Fracture:

Open I Tibia Fibula (R) Lacerated Wounded

Leg

Individual Case Study on

Philippine Orthopedic Center

Nursingcasestudy.blogspot.com
I. INTRODUCTION

The case was about a 6-year-old male who had an open fracture on his right lower
leg, which he incurred while crossing the street and was accidentally, bumped by a
jeepney. He was brought on a stretcher accompanied by relatives on POC referred
by Ospital ng San Jose Del Monte for debridement and for an external fixator.
Admitted on Aug 7, 2007.

A fracture is a break in the continuity of bone. It is defined according to type and

extent. Fractures occur when the bone is subjected to stress greater that it can
absorb. A direct blow, crushing force, sudden twisting motion, or even extreme
muscle contraction can cause fractures. Bones can fracture as a result of direct
trauma or indirect trauma. Direct trauma consists of direct force applied to the bone;
direct mechanisms include tapping fractures (eg, bumper injury), penetrating
fractures (eg, gunshot wound), and crush fractures. Indirect trauma involves forces
acting at a distance from the fracture site. Indirect mechanisms include tension
(traction), compressive, and rotational forces.

In the case of the patient he had a direct trauma (bumped by a jeepney) where he
had an open wound fracture, where his right lower leg was affected especially the
tibia and fibula.

I, a student nurse, will study on this particular case for familiarization of fractures as
well as execution of nursing skills in orthopedic cases rendering care to a patient.

a. Objectives

After successful accomplishment of this case presentation, the students will be

able to:

 Discuss the anatomy and physiology of the skeletal system that

are directly affected in the fracture and relate the concepts to the
actual situation of the patient. In this case the bones (phalanges)
in the foot.

 Explain the pathophysiology of a fracture.

 Determine the nursing priorities and nursing management

requisite and executable in a foot fracture, and incorporate these
in the creation of a pertinent nursing care plan

 Distinguish the different pharmacological actions of the drugs

involved in the treatment of a fracture, and identify the nursing
considerations that must be employed

 Formulate relevant health teachings and outpatient care for a

patient with a fracture.
II. NURSING ASSESSMENT

a. Personal Data
Patient’s Name: R.L.
Age: 6 y/o
Sex: Male
Address: Sapang Palay Bulacan
Civil Status: Single
Nationality: Filipino
Religion: Catholic
Admission Date: Aug 07, 2007

Chief complaint: Lacerated Wound Right Leg

Clinical impression: Open I Tibia Fibula (R) Leg Lacerated Wound

Attending physician: Dr. Mutia

b. History of Past Illness

The patient had complete immunization during her childhood. Non-hypertensive,

non-diabetic, non-asthmatic, no heart and circulation problems such as chest
pain, weakness, shortness of breath, slurred speech or problems with vision. No
allergies from aspirin and no history of stomach ulcers or bleeding. No past
hospitalizations occurred until present.

c. History of Present Illness

The patient had an accident while crossing the street, accidentally he didn’t
noticed the jeepney approaching from behind him. He was bumped by the
jeepney and sustained a direct trauma on his right leg. His tibia and fibula
sustained an open wound fracture. The patient was then immediately rushed in
Ospital ng San Jose Del Monte, was then x-rayed and had the result Open I Tibia
Fibula (R) Leg. The orthopedic surgeon referred for his debridement and fixator
to POC and was admitted Aug 07, 2007.

d. Psychosocial History

The patient was a male 6-year-old prep from Bulacan City. The client is active in
class, do homework and studies well. The client’s diet generally involved a
variety of home-cooked / home prepared. He had a good appetite. During
weekends he plays with his neighbors usual for a child’s play age.

e. Family History

The patient’s parents were both still living. The father is an electrician and
mother is a housewife. Parents had no established health problem. They were
both negative for having diabetes. Eldest of 3 children, youngest is 2 years old.
f. Physical Examination/Assessment

Patient’s Name: R.L.

Age: 6 y/o
Sex: Male
Address: Sapang Palay Bulacan
Civil Status: Single

Chief complaint: Lacerated Wound Right Leg

Clinical impression: Open I Tibia Fibula (R) Leg Lacerated Wound

Aug 07, 2007: T – 38.1°C PR – 100 bpm RR—20 bpm BP – 120/70 mmHg
Aug 08, 2007: T – 37.4°C PR – 97 bpm RR—19 bpm BP – 120/70 mmHg

HEAD

The skull is rounded with parietal prominence and smooth in contour. The skull is free of any
nodules, masses and depressions. The hair is thick, straight, black and shiny with equal
distribution. Portions of the scalp have no dandruff. No lesions are noted.

EYES

Patient did not wear eyeglasses and disclaimed having vision problems. The general character of
his face was calm and attentive. He had moderately thin eyebrows with rounded eyes that lied
symmetrical to the nose. No discharges were noted on both eyes. The conjunctiva appeared
lustrous pink, while the sclera looked white. The pupils were black and equally round. They were
reactive to light, showing constriction and dilation capabilities when stimulated by illuminating at
different distances.

EARS

The patient did not have any family history of hearing problems or any ear problems. The auricles
or pinna are aligned with the outer canthus of the eyes, did not possess any deformities, lumps and
lesions. No swelling and discharge were observed in the external canal. Client had no history of
hearing problem. Her auditory acuity was good as he was very sensitive and responsive to sounds
produced at varying distances.

NOSE

The nose was flat but symmetrical in shape. No inflammation, flaring, and lesions were present.
The internal mucosa was dry and void of any discharges.

MOUTH

The outer lips were pink and relatively moist, showing no signs of pallor or cyanosis. The interior of
the lips were smooth, moist and light pink. No lesions, edema, and ulcerations were found. The
gums and tongue likewise looked pink and moist. The tonsils were intact and un-inflamed.

NECK

The neck muscles (sternocleidomastoid and trapezius muscles) did not have any swelling or
masses. Head movements are coordinated, smooth and without any discomfort. The neck was
symmetrical in shape with no mass palpated along the lymph nodes. The neck muscles
demonstrated strength with the client’s ability to push his head against an antagonizing force of a
hand.

THORAX & LUNGS

The patient had no history of major respiratory ailments. He did not develop difficulties in
breathing. His breath sounds were auscultated and showed absence of wheezing, rales, and
stridor. The respiratory rates were 20 and 22 breaths per minute on April 18 and 19, respectively.

HEART

The patient alleged having no history of heart disorders. His heart sounds were auscultated and
was found free from murmurs. His pulse rates were 80 and 69 beats per minute on April 18 and
19, respectively.

ABDOMEN

The abdominal contour was not protuberant when in standing position. The abdomen was flat and
soft upon palpation and revealed no abdominal bowel sounds. Thise were no scars, lesions, and
hisnias marked.

EXTREMITIES

The hands and wrists were intact with complete sets of fingers. No swelling and redness was
evident. Client was easily & painlessly able to perform range of motion exercises with his hands
and wrists. The elbows showed no swelling and deformities. Patient had no problems extending
and flexing his forearms. Decreased Range of Motion on the right leg, swelling, open wound and
deformation found on the right leg. The rest of the legs and feet of the left side were unaffected and
demonstrated ability to perform range of motion exercises.

NEUROLOGICAL EXAMINATION

Patient was alert and well oriented with the time, place and people he was involved with. He was a
little bit shy but vocal about his emotions and feelings. Fear of the procedure. Inspite of shyness,
was able to communicate and interact well, and was very accommodating in answering questions.
III. ANATOMY & PHYSIOLOGY OF THE SKELETAL SYSTEM
(TIBIA AND FIBULA)
IV. PATHOPHYSIOLOGY / SYMPTOMATOLOGY

In the case of the client the major risk factor

Osteoporosis, Exercise and Sports was trauma where he was accidentally
RISK FACTORS Injury, Dental Emergencies, bumped by a jeepney
Perinatal Problems, Overuse,
Trauma

In the case of the client specifically open I tibia

AFFECTED PART Bones of Lower Right Leg fibula right leg.

The client had a open wound fracture.

DISEASE PROCESS FRACTURE

Signs and symptoms (Book Med Signs and symptoms experienced

Surgcial Nursing Lipincott Williams by the patient
and Wilkins 10 ed.)
 Felt extreme pain.
 Experiences muscle spasm  Can’t move his right leg and
and continuos pain that had an open wound .
increases in severity until bone  The right leg is swelling.
fragments are immobilized
 Loss of function, deformity,
abnormal movement, and
shortening of the extremity
may be noted.
 Crepitus, local swelling, and
discoloration may be seen.

Diagnostic Tests (Med Surgical Diagnostic Tests done on the

Nursig Saunders 6th ed.) patient

 Tomography – can be used to  X-Ray – was done to the

locate bone destruction, small patient upon rushed to Ospital
cavities, foreign bodies, and ng San Jose Del Monte
lesions overshadowed by other
structures.
 Bone Scans – images of the
skeleton are taken after
radioisotopes is injected
intravenously and allowed to
migrate to bone.
 Radiography – x-ray
examinations obtaining a plain
film, usually an anteroposterior
or lateral view, possibly both.
 Treatment (Illustrated Manual of Treatment on Patient
Nursing Practice Springhouse)
 Debridement and fixation –
 Drug Therapy procedure involves
 Surgery – arthroscopic debridement and a fixator to fix
surgery, open reduction and the fractured bone.
internal fixation, amputation,
laminectomy and spinal fusion,
joint replacement, etc.
 Non-surgical Treatments –
closed reduction,
immobilization

Nursing Management (Illustrated Nursing Management for the

Manual of Nursing Practice
Springhouse)
Patient preparation. If the patient will
be receiving a general anesthetic,
instruct him not to eat after midnight.
Tell him he’ll receive a sedative
before surgery. If appropriate,
explain how traction can reduce
pain, relieve spasms, and maintain
alignment while he awaits surgery.
Mention that he’ll need to wear a
bandage, sling, or cast
postoperatively to immobilize the
fracture or dislocation
patient:
Witnessed consent for procedure
signed and secured
Needed materials supplies and
material prepared. (fixator)
Explanation of procedure was
explained.
Skin preparation was done.
Post care rendered.
Back to room and on Diet as
Tolerated.

Five phases of fracture healing are the following (Frost, 1989):

1. Fracture and inflammatory phase

2. Granulation tissue formation
3. Callus formation
4. Lamellar bone deposition
5. Remodeling

Injury involves the actual fracture to the bone, including insult to bone marrow, periosteum,
and local soft tissues. Various biochemical signaling substances are involved in the formation of
the granulation tissue stage, lasting roughly 2 weeks. Within 7 days, the body forms granulation
tissue between the fracture fragments. The most important stage in fracture healing is the
inflammatory phase and subsequent hematoma formation. It is during this stage that the cellular
signaling mechanisms work via chemotaxis and an inflammatory mechanism to attract the cells
necessary to initiate the healing response.

During callus formation, cell proliferation and differentiation begin to produce osteoblasts
and chondroblasts in the granulation tissue. The osteoblasts and chondroblasts synthesize the
extracellular organic matrices of woven bone and cartilage respectively, and then the newly
formed bone is mineralized. This stage requires 4-16 weeks.

During the fourth stage, the meshlike callus of woven bone is replaced by lamellar bone,
which is organized parallel to the axis of the bone. The final stage involves remodeling of the
bone at the site of the healing fracture by various cellular types such as osteoclasts. The final 2
stages require 1-4 years.

Patients who have poor prognostic factors in terms of fracture healing are at increased risk
for complications of fracture healing such as nonunion, malunion, osteomyelitis, and chronic
pain.

Patient factors influencing fracture healing

Factors Ideal Problematic

Age (Farmer, 1984) Youth Advanced age (>40 y)
Trauma (Schemling, 1995) Single limb Multiple traumatic injuries
Medications (Giannoudis, 2000) None Nonsteroidal anti-
inflammatory drugs
(NSAIDs), corticosteroids
Social factors (Kwiatkowski, Nonsmoking Smoking
1996)
Local factors (Mollitt, 2002) No infection Local infection
Type (Rockwood, 1996) Closed fracture, Open fracture with poor blood
neurovascularly intact supply
Nutrition (Hernandez-Avila, Well nourished Poor nutrition
1991)

There were no signs of infection just swelling. It was a closed fracture and no skin break and the
patient was well nourished.
 V. NURSING MANAGEMENT
Name of Patient: R.L.
Age: 6 y/o
Sex : male
Religion: Catholic
Action
Immediate assessment includes airway,
breathing and circulation. Monitor the vital
signs until they are within normal limits and
stable.
Monitor the patient for signs and symptoms of
neurovascular compromise comparing
findings to the unaffected limb.
a) Check for diminished or absent
pedal pulses.
b) Check for capillary refill time. > 3 seconds
c) Observe for pallor, blanching,
cyanosis, and coolness of
extremity.
d) Check for complaints of
abnormal sensations, e.g.
tingling and numbness.
e) Observe for increased pain not
controlled by medication.
Monitor intravenous
infusions and continue
according to prescription of
surgeon or anaesthetist.
Assess the patient’s level of
pain control and administer
analgesia as prescribed. Ensure
that if a patient controlled
analgesia device (P.C.A.) is
used, the corresponding
hospital policy is followed. It is
important for the patient to
obtain effective pain relief in
order to start an early
programme of both limb and
deep breathing exercises in relative comfort
Date admitted: Aug 07, 2007
Chief complaint:
Diagnosis:
Rationale
• To assess the overall general
condition of the patient post
anaesthetic.
• Careful monitoring enables
early detection.
Surgical trauma causes swelling and edema, which
can compromise circulation and compress nerves.
Prolonged capillary refill time points to diminished
capillary
perfusion
These signs may indicate
compromised circulation.
These symptoms may result
from nerve compression.
Tissue and nerve ischaemia
produces a deep, throbbing
unrelenting pain.
• The patient’s status of
hydration needs to be
monitored to prevent
electrolyte imbalance or
circulatory overload.
• To monitor the effectiveness of
the prescribed analgesia. Pain
management is very important
to prevent vicious cycles of
pain, tension and anxiety that
breeds more pain and equally
important prevents
participation in physiotherapy
and self care.
Action Rationale
The patient’s Waterlow Score is assessed. • These measures help to minimise the risk of
Specifically assess skin over bony complications of skin breakdown. Frequent
prominences (sacrum, trochanters, scapulae, repositioning is required to alleviate pressure pain
elbows, heels, inner and outer knees, inner and discomfort. A thorough skin assessment should
and outer malleolus and back of head). Areas be carried out each time the patient is
where skin is stretched tautly over bony repositioned.
prominences are at a greater risk of
breakdown, because the possibility of
ischaemia to skin is high due to compression
of skin capillaries between a hard surface (i.e.
mattress, chair) and the bone.The decision to
nurse the patient on a pressure-relieving
mattress will depend upon the nurse’s clinical
judgement and the patient’s condition.

The wound dressing is monitored for oozing
from the incision site. If the patient has
a portovac, observe the drainage from the
wound through the portovac drains
and record appropriately.
• Careful monitoring enables early detection of
complications. Hypertension and vasospasm during
surgery can result in temporary haemostasis and
can result in delayed bleeding (Griffen
1999).

The leg and the external fixator must be • To prevent pain on movement, and to maintain
moved as a unit and the amount of support correct alignment.
required by the nurse is determined by the
patient’s ability to control the leg during
the move. The patient should use the
overhead monkey pole to assist with body
position changes.

Pin-sites and wounds must be constantly • Prophylactic antibiotics are

observed for signs of infection: Observations administered to prevent
should include determining pin stability, infection.
assessing skin tension at insertion site, noting
colour, odour and characteristics of any
drainage. Pin-sites should be attended to
under strict aseptic technique, initially daily
or more often as required.

Continuously assess the • Early detection and treatment.

patient for signs and symptoms
of: Deep Venous Thrombosis (D.V.T.)
Positive Homans Sign Swelling of leg,
Tenderness in calf.
 DRUG STUDY

DATE ORDERED MEDICATION AND ACTION INDICATION NURSING

TREATMENT CONSIDERATION

7-7-7 Generic Name: Inhibits protein Serious infections Used cautiously in

Amikacin Sulfate synthesis by binding caused by impaired renal
Brand Name: directly to the 30S pseudomonas function
Amikin ribosomal subunit. aeruginosa
Classification: Generally Obtain culture
Aminoglycosides bactericidal. sensitivity tests
before first dose.
50mg/ml IM / IV
infusion Q12 Weigh patient and
obtain baseline renal
function studies
before therapy
begins.

V. EVALUATION

PROGNOSIS

* Tibia and fibula fractures

Prognosis is generally good yet is dependent on degree of soft-tissue injury and

bony comminution.

Prognosis is good for isolated fibula fractures.

MEDICATIONS

Analgesics -- Pain control is essential to quality patient care. It ensures patient

comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many
analgesics have sedating properties that benefit patients who have sustained fractures.

Toxoids -- This agent is used for tetanus immunization. Booster injection in previously
immunized individuals is recommended to prevent this potentially lethal syndrome.
 EXERCISE

Consult with the patient’s doctor and physical therapist to coordinate

rehabilitation orders (exercise, Range of motion) and teaching. Describe the gait
teach and explain the reason why to do the exercise. Then demonstrate the gait
as necessary. Assist how to use his crutches.

Three point gait – patient who can bear only partial or no weight on one
leg. Instruct her to advance both crutches 6 to 8 inches (15 to 20 cm) along with
the involved leg. Then tell her to bring the uninvolved leg forward and to bear the
bulk of her weight on the crutches but some of it on the involved leg, if possible.
Stress the importance of taking steps of equal length and duration with no
pauses.
Teach the patient using crutches to get up from a chair, tell her to hold
both crutches in one hand, with the tips resting firmly on the floor. Then, instruct
him to push from the chair with her free hand, supporting herself with the
crutches. To sit down, the patient reverses the process, tell her to support herself
with the crutches in one hand and lower herself with the other.
Teach the patient to ascend stairs using the three point gait, tell her to
lead with the uninvolved and to follow with both the crutches and the involved
leg. To descend stairs, he should lead with the crutches and the involved leg and
follow with the good leg.

TREATMENT

Prehospital Care:

* Addressed airway, breathing, and circulation.

* Checked and documented neurovascular status.

* Applied sterile dressing to open wounds.

* Apply gentle traction to reduce gross deformities; splint the extremity.

* Administer parenteral analgesics for an isolated extremity injury in a

hemodynamically stable patient.

Emergency Department Care:

* Open fractures must be diagnosed and treated appropriately. Tetanus had been
updated and appropriate antibiotics given. This should involve antistaphylococcal
coverage and consideration of an aminoglycoside for more severe wounds. Orthopedics
consulted for emergent debridement and wound care. Fractures with tissue at risk for
opening protected to prevent further morbidity.
 * Compartment syndrome can develop in fractures of the lower leg.

Signs of compartment syndrome include crescendo symptoms, pain with passive

movement of involved muscles, paresthesias, pallor, and a very late finding is
pulselessness.

o If compartment syndrome is suspected, obtain an emergent orthopedic consult

and measure compartment pressures. Compartment syndrome must be treated
promptly with an emergency surgical fasciotomy. If untreated, the increased
compartment pressures can cause ischemia and necrosis of the structures within that
facial compartment and permanent disability.

* Tibial plateau fracture

o Immobilize nondisplaced fractures and have the patient remain

nonweightbearing.

o Obtain an orthopedic consultation for displaced (depressed) fractures, which

require open reduction and internal fixation. Articular depression of greater than 3 mm
may be considered for surgery.

* Proximal tibia fractures

o Surgically repaired proximal tibia fractures include external fixation, plating, and
intramedullary nailing.

HYGIENE

Instruct patient or family member in bathing and hygiene techniques. Have

one of them demonstrate it under supervision. Instructions to a family member
can be given in writing. Return demonstration identifies problem areas and
increases self-confidence.
Use of bedpan or urinal at bedside during night if the patient doesn’t want
to go up in the dark to go to the bathroom.

OUT-PATIENT CARE

Client should be reminded about his follow-up care with the physician after
one week.
Give referral on health care delivery system such as physical therapist
near to her location.
DIET
Diet as Tolerated was ordered by the physician to the patient. Stress the
importance of a high-carbohydrate and high-protein diet for adequate healing,
and then assist the client in making food choices as necessary.

SOCIAL ACTIVITIES

Patient will stay home, he can invite and accommodate friends at his
home. He can’t still go to school until proper instructions given by the doctor that
he can go to school already.