Transcript CASE PRESENTATION ON TIBIAL FRACTURE

NAME
: MR.S.K.R
 AGE/SEX
: 40YRS/MALE
 IP NO
: 196279
 DATE OF ADMISSION : 09/02/13
COMPLAINTS
: MULTIPLE
LACERATED WOUNDS IN RT
LEG,PAIN IN
RT WRIST,TENDERNESS OVER LT KNEE
 DIAGNOSIS
: COMMINUTED
TIBIAL SHAFT FRACTURE
 DISCHARGED ON
:30/12/12
GENERAL APPEARANCE
• Patient was drowsy for several minutes
• Unable to mobilize his rt lower extremity.
VITAL SIGNS OF THE PATIENT ARE
BP
: 120/80 mm of hg
PR
:86/mt
RR
:16/mt
SPO2 : 98%
SKIN

Skin is warm to touch.
 Tenderness over rt ankle
 Laceration on rt toes
 Noted abrasions on rt lower limb.
HEAD AND NECK
Hair Is Equally Disrtibuted.
Absence Of Dandruff.
EYES
Able to move both eyes
EARS


Patients pinna is same color as facial.
Able to hear sounds clearly .

No discharges
NECK AND THROAT



Lips are pink but dry.
Teeth is properly aligned with no dentures.
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
120/80mmof
hg.
GENITO URINARY
Normal pubic hair
GASTRO INTESTINAL
 No Tender Ness Of Abdomen and its soft .
MUSCULO SKELETAL




Unable To Mobilize His Lt Lower Limb.
Has Pain During Examination.
Tenderness at site of fracture
Lower extremity appear shortened
NEUROLOGIC


To Follow Commands.
No neurovascular deficit.
PRESENT MEDICAL HISTORY
Patient was brought to E.R by REDCRESCENT ambulance after
he was involved in R.T.A with complaints of :

MULTIPLE LACERATED WOUNDS IN Rt LEG,PAIN IN RT WRIST,TENDERNESS
OVER LT KNEE.
Patient was diagnosed with comminuted fracture on tibial
shaft rt leg.
PRESENT SURGICAL HISTORY
He underwent external fixation of tibia on the
same day of admission as an emergency case
PAST MEDICAL AND SURGICAL HISTORY
No past history
Investigations Done For The Patient
1.X-Ray skull ,chest ,hand and ankle
2. CT Scan (lumbosacral spine,lower extremity)
3.Blood investigations like
•PT INR
•SERUM
ELECTROLYTES
•RH TYPING and ABO
•CBC
LAB REPORTS
TEST on 17/12/12
CBC
HB
HCT
RBC
PLT
RESULT
11.1g/dl
33.8g/dl
4.02
REFERENCE RANGE
13.7-17.5g/dl
40.1-51.0g\dl
4.63-6.08 *10^6/ul
254
163-337/ul
sodium
134
135-150 mmol/l
pottassium
3.8
3.5-5.0mm0l/l
PT
13.1
10.0-17.0sec
APTT
28.1
26.1-36.3sec
INR
1.2
2.4theraputic
RH typing
B+ve
TREATMENT DONE FOR THE PATIENT
SURGICAL INTERVENTION_ EXTERNAL FIXATION OF RT TIBIA.
Medications
IV FLUIDS
N.S 0.9%
Dextrose 5%
ANALGESICS
• diclofenac 75mg im .
• pethedine 50 mg im.
ANTIBIOTICS
inj . augmentin 1.2 gm iv tid
inj. flagyl 500mg iv bd
inj .amikacin 500mg iv bd
• The tibia is the larger bone in your lower leg. Tibial shaft
fractures occur along the length of the bone.
Types of Tibial Shaft Fractures
The tibia can break in several ways.
The severity of the fracture usually depends on the amount of
force that caused the break. The fibula is often broken as well
Common types of tibial fractures include
STABLE FRACTURE: This type of fracture is barely out of place. The
broken ends of the bones basically line up correctly and are
aligned. In a stable fracture, the bones usually stay in place during
healing.
DISPLACED FRACTURE: When a bone breaks and is displaced, the
broken ends are separated and do not line up. These types of
fractures often require surgery to put the pieces back together.
.
Transverse fracture:
This type of fracture has a horizontal fracture line. This fracture can be unstable,
especially if the fibula is also broken.
Oblique fracture:
This type of fracture has an angled pattern and is typically unstable. If an oblique fracture is
initially stable or minimally displaced, over time it can become more out of place. This is
especially true if the fibula is not broken.
Spiral fracture:
This type of fracture is caused by a twisting force. The result is a spiral-shaped fracture line
about the bone, like a staircase. Spiral fractures can be displaced or stable, depending on
how much force causes the fracture.
Comminuted fracture:
This type of fracture is very unstable. The bone shatters into three or more pieces.
Open fracture:
When broken bones break through the skin, they are called open or compound fractures.
Open fractures often involve much more damage to the surrounding muscles, tendons,
and ligaments. They have a higher risk for complications and take a longer time to heal.
Closed fracture:
With this injury, the broken bones do not break the skin.
Although the skin is not broken, internal soft tissues can still be badly damaged.
In extreme cases, excessive swelling may cut off blood supply and lead to muscle death,
and in rare cases, amputation.
ANATOMY AND PHYSIOLOGY
Tibia is medial bone of the leg, also known as shinbone or
shankbone.
It is larger and stronger of the two bones of leg, i.e. it is stronger
and longer than fibula.It connects the knee with ankle and is the
major weight bearing force of body.Like all other typical long bones,
it has two ends and an intervening shaft.
The cross-section of tibia is triangular in shape
A.
Proximal end of tibia:
The proximal end of tibia is expanded and is a bearing surface for
weight of the body, which is transmitted through femur.
There are massive medial and lateral condyles and an intercondylar area
intervening between the condyles.
There is also a prominent tibialtuberosity
I.
Condyles:
There are two condyles of tibia: medial and lateral.
Both condyles have an articular surface proximally, which articulates with
corresponding condyles of femur.
There is an intercondylar area between the two condyles, which marks the
separation between the two. Both condyles are visible and palpable in
living subjects.
Lateral condyle has a fibular facet for attachment of fibula.
ii.
Tibial Tuberosity:
Is a little projection in the area where the anterior condylar surface merge
with each other.
It is divided into a proximal smooth and a distal rough region. To the
smooth part of tibial tuberosity attaches the patellar tendon.
B.Shaft of tibia:
shaft of tibia is triangular in cross section. Consequently, it consists of
three borders and three surfaces.
•
Borders:
The borders of tibia are named as: anterior border, medial border and
lateral (interosseous border).
•
Surfaces:
The surfaces of tibial shaft are named as: anteromedial surface,
posterior surface and lateral surface
C .Distal end of Tibia:
Distal end is slightly expanded and has 5 surfaces namely anterior,
medial, posterior, lateral and distal
The distal end of tibia is rotated laterally, an effect known as tibial
torsion.
The lateral surface of distal end contains the triangular fibular notch for
attachemnt of fibula.
Medial Malleolus:
It is a strong pyramidal process prolonged from the distal end of the tibia
medially.It ends proximal to the lateral malleolus, which is also more
posterior. Its main role is to deepen the articular surface for ankle joint.
Tibia/Fibula Anterior view
1.Lateral tibial
plateau
2.Tibial tuberosity
3.Fibular head
4.Fibular shaft
5.Lateral malleolus
6.Tibia plafond
7.Medial malleolus
8.Tibia shaft
9.Medial tibial
plateau
BLOOD SUPPLY TO TIBIA
Proximal end receives its blood supply form metaphyseal vessels, which arise
from genicular arterial anastomosis.
Nutrient foramen of tibia usually lies near the soleal line. The nutrient artery which is
transmitted through this foramen comes from posterior tibial artery.
oThe periosteal blood supply to the
shaft arises from anterior tibial
artery.
ometaphysis receives its blood from
anastomosis around the ankle joint.
The muscles of the leg may be divided into three groups: anterior, posterior, and lateral.
The Anterior Crural Muscles
Tibialis anterior.
Extensor digitorum longus.
Extensor hallucis longus.
Peronæus tertius
The Posterior Crural Muscles—The muscles of the back of the leg
are subdivided two groups—superficial and deep.
TheSuperficialGroup
Gastrocnemius.
Soleus.
Plantaris
The Deep Group
Popliteus.
Flexor hallucis longus.
flexor digitorius longus ,
tibialis posterior
1.
2.
High-energy collisions, such as an automobile or motorcycle crash.
Sports injuries, such as a fall while skiing or running into another player
during soccer.
SIGNS AND SYMPTOMS
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.
Obvious deformity such as angulation or shortening (the legs are not the
same length)
Breaks in the skin
Contusions (bruises)
Swelling
Bony prominences under the skin
Instability (some patients may retain a degree of stability if the fibula remains
intact or the fracture is incomplete)
.
Nonsurgical Treatment
Nonsurgical treatment may be recommended for patients who:
Are poor surgical candidates due to their overall health problems
Are less active, so are better able to tolerate small degrees of angulation or
differences in leg length
Have closed fractures with only two major bone fragments and little
displacement
•Initial treatment.
Your doctor may initially apply a splint to provide comfort and support. Unlike a full
cast, a splint can be tightened or loosened, and allows swelling to occur safely.
•Cast and functional brace.
One proven nonsurgical treatment method is to immobilize the fracture in
a cast for initial healing. After weeks in the cast, it can be replaced with a functional brace
made of plastic and fasteners. The brace will provide protection and support until healing
is complete.
SURGICAL TREATMENT
Intramedullary Nailing.
The current most popular form of surgical treatment for tibial
fractures is imnailing.
Plates and screws
These tools are reserved for fractures in which intramedullary
nailing may not be possible or optimal, such as certain fractures
that extend into either the knee or ankle joints.
External fixation.
In this type of operation, metal pins or screws are placed into
the bone above and below the fracture site.
Sharp fragments may cut or tear adjacent muscles, nerves, or blood vessels.
Excessive swelling may lead to compartment syndrome, a condition in
which the swelling cuts off blood supply to the leg. This can result in severe
consequences and requires emergency surgery once it is diagnosed.
Open fractures can result in long-term deep bony infection or osteomyelitis,
although prevention of infection has improved dramatically over the past
generation.
Surgical Complications
Malalignment, or the inability to correctly position the broken
fragments
Infection
Nerve injury
Vascular injury Blood clots (these may also occur without
surgery)
Nonunion (failure of bone to heal)
Angulation (with treatment by external fixation
1.Provide emergency care if requires (hemostasis, respiratory care, prevention of shock).
2. Provide fracture fixation to prevent following injury of tissues.
3. Monitor fluids input and output continuously, insert IV catheter, urinary catheter.
4. Monitor client’s vital signs.
5.Monitor client’s laboratory tests results for abnormal values.
6. Administer IV therap analgesics,antibiotics, and other medications as prescribed.
7. Prepare client and his family for surgical intervention if required
provide care to a client with cast (observe signs of circulatory impairment –
change in skin color and temperature, diminished distal pulses, pain and
swelling of the extremity;)
8.Observe for signs of thrombophlebitis, report immediately.
9. Provide appropriate skin care to prevent pressure sores.
10. Encourage fluid intake and high-protein, high-vitamin, high-calcium diet.
11. Teach the client appropriate crutch-walking techniques .
12.Provide emotional support to client, explain all procedures to decrease anxiety
and to obtain cooperation.
13. Instruct client regarding fracture healing process, diagnostic procedures,
treatment and its complications.
PRIORITIZATION OF NURSING PROBLEMS

Acute Pain Related To Fracture

Impaired Physical Mobility Secondary To Fracture

Knowledge Deficit Regarding Treatment Regimen And
Disease Condition.

Risk For Infection Due To open fracture.
.
ASSESSMENT NURSING
DIAGNOSI
S
Subjective
“I have severe
pain while
moving my
lower limb”
as verbalized
by the patient
Pain scale 7/10 as 0 is
the lowest
and 10/10 is
the highest
objective
 Facial
grimace
 Verbal
report of
pain.
PLANNING
IMPLEMENTATION
After series of
Acute
nursing
Pain
interventions the
Related To
Fracture
1. pain scale assessment
as per pain scale done
2.Maintained
client should
immobilization of
manifest a decrease affected part using
in pain scale from
cast,and skin traction.
7/10 to 2-3/10. with 4.Elevated and supported
in 12 hrs.
injured extremity.
5.Encouraged patient to
discuss problems related
to injury
6.Taught divertional
activities like listening to
music .
7.Administerd analgesia
as prescribed as per pain
scale
RATIONAL
1.To identify the onset
,intensity and duration of
pain.
2.Relieves pain and
prevents bone
displacement and
extension of tissue injury
.
4.Promotes venous return,
decreases edema, and
may reduce pain.
5.helps to relieve the
anxiety
6..To destract clients
attention from pain.
7.To relieve the pain.
EVALUATION
After 12 Hrs Of Nursing
Interventions The Goals
Were Met As Evidenced
By-

Decrease in
Pain scale from
7/10 to 2-3/10

Verbalize relief of
pain.

Positive
response during
evaluation.
Display relaxed
manner ,able to
participate in
activities

ASSESMENT
SUBJECTIVE
‘’ I cannot move”as
verbaluized by the
patient.
OBJECTIVE


Limited range of
motion.
Inability to
perform action
as instructed.
NSG
DIAGNOSIS
IMPAIRED
PHYSICAL
MOBILITY
SECONDAR
Y TO
FRACTURE
PLANNING
IMPLEMENTATION
Within 12 hrs Patient 1.Supported affected part
will be able to
using pillows. Provide
Perform his physical
activity and free of
complications as
evidenced by ….



footboard, wrist splints,
trochanter
RATIONAL
1.To maintain
position and reduce
risk of pressure
ulcers. .
.2.Instruct ed/assist ed in
2..Increases blood
collaboration with the
flow to muscles and
physiotherapist patient with bone to improve
Participates in
muscle tone,
active and passive ROM
activities of daily excercises of affected and
maintain joint
mobility
living
unaffected limb.
Performs
physical
activities
independently
Intact skin and
abcence of
thrombophlebiti
s
3.To identify
3.Determined presence of
complications
complications related to
immobility such as pneumonia
,elimination problem
,decubitus ulcer.
.4.Encouraged adequate intake 4. to promote
healing process.
of fluids 2-3L/day
5.Provide d/assisted/helped
mobility by use of wheel
chair,crutches,walker as soon
as possible..
5.Early mobility
reduces
complications of
bed rest (e.g.,
phlebitis) and
promotes healing
and normalization
of organ function.
EVALUATION
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 with
assistance from the
staff by the end of
this shift.

Encourage early ambulation by using crutches and wheel chair.
Encourage him to perform passive and active excercises.
Discuss prevention of recurrent fractures.
Teach symptoms needing attention such as numbness,decreased
function,increased pain,elevated temperature.
Teach the importance of follow up care.
Encourage follow up medical supervision to monitor for union
problems.
Encourage adequate balanced diet to promote bone and soft tissue
healing.
oA CASE OF RTA PATIENT WITH FRACTURE OF TIBIAL SHAFT WAS
UNABLE TO MOVE HIS LEFT LOWER EXTREMITY.
oPATIENT HAD UNDERGONE EXTERNAL FIXATION OF TIBIA AND D
FIBULA ON SAME DAY OF ADMISSION (09/02/13) AS AN INITIAL
EMERGENCY CARE AND LATER HE HAD UNDERGONE IM NAILING OF TIBIA
oPATIENT WAS DISCHARGED ON 24/02/13
oPATIENT WAS INSTRUCTED FOR FOLLOW-UP AFTER 2 WEEKS.