. Monitor client’s vital signs.
6. Monitor client’s laboratory tests results for abnormal values.
7. Administer IV therapy, analgesics, antibiotics, and other medications as
prescribed.
8. Prepare client and his family for surgical intervention if required.
9. For client after surgical intervention provide routine postoperative care and teach
about possible postoperative complications.
10. Provide care to client with cast (observe signs of circulatory impairment – change
in skin color and temperature, diminished distal pulses, pain and swelling of the
extremity; protect the cast from damage).
11. Provide care to client in traction (check the weights are hanging freely, observe
skin for irritation and site of skeletal traction insertion for signs of infection; use
aseptic technique when cleaning the site of insertion).
12. In case of hip fracture and hip replacement maintain the adduction of the affected
extremity.
13. Provide respiratory exercises to prevent lung complications.
14. Observe for signs of thrombophlebitis, report immediately.
15. Provide appropriate skin care to prevent pressure sores.
16. Encourage fluid intake and high-protein, high-vitamin, high-calcium diet.
CLOSED FRACTURES
 Instruct the patient regarding the proper methods to control pain and edema
(elevate extremity to heart level,take analgesia as prescribed etc).
 Teach patient how to use assistive devices safely.
 teach exercises to maintain the health of unaffected muscles and to
strengthen muscles needed for transferring and for using assistive devices
(crutches,walker).
 provide health teaching regarding self care ,medication information,monitoring
potential complications .
 need for continuing health care supervision .
OPEN FRACTURES
 Administer IV antibiotics immediately upon the patients arrival in hospital
 Perform wound irrigation and debridement .
 Asses neurovascular status frequently
 Take the patient temperature regularly and monitor signs of infection.
(The objective of the management is to prevent infection and promote healing of
bone and tissue.)
 1.Acute Pain Related To Fracture And Surgery.
 2. Impaired Physical Mobility Secondary To Fracture
And Surgery.
 3.Knowledge Deficit Regarding Treatment Regimen
And Disease Condition.
 4.Risk For Fat Embolism Due To Fractutre Of Long
Bones.
 5.Risk For Infection Due To Surgical Intervention And
Injury .
ASSESSMENT
PLANNING
IMPEMENTATION
CUES/EVIDENCE
NURSING
DIAGNOSIS
GOALS AND DESIRED NURSING
OUTCOME
ORDER/ACTION
Subjective
Acute Pain
Related To
Fracture And
Surgery.
After series of
nursing
interventions the
client should
manifest a decrease
in pain scale from
5/10 to 0/10.
“I
have severe
pain while
moving my
lower limb” as
verbalized by
the patient
Pain scale 5/10 as 0 is the
lowest and
10/10 is the
highest
objective


Facial
grimace
Verbal
report of
pain.
RATIONAL FOR ACTION
1.Asses the
patients pain scale
and perception.
2.Monitor vital
signs and pain
scale .
1.To identify the onset
,intensity and duration of
pain.
2.To obtain base line vital
signs .
(Vital signs changes
during
pain and for
future comparison after
intervention.
3.Maintain
3.Relieves pain and
immobilization of prevents bone
affected part
displacement and
using cast,and
extension of tissue injury
skin traction.
.
4.Elevate and 4.Promotes venous
support injured return, decreases edema,
and may reduce pain.
extremity.
5.Teach
divertional
activities
6.Administer
analgesia as
prescribed .
5.To destract clients
attention from pain.
6.To relieve the pain.
EVALUATION
EVALUATION
After 12 Hrs Of Nursing
Interventions The Goals Were
Met As Evidenced By-

Decrease in Pain
scale from 5/10 to 0/10

No pain and discomfort

Verbalize relief of pain.

Positive response
during evaluation.

Display relaxed manner,
able to participate in
activities, and sleep and
rest appropriately.
Pain Control
ASSESMENT
CUES/EVIDENCE
NURSING
DIAGNOSIS
PLANNING
GOALS AND DESIRED
OUTCOME
IMPLEMENTATION
NURSING
ORDER/ACTION
SUBJECTIVE
Patient will be able to
1.Support affected part
using pillows. Provide
footboard, wrist splints,
trochanter.
‘’ I cannot move my
leg properly and I
have pain during
motion ‘’ as
verbaluized by the
patient.
IMPAIRED
PHYSICAL
MOBILITY
,ACUTE PAIN
SECONDARY
TO FRACTURE
AND SURGERY
Perform his physical
activity and free of
complications as
evidenced by ….

OBJECTIVE




Limited range
of motion.
Inability to
perform action
as instructed.
with cast on left
leg .
decreased



Participates in
activities of daily
living
Performs physical
activities
independently
Intact skin and
abcence of
thrombophlebitis
Normal bowel
pattern.
EVALUATION
RATIONAL FOR EVALUATION
ACTION
1.To maintain
position and
function and
reduce risk of
pressure ulcers.
2.Determine presence
of complications related .
to immobility such as
pneumonia ,elimination 2.To assess
presence of
problem ,decubitus
complications
ulcer.
AFTER 12 HOURS OF NURSING
INTERVENTIONS THE GOALS
WERE MET AS EVIDENCED BY…

Patient performs
physical activities
independently or with
assistive devices as
needed.

Free of complications of
immobility as evidenced
by intact skin ,absence of
thrombophlebitis ,normal
bowel pattern
Pt able to fully complete
passive range of motion
exercises withassistance
from the staff by the end
of this shift. Pt did not
complain of any pain
associated with exercise
session.
3.Promote well
3.Encourage adequate
intake of fluids 2-3L/day being and
maximize and
energy
production...
4.Instruct /assist patient
with active and passive
ROM excercises of
affected and unaffected
limb like
flexion,extension
abduction and
adduction.
4.Increases blood
flow to muscles
and bone to
improve muscle
tone, maintain
joint mobility;
prevent
contractures/atro
phy and calcium
resorption from
disuse .

Conclusion
•
A case of RTA patient with fracture of femoral shaft and was
unable to move his left lower extremity.
• Initially patient was on skin traction.
• Surgical treatment Intra Medullary Nailing done on 18/12/12.
• Patient is able to move on walker.
• Health education given on home care including physiotherapy .
• Patient was discharged on 30/12/2012.
• Patient was told to come for follow-up after 2 weeks.
Bibiliography
1.Lippincott manual of nursing practices 9 th edition.
2.www.Local health.com.
3.ortho info.aas.org.
4.Gray”s femur anatomy and physiology of human body.
5.www.health type .com
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YOU