INTRODUCTION REPORT

OF TIBIA FIBULA FRACTURE

A. Anatomy Physiology The

tibia or shin bone is the main skeleton or medial bone of the lower leg and fibula. The
tibia is a tube bone with a rod and two ends, namely: The upper end which is the surface of the
two plains of the joint surface of the femur and knee joint. The lower end that makes a joint
with three bones, namely the femur, fibula and talus.
The fibula or calf bone is the lateral bone of the lower leg, this bone is a pipe bone with a
rod and two ends
. Bone Functions
1) Gives strength to the body's skeleton.
2) Place of attachment of muscles.
3) Protects important organs.
4) Place of manufacture of blood cells.
5) Mineral salt storage area.

B. Definition
of cruris fracture is a break in the continuity of the bone and is determined according to
the type and extent, occurs in the tibia and fibula bones. A fracture occurs when the bone is
subjected to stress greater than it can absorb. (Brunner & Suddart, 2002) Cruris
fracture is a condition of structural tissue discontinuity in the tibia and fibula (Silvia
Anderson Price, 1995)

C. Fracture
Classification There are four main classifications of fractures, namely:
 1. Incomplete
Fractures that involve only the cross section of the bone.
2. Complete
The fracture line involves the entire cross section of the bone and the bone fragments
are usually displaced or displaced (displaced from their normal position).
3. Closed (simple)
Fracture is not widespread and does not cause a tear in the skin.
4. Open (compound)
Bone fragments extending through the muscle and the skin is divided into 3 degrees:
Grade 1: wound less than 1 cm, slight soft tissue damage, no signs of crushing, simple
fracture or mild comminuted and minimal contamination.
Grade 2: laceration more than 1 cm, soft tissue damage, not extensive, moderate
comminuted fracture, and moderate contamination.
Grade 3: extensive soft tissue damage (skin, muscle and neurovascular structures) and
high degree of contamination.

D. Etiology
According to (Rasjad, 2009) the main causes of tibia fractures are caused by blows
that bend the knee joint and tear the medial ligament of the joint, direct impact on the tibia
bone, such as traffic accidents, and the fragility of the bone structure.fractures are as
follows:
1. traumaDirectof
Fractures caused by direct impact on bone tissue such as in traffic accidents, falls from a
height, and impact of hard objects by direct force.
2. Indirect trauma (indirect)
Fractures that are not caused by direct impact, but are caused by an excessive load on
bone or muscle tissue, for example, as in athletes or gymnasts who use only one hand to
support their body weight.
3. Pathological trauma
Fractures caused by disease processes such as osteomyelitis, osteosarcoma,
osteomalacia, Cushing's syndrome, complications of cortisone / ACTH, osteogenesis
imperfecta (a congenital disorder that affects the formation of osteoblasts). Occurs
because the bone structure is weak and breaks easily.
a. Osteoporosis occurs because the rate of bone reabsorption exceeds the rate of bone
formation, resulting in bone becoming porous and brittle and can fracture.
 b. Osteomyelitis is an infection of the bone and bone marrow caused by pyogenous
bacteria in which microorganisms originate from foci elsewhere and circulate
through the blood circulation.
c. Osteoarthritis is caused by damaged or thinning of the joint cushion and cartilage.

E. Clinical
Manifestations Clinical manifestations of tibial fracture are:
1. Severe pain in the fracture area, and increases when pressed / palpated
2. Unable to move the foot
3. Deformity occurs due to changes in the position of bone fragments. Can form an angle
due to the pressure of union and unbalanced muscle impulses. It is also possible to
shorten the lower extremity due to the pull of the lower extremity muscles as the
fragment slips and overlaps with other bone. And it can also occur rotationally due to
unbalanced pull by the muscles attached to the bone fragments so that the fracture
fragment rotates out of its normal longitudinal axis.
4. The presence of crepitus (palpable bone creaks) is caused by friction between one
fragment and another.
5. Ecchymosis or subcutaneous bleeding occurs due to damage to blood vessels so that
blood seeps under the skin around the skin area.
6. Swelling and discoloration of the skin occurs due to extravasation of blood and tissue
fluid around the fracture area.

F. Pathophysiology
G. Supporting
a. Examination X
Determine the area or location of at least 2 projections, anterior, posterior lateral.
b. Bone CT scan, MRI fomogram
To clearly see the damaged area.
c. Arteriogram (if vascular damage occurs)
d. Capillary blood count
- HT may increase (hema concentration) increase or decrease.
- Increased creatinine, drug trauma, increased renal creatinine.
- Calcium Ca levels, Hb

H. Management
The basic concepts that must be considered when treating fractures are: recognition, reduction,
retention, and rehabilitation.
1. Recognition / Recognition
History of events must be clear to determine the diagnosis and further action.
2. Reduction/Manipulation/Repositioning
is an attempt to manipulate bone fragments so that they return to their original optimal
state. The reduction method is divided into;

● Closed Reduction ; performed by returning the bone fragments to their position (the

ends are interconnected). The extremity is maintained in the desired position while in a
cast, splint or other device. Immobilization devices will maintain reduction and stabilize
the extremity for bone healing. X-rays should be taken to see if the bone fragments are
in the correct alignment.

● Traction: a device that can be used to pull a fractured limb to straighten the bone. The

weight of traction is adjusted to the muscle spasm that occurs.

o Skin traction is pulling the fractured bone by applying a plaster directly to the skin
to maintain its shape, helping to induce muscle spasm in the injured area and is
usually used for a short period of time (48-72 hours).
o Skeletal traction is traction used to straighten injured bones and long joints to
maintain traction, breaking the pins (wires) into the bone.
o Maintenance traction is a continuation of traction, continued strength can be applied
directly to the bone with wires or pins.

● Open reduction: performed by surgically reducing bone fragments. Internal fixation

devices in the form of pins, wires, screws, nail plates, or metal bars are used to hold the
bone fragments in position until solid bone healing occurs. This device can be placed on
 the side of the bone or directly into the bone marrow cavity, it maintains a strong
approximation and fixation of the bone fragments.

⮚ OREF (Open Reduction External Fixation) is an open reduction with internal

fixation where the bone is transfixed above and below the fracture, screws or wires
are transfixed proximally and distally and then connected to each other by another
rod.
External fixation is used to treat open fractures with soft tissue damage. This device
provides stable support for communicative fractures (crushed or crushed). The pins
that have been installed are kept in position, then attached to the frame. This
fixation provides comfort for patients who have damaged bone fragments.

⮚ ORIF (Open Reduction Internal Fixation) is a fracture management method by

means of open reduction surgery and internal fixation where an incision is made at
the site of the injury and is found along the anatomic plane of the fracture site.
3. Retention / Immobilization
It is an attempt to hold the bone fragments back to their original state optimally. Fracture
immobilization. After the fracture is reduced, the bone fragments must be immobilized, or
maintained in the correct alignment until fusion occurs. Immobilization can be done with
external or internal fixation. Methods of external fixation include dressings, casts, splints,
continuous traction, pin and cast techniques, or external fixators. Metal implants can be
used for internal fixation which acts as an internal splint to immobilize the fracture.
4. Rehabilitation
Aims to restore functional activities as much as possible to avoid atrophy or contractures.
If the situation allows, should immediately begin exercises to maintain limb strength and
mobilization.

I. Bone Healing Process

a. Hematoma or Inflammation Stage (1-3 days)
Hematoma is formed from blood that comes from torn blood vessels. Hematoma is covered
by surrounding soft tissue (periosteum and muscle). This happens about 1-2 x 24 hours.
b. Proliferation Stage (3 days – 2 weeks)
Cells proliferate from the inner layer of the periosteum around the fracture. These cells
become precursors of osteoblasts, and will grow towards bone fragments. Proliferation also
occurs in bone marrow tissue.
c. Callus Stage (2-6 weeks)
Osteoblasts form soft bone (callus) and provide rigidity to fractures. If you see a callus
mass on X-ray, it means the fracture has coalesced.
 d. Ossification Stage / Soft tissue hardening (3 weeks-6 months)
Callus hardens and closes the fracture hole (fracture gap) between the periosteum and the
cortex, joining the fragments. And gradually the bones become mature. Bone union that
can be confirmed by X-ray is said to have occurred when there is no movement with light
stress and no tenderness with direct pressure on the direct area.
e. Consolidation and Remodeling Stage (6 months – 1 year)
Unnecessary callus is removed/reabsorbed from the healed bone. The process of
reabsorption and storage of bone along the fracture line provides bone strength to
withstand all loads.

J. Complications
Complications that occur in tibial fractures are:
1. Early complications;
Compartment Syndrome : This complication is very dangerous because it can cause
vascularization of the lower extremities which can threaten the survival of the lower
extremities. The mechanism of fracture of the tibia occurs intra-compartment bleeding, this
will cause the intracompartmental pressure to rise, causing venous return to be disrupted.
This will cause oedema. With edema the intracompartmental pressure increases until it is
so high that it clogs the intracompartmental arteries. Symptoms are pain in the lower
extremities and paraesthesia is found, the pain will increase when the finger is moved
passively. If this continues long enough, paralysis of the extensor hallucis longus, extensor
digitorum longus and tibial anterior muscles can occur.
2. Long-term complications:

⮚ Malunion: In a condition where the broken bone has healed in an improper position.

Malunion is a bone healing characterized by increasing levels of strength and

deformity.

⮚ Delayed Union : is a healing process that continues at a slower pace than normal.

Delayed union is the failure of the fracture to consolidate in accordance with the time
it takes for the bones to join. This is caused due to decreased blood supply to the
bones.

⮚ Nonunion:is the failure of the fracture to consolidate and produce a complete, strong,

and stable connection after 6-9 months. Nonunion is characterized by excessive

movement of the fracture site to form a false joint or pseudoarthrosis. It is also
caused due to less blood flow.
K. Concepts of Nursing Care
In the assessment of the focus that needs to be considered in fracture patients, there are various
kinds, including:
a. History of current illness.
Review the chronology of trauma that caused cruris fractures, what help did you get, did you
go to a traditional healer for fractures. In addition, by knowing the mechanism of the
accident, nurses can find out other accident injuries. The presence of knee trauma indicates a
fracture of the proximal tibia. The presence of angulation trauma will cause a converse or
short oblique fracture, while rotational trauma will cause a spiral type. The main cause of
fractures is road traffic accidents.
b. Past medical history
In some circumstances, clients who have been treated with traditional healers for fractures in
the past often experience mal-union. Certain diseases such as bone cancer or cause
pathological fractures so that the bones are difficult to connect. In addition, diabetic clients
with foot injuries are at high risk of developing acute and chronic osteomyelitis and diabetes
which inhibits bone healing.
c Family history of disease Familial
disease associated with cruris fractures is one of the predisposing factors for fractures, such
as osteoporosis which often occurs in several generations and bone cancer which tends to be
inherited genetically.
d. Functional health pattern
1) Activity/rest
Limitation/loss of function in the affected area (may be immediate, fracture itself or
occurs secondary to tissue swelling, pain)
2) Circulatory
a. Hypertension (sometimes seen as a response to pain or anxiety) or hypotension (loss of
blood)
b. Tachycardia (stress response, hypovolemia)
c. Decreased/no pulse distal to the injury, slow capillary refill, central to the affected
area.
d. Tissue swelling or hematoma mass on the injured side.
3) Neurosensory
a. Loss of movement / sensation, muscle spasm
b. Numbness / tingling (paresthesias)
c. Local deformities: abnormal angulation, shortening, rotation, crepitus (creaking sound)
Muscle spasm, visible weakness / loss of function.
d. Agitation (may be body pain/anxiety or other trauma)
4) Pain/comfort
a. Sudden severe pain at the time of injury (may be localized to the area of tissue/bone
damage on immobilization), no pain due to nerve damage.
b. Muscle spasms/cramps (after immobilization)
 5) Safety
a. Skin lacerations, tissue avulsions, bleeding, discoloration
b. Local swelling (may increase gradually or suddenly).
6) Patterns of relationships and roles
The client will lose his role in the family and in society because the client must undergo
hospitalization.
7) Patterns of perception and self-concept
The impact that arises from a fractured client is the emergence of fear and disability due
to the fracture he experienced, anxiety, a sense of inability to carry out normal activities
and a wrong view of himself.
8) Sensory and cognitive patterns The tactile
power of fracture patients is reduced, especially in the distal part of the fracture, while
other senses and cognitive are not impaired. In addition, there is also pain due to fracture.
9) Patterns of values and beliefs
Fracture clients cannot worship properly, especially frequency and concentration in
worship. This is due to the pain and limitation of motion experienced by the client

L. . Nursing Diagnosis and Interventions.

1. Damage to skin integrity.
2. Impaired physical mobility.
3. Hivopolemic shock.
4. Disorders of tissue perfusion.
5. Acute pain
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E. Oswari, 2011, Bedah dan Perawatannya, cetakan VI, Jakarta.

Keliat Anna Budi, SKp, MSC,2010, Proses Keperawatan, penerbit EGC, Jakarta.
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Jakarta.
Rasjad Chaeruddin, Ph. D. Prof, 2009, Ilmu Bedah Orthopedi, cetakan IV, penerbit Bintang
Lamumpatue, Makassar
Brunner dan Suddarth, 2002. Keperawatan Medikal Bedah, Edisi 3. EGC: Jakarta
Price, Silvia Anderson. 2005. Patofisiologi: Konsep Klinis proses-proses pengkajian. Jakarta:
EGC