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Open Type III-S Complete Comminuted Fracture D3-L Femur

A Case Study

Submitted to:Helen Ferriols. MAN

Clinical InstructorEast Avenue Medical Center

In Partial fulfillment of the Requirementsin the Related Learning Experience

Baquilar, Lorielyn D.Caloza, Anivill B.

Cantor, Christopher C.De Vega, Joyce M.

Echevarria, Adora S.Lovedioro, Vergel C.

Lozada, Rose Ann Shayne F.Madredeo, Ronalyn B.

Natividad, Brian C.Pring, Bernardino L.Salvador, Charles V.

Group CBSN III

Reasons for choosing the Case:

We choose this case because it requires a broader scope of research which will benefit us We chose this case to learn orthopedic in advance To have a study to share to our fellow student

Background Knowledge

A Fracture is a break in the continuity of bone and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures are cause by direct blows, crushing forces, sudden twisting motions, extreme muscle contractions. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause the fracture or by fracture fragments.

TYPES OF FRACTURE

Greenstick fracture: an incomplete fracture in which the bone is bent. This type occurs most often in children.

Transverse fracture: a fracture at a right angle to the bone's axis.

Oblique fracture: a fracture in which the break has a curved or sloped pattern.

Comminuted fracture: a fracture in which the bone fragments into several pieces.

An impacted fracture is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture. Other types of fracture are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack

A depressed fracture results from a force that drives a piece of bone down.  This fracture may effect the outer table of the skull, the inner table, or both if the force is strong and localized. This is a depressed fracture on the left parietal part of a skull.

An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma

An uncomplicated closed fracture/simple fracture in which the fractured ends of the bone do not break the skin.

A spiral fracture (also called a torsion fracture) is a bone fracture in which the bone has been twisted apart

A compression fracture occurs when the normal vertebral body of the spine is squished, or compressed, to a smaller height

Compound fracture: A fracture in which the bone is sticking through the skin. Also called an open fracture.

Skeletal Tractions

Patients Profile

Name: MC

Age: 57 years old

Date of Birth: July 7, 1952

Status: Widowed

Nationality: Filipino

Religion: Roman Catholic

Home Address: Batasan Hills Quezon City

Date of Admission: December 24, 2009

Time of Admission: 8:15 am

Admitting Diagnosis: Fx Open III-S Complete Comminuted D3-L Femur

Past Medical History

Highblood

Asthma

Breast Mass at Lateral aspect of the left Breast

Patient’s General Appearance

Date Performed: January 18, 2010Time: 9:00 am

Name: MCAge: 57 years oldPrimary Language: TagalogHeight: 5’3’’Weight: 54 kgVital Signs:

BP- 110/80 mmHGTemp- 36.9 CPR- 82 BPMRR- 22

Assessment:

Hair Color- Black and White

Body Build- Proportionate

Overall hygiene and grooming- Clean and neat

Note Body and Breath Odor- No Body odor; No Breath odor

Signs of distress in posture or facial Expression- no distress noted

Note obvious signs of Health/ Illness- Weak and with fractured at left Leg

Client’s Attitude- Cooperative and able to follow instructions

Client’s affect/mood; appropriateness of the responses- Appropriate to situation

Quantity of Speech, Quality and Organization- understable, clear tone; exhibits thought association

Relevance and organization of thoughts- makes sense; has sense of reality

Physical Assessment

PARTS TO BE ASSESSED

OBSERVATION MEASUREMENT NORMAL FINDINGS

INTERPRETATION

I. Gross general appearance

1.1 Height

1.2 Weight

1.3 Body Build

1.4 Posture/ Gait

1.5 Skin Color

1.6 Personal Hygiene/ Grooming

1.7 Body Breath Odor

1.8 Nutritional Status

1.9 Age appropriateness

1.10 Sensory status

fair skin color

neat and clean

No Body and Breath Odor

BMI: 21.1

Her face is Appropriate to her

ageWell developed

1.6 m

54 kg

normal posture

fair skin color

no foul smelling odorBMI: 18.5-24.9

Appropriate to Age

Well developed

Normal

Normal

Ectomorphic

Normal

Normal

Normal

Normal

Normal

Normal

Normal

2. Physiological Cues

2.1 Temperature

2.2 Pulse

2.3 Respiration

2.4 Blood Pressure

36.9 C

82 bpm

22 cpm

110/80 mmHG

36.5-37.5 C60-100 bpm16-22 cpm

120/80 mmhg

Normal

Normal

Normal

Normal

3. Behavior

3.1 Verbal(Speech-quality;

quantity; coherence; relevance;

pattern; organization of

thought)

-good speech quality

-understable, clear tone; exhibits

thought association

- good speech quality

-organized the thought

Normal

3.2 Non-verbalBody language

GestureMovement

Facial expressionAttitude

Affect/ moodAppropriateness of response

-can response to a body language-can do facial

expression

-can response to a body language

-can do facial expression

-

Normal

HEAD TO TOE PHYSICAL

EXAMINATION

TECHNIQUE NORMAL / STANDARD

ACTUAL FINDINGS

ANALYSIS

Head1. Skull

PalpationSize, shape, contour, any

lumps, deformities

-rounded-smooth skull

contour-absence of nodules

or masses

-symmetrical in shape

-smooth skull contour

-absence of nodules or

masses

Normal

2. Scalp / hair InspectionAppearance, hair

color, distribution, texture, presence of lice, nits and

dandruff

-hair evenly distributed

-hair black in color-silky hair

-no presence of nits and lice

-no presence of tenderness

-even distribution of

hair-black and white hair

color-silky

-no presence of nits and

lice-not tender

Normal

3. Face Inspection -rounded; -rounded Normal

Note symmetry, shape, expression, Appearance and

movements

symmetric or slightly asymmetric

facial features-symmetric facial

movements

-symmetric facial

movements

4. Eyes/Vision Eye Structuresa. Eyeball - noteAny protrusion

b. Lid marginsObserve scaling

Secretions, position,

Symmetry, ability to blink and frequency

c. Conjunctiva note color, appearance

d. Sclera – note Color, appearance

e. Pupils – size, Shape, symmetry, Reaction to light,

and accommodation

f. Eyebrows/lashesColor, symmetry, quantity of hair,

placement

g. Eye movement in all directions

-no protrusion

-lids close symmetrically-no secretion-symmetrical

-15-20 blinks/min

-transparent; shiny, smooth, and pink or

red

-sclera appears white in color

-pupil equally round reactive to light accommodation

(PERRLA)

-evenly distributed hair

-black and white in color

-symmetrically aligned

-curled slightly outward

-both eyes coordinated

(cardinal movement/s)

-no protrusion -symmetrical closeness of lids-no secretion

-symmetrical-can blinks

16/min

-pinkish in color-shiny

-white in color

-pupil equally round

-even distribution of

hair-black and

white-aligned

symmetrical

-coordinates by movement

Normal

Normal

Normal

Normal

Normal

Normal

Normal

5. Ears/hearing a. PinnaInspection

Parallelism, size, shape, appearance,

placement.

PalpationPalpate for

firmness of the cartilage and for

tenderness.b. External canal

InspectionCheck color,

appearance, and any discharge.

e. Hearing acuityWhisper from clients ear at a

distance of 2 feet away from the

clients back

-symmetrical; aligned with outer

canthus of eye, about 10 from

verical

-mobile, firm, and not tender; pinna recoils after it is

folded

-grayish tan color-presence of wet

cerumen in various shades of brown

-no discharge

-able to hear ticking in both ears

-normal voice tone (audible)

-symmetrical

-firm-not tender

- grayish an in color

-wet cerumen

-able to hear on both ears

Normal

Normal

Normal

Normal

6. Nose InspectionPlacement,

discharges and Patency

-symmetric and straight

-no discharge-air moves freely as

the client breaths through the nares

-midline alignment

-no discharge-air moves

freely

Normal

7. Mouth / lips InspectionColor, shape, moisture and symmetry, appearance

Gums

-uniform pink color-soft, moist, smooth

texture-symmetry of

contour-ability to purse lips

-pink gums-moist, firm texture

to gums

-pinkish in color

-soft, moist,smooth

-ability to purse lips

-pinkish in color

Normal

Color, appearance

TeethColor,

arrangement, general condition,

breathTongue

Size, color, shape, symmetry, moisture, movement

Palate – Hard / soft

Color, texture, shape

Soft Palate –(w/ penlight)

pink, smooth uvula in midline

Oropharynx / tonsil

Color, texture, elicit gag reflex

present

-no retraction of gums

-smooth, white, shinny tooth

enamel,

-pink color-moves freely

-moist; slightly rough

-symmetrically aligned

-lighter pink hard palate

-light pink, smooth-soft palate

-more irregular texture

-symmetrical in shape

-pink in color-uvula positioned in

midline of soft palate

-pink and smooth posterior wall

-gag reflex present

-firm and moist

-No more Tooth

-pinkish-symmetrical

-moist

-pinkish in color

-smooth-symmetry of

the shape

-pinkish-uvula present

in midline

-pinkish-smooth

-presence of gag reflex

Normal

Normal

Normal

Normal

Normal

8. Cheeks InspectionColor, appearance

-pink in color -Fair color Normal

9. Neck (Inspection)Symmetry, position,

movement (chin to chest, ear to

shoulder)

-symmetrical (muscles equal in

size)-coordinated,

smooth movements

-head centered

Normal

(Palpation)Palpate for lumps, nodes, tenderness

with no discomfort-complete range of

motion

-lymph nodes not palpable -not palpable Normal

10. ChestAnterior

Posterior

(Inspection)Note symmetry,

color, deformities, breathing pattern

(Palpation)Any lumps,

masses

InspectionSymmetry, retractions, deformities

Palpate for vocal (tactile) fremitus

AuscultateBreath sounds

-skin intact-quiet, rhythmic and

effortless respirations

-no masses

-chest wall intact-spinal column is

straight-right and left

shoulders and hips are at the same

height

-bilateral symmetry of vocal fremitus

-vasicular and bronchovesicular

breath sounds

-rhythmic respirations

Normal

11. Heart InspectionCheck for lifts,

heaves, pulsationPalpation

2nd ICS (right)Aortic valve2nd ICS (left)

pulmonic valve5th ICS (left sternal border) tricuspidmid-clavicular – below the nipple)

apical

AuscultationCheck cardiac rate

-complete pulsation of the heart, normal

heart sound

Normal

at apical area

InspectJugular Veins for

distention

-normal heart rate-usually heard at all

sites

-no distention-veins not visible

Normal

Normal

12. Breast InspectionSize, Shape,

symmetry, color, any dimpling,

discharges in the nipples

PalpationNote any mumps,

masses, tenderness,

(clockwise borders inward)

-skin uniform in color; skin smooth

and intact; no nipple discharge

-no tenderness, masses/nodules

-Presence of Breast

Mass(7x5 cm) at Lateral

Aspect of the Left Breast

Normal

Abnormal

13. Abdomen InspectionColor, contour, symmetry, skin integrity, scars

Auscultate for bowel sounds,

vascular sounds, peritoneal friction

rub

PalpationPalpate 4

quadrants, note areas of

tenderness, lumps, masses, distention in circular motion using finger pads.

PercussionPercuss 4

quadrants from

-unblemished skin; uniform in color;

symmetric contour

-audible bowel sound

-absence of arterial bruits

-absence of friction rub

-no tenderness; relax abdomen with smooth, consistent

tension

Normal

Normal

Normal

LQD clockwise, note any tympany

or dullness-tympany over the stomach and gas

filled bowels, dullness especially over the liver and spleen, or a full

bladder

Normal

14. Upper Extremities

InspectionSymmetry, size,

length, deformities, skin

lesions, scars, ROM movement

HandsSize, number of fingers, color of nail, capillary refill, hygiene

movement

-equal in size, both side of the body-range of motion

varies

-5 fingers in 1 hand-pinkish color, able to return after the

capillary refill

-symmetrical

-able to return capillary refill

within 2-3 seconds

-5 fingers in 1 hand

Normal

Normal

15. Lower Extremities

InspectionSymmetry, size, length, deformities, hair distribution, scars, lesions, movement (flexion, extension, rotation)

FeetInspectionColor, symmetry, deformities, number of toes, scars, lesions, hygiene. Movement (flexion, extension, rotation)

-no deformities, no skin lesion and

scars

-fair skin color-no scars/lesions-can extend, flex

and rotate-skin intact

-presence of Gun shot

wound at Left femur

-fair skin color

-presence of gun shot

wound at Left femur

-can’t extend and flex Left

Leg

Abnormal

Abnormal

Course in the ward

Doctor’s Order Nursing Responsibilities

1.) Maintain Tractions Inspect Integrity of Tractions Inspect for Infections Daily wound Dressing Educate Patient for proper

immobilization

2.) Safety Ensure Client’s Safety Side rail’s Up for safety Put Client’s belongings within reach Educate significant others about safety

precautions

3.) Refer for OR schedule Assess patient’s financial status Refer for Social service( PCSO, Phil

Health) Educate patient regarding operation

Anatomy and Physiology

Skeletal System

The skeleton has six main functions

Support- It provides the framework which supports the body and maintain its shape. Movement- The bones are the levers that help the body move in different directions and in

different ways. Protection

The skeleton protects many vital organs

Cranium protects the brain. Ribs/Sternum protects the lungs, heart and some digestive organs. Pelvis protects and supports the digestive and reproductive organs. Spinal column protects the spine..

Blood cell production

Inside of the long bones in our bodies, there is a cavity that is filled with a substance called Bone Marrow. In this tissue, new blood cells are produced, and damaged blood cells are repaired. Red bone marrow produces red blood cells, white blood cells and other blood elements.

The skeleton is the site of hematopoiesis, which takes place in red bone marrow. Marrow is found in the center of long bones.

Storage

Mineral is a substance that the body needs to carry out all of our bodily functions like thinking, breathing and moving around. One of the minerals that the body needs is calcium. Calcium is a major part of bone, and this is where the body stores its calcium.

Endocrine regulation

Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat.

Fractured femur with plate and screws

Laboratory Results

Hematology Dec. 24 Jan. 4 Normal UnitsWBC 22.1 15.9 5-10 Adults

9-20 New bornX109/L

Hemoglobin 119 95 140-170 M 120-140 F

gm/L

Hematocrit 0.367 0.28 0.45-0.50 M0.38-0.48 F

%

Neutrophils 0.86 0.46 0.31-0.76 Adult 0.40-0.50 Newborn

%

Lymphocytes 0.11 0.30 0.24-0.44 Adult 0.31-0.60 New

born

%

Monocytes 0.02 0.02 0.00-0.06 Adult %Eosinophils - 0.20 0.02-0.04 %Basophils - 0.02 0.00-0.01 %Bands 0.01 - 0.02-0.04 %Platelet Adequate 182 150-450 X109/LMCV 90.8 86.2 80-100 FlMCH 29.5 29.4 27-31 PgMCHC 325 341 320-360 g/LRDW 13.2 12.8 11.0-14.6 %

Serology Results Findings UnitsGlucose 4.8 3.9 mmol/L

N Cholesterol 4.4 0.0-5.2 mmol/LLDL Cholesterol 3.3 2.6-4.1 mmol/L

Triglycerides 0.94 0.4-1.7 mmol/LHDL-Cholesterol 0.64 0.91-1.56 mmol/L

Blood Urea Nitrogen 4.9 2.5-6.1 mmol/LCreatinine 78 53-115 umol/L

Sodium 138 135-148 mmol/Lpotassium 3.7 3.5-5.3 mmol/L