

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

 Ableto 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 defici

t.

 PRESENT MEDICAL HISTORY Patient was brought to E.R by REDCRESCENT he was involved in R.T.A with complaints of :  ambulance after

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.

 P RESENT 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

TEST on 17/12/12 CBC HB HCT RBC

LAB REPORTS

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 PLT sodium pottassium PT APTT INR RH typing 254 134 3.8

13.1 28.1

1.2

B+ve 163-337/ul 135-150 mmol/l 3.5-5.0mm0l/l 10.0-17.0sec

26.1-36.3sec

2.4theraputic

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 

S TABLE 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.



D ISPLACED 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 living subjects.

between the two condyles, which marks the separation between the two. Both condyles are visible and palpable in Lateral condyle has a fibular facet for attachment of fibula.

ii. Tibial Tuberosity with each other.

:

Is a little projection in the area where the anterior condylar surface merge 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 .

o The periosteal blood supply to the shaft arises from anterior tibial artery.

o metaphysis 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.

S URGICAL T REATMENT

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.

.

EVALUATION

DIAGNOSI S

Subjective “ I have severe pain while moving my lower limb” as verbalized Pain Related To Fractur e After series of nursing interventions the client should manifest a decrease in pain scale from 7/10 to 2-3/10 . with by the patient in 12 hrs.

Pain scale - 7/10 as 0 is the lowest and 10/10 is the highest objective  Facial  grimace Verbal report of pain.

1. pain scale assessment as per pain scale done 2.Maintained immobilization of affected part using cast,and skin traction.

4.

Elevated and supported injured extremity .

.

1.To identify the onset ,intensity and duration of pain.

2.Relieves pain and prevents bone displacement and extension of tissue injury 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

4.Promotes venous return,

pain.

decreases edema, and 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 may reduce pain.

5.helps to relieve the anxiety 6..To destract clients attention from pain.

7.To relieve the 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 RATIONAL EVALUATION

Within 12 hrs Patient will be able to Perform his physical 1.Supported affected part using pillows.

footboard, wrist splints, trochanter Provide activity and free of complications as

activities

.

2.Instruct ed/assist ed in evidenced by ….

 

physical

collaboration with the physiotherapist patient with Participates in active and passive ROM activities of daily excercises of affected and living unaffected limb.

Performs

3.Determined presence of complications related to

independently

immobility such as pneumonia  Intact skin and ,elimination problem abcence of ,decubitus ulcer.

thrombophlebiti s .4.Encouraged adequate intake 1.To maintain position and reduce NURSING INTERVENTIONS risk of pressure ulcers. .

2..Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility  3.To identify complications 4. to promote AFTER 12 HOURS OF 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 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. 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.

o A CASE OF RTA PATIENT WITH FRACTURE OF TIBIAL SHAFT WAS UNABLE TO MOVE HIS LEFT LOWER EXTREMITY.

o PATIENT 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 o PATIENT WAS DISCHARGED ON 24/02/13 o PATIENT WAS INSTRUCTED FOR FOLLOW-UP AFTER 2 WEEKS.