CASEPRESENTATION ON FEMORAL SHAFT FRACTURE

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CASEPRESENTATION ONFEMORAL SHAFT FRACTURE

• PREPARED BY
• 
  DHANYA VIJAYAN
• OPERATING ROOM

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DEMOGRAPHIC DATA

• NAME MR.M. K. Z
• AGE/SEX 19YRS/MALE IP NO
  192407
  
  
  
  
  
  
  
  
  
• DATE OF ADMISSION 17/12/12
• 
  
  DIAGNOSIS
  FEMORAL SHAFT FRACTURE
  
• SURGERY ON INTRAMEDULLARY
  NAILING ON 18/12/12
• DISCHARGED ON 30/12/12

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PHYSICAL ASSESMENT

• GENERAL APPEARANCE
• Patient is conscious and coherent.
• Looks weak and fatigue.
• Unable to mobilize his left lower extremity.
• VITAL SIGNS
• BP 124/86mm of Hg
• PR 82bpm
• RR 20cpm
• Temp 98.6F
• SPO2 98

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.

• SKIN
• Skin is warm .
• Has swelling on rt leg.
• Noted abrasions on rt arm and lower limbs

• HEAD
• Hair is equally disrtibuted.
• Absence of dandruff

• EYES
• Able to move both eyes
• On inspection of eyes ,the rt eye is reddish and
  the eyelid has dark discouloration .

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EARS

• Patients pinna is same colour as fascial.
• Able to hear sounds clearly .
• No discharges.

MOUTH

• Lips are pink but dry.
• Teeth is propely aligned with no dentures.

NECK

• No tenderness of node

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THORAX

• The Thorax Is Symmetric On Inspection

CARDIO VASCULAR

• Absence Of Chest Pain .
  
  
• Heart sounds are clear.
• Upon auscultation his Bp is 132/78mmof hg.

• GENITO URINARY
• 
  

• With foley catheter fr.16
• 
  

. GASTRO INTESTINAL
.

• No Tender Ness Of Abdomen and its soft .
  
• Had enema once and he was kept on NPO for 8hrs.

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. MUSCULOSKELETAL

• Unable To Mobilize His Lt Lower Limb.
• Has Pain During Examination.
• Cannot Perform ADL.
• Tenderness at site of fracture.
• Visible deformity.
• Lower extremity appear shortened.
• Crepitus noted with movement.

NEUROLOGIC

• Patient Is Mentally Alert And Oriented With
  Circumstances.
• Able To Follow Commands.
• No neurovascular deficit.

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PATIENT HISTORY

• PAST MEDICAL AND SURGICAL HISTORY
• H/O Adenotonsilectomy 10yrs back
• PRESENT MEDICAL HISTORY
• Patient was brought in E.R on 17/12/12 by RED
  CRESCENT due to R.T.A.After further
  investigations he was diagnosed with fracture
  on femoral shaft rt side.
• PRESENT SURGICAL HISTORY
• He underwent intramedullary nailing of lt femur
  on 18/12/12.

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INVESTIGATIONS DONE FOR THE PATIENT

• X-Ray Pelvic And Femur
• CT lower extremity
• CT lumbar and thoracic spine
• Blood investigations like
  
• CBC
• PT INR
• SERUM ELECTROLYTES
• RH TYPING

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TREATMENT

• SURGICAL INTERVENTION IM NAILING
  
  
• MEDICATIONS
• Inj .Risek 40mg od
• InjAugmentin1.2gm Bd
• Inj.Amikacin 500mg bd
• Inj.Perfelgan 1 gm.

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LAB REPORTS
TEST on 17/12/12 RESULT REFERENCE RANGE
CBC HB HCT RBC 12.1g/dl 35.8g/dl 4.81 13.7-17.5g/dl 40.1-51.0g\dl 4.63-6.08 106/ul
PLT 198 163-337/ul
sodium 138 135-150 mmol/l
pottassium 4.0 3.5-5.0mm0l/l
PT 13.4 10.0-17.0sec
APTT 29.2 26.1-36.3sec
INR 1.3 2.4theraputic
RH typing Abve
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TOPIC PRESENTATION

• FEMORAL SHAFT FRACTURE
• The femur is the anatomical name given to the
  thigh bone .It is the largest and strongest bone
  of the body. The long, straight part of the femur
  is called the femoral shaft.
• When there is a break anywhere along this
  length of bone, it is called a femoral shaft
  fracture.
• The most common types of femoral
  shaft fractures include
• Transverse fracture.
  
• In this type of fracture,
  the break is a straight horizontal line going
  across the femoral shaft.
• b.Oblique fracture.
  
• This type of fracture has an
  angled line across the shaft.

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C.Spiral fracture. The fracture line
encircles the shaft like the stripes on a candy
cane. A twisting force to the thigh causes
this type of fracture. d.Open or compound
fracture

If a bone breaks in such a way
that bone fragments stick out through the skin or
a wound penetrates down to the broken bone, the
fracture is called an open or compound
fracture. They have a higher risk for
complications especially infections and take a
longer time to heal. e.Comminuted fracture In
this type of fracture, the bone has broken into
three or more pieces.
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open fracture
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ANATOMY AND PHYSIOLOGY
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• The femur is the longest and strongest bone in
  the skeleton, is almost perfectly cylindrical in
  the greater part of its extent It is divisible
  into a body and two extremities .

• The Upper Extremity (proximal extremity),
  presents a head, a neck, a greater and a lesser
  trochanter

• The Head (caput femoris). is globular and forms
  rather more than a hemisphere and fits in to
  the acetabulam (a cup shaped socket in the
  pelvis) .

• The Neck (collum femoris).The neck is a
  flattened pyramidal process of bone, connecting
  the head with the body

• The Greater Trochanter (trochanter major great
  trochanter) is a large, irregular, quadrilateral
  eminence, situated at the junction of the neck
  with the upper part of the body.

• The Lesser Trochanter (trochanter minor small
  trochanter) is a conical eminence it projects
  from the lower and back part of the base of the
  neck.

Running obliquely downward and medialward from
the tubercle is the intertrochanteric line
(spiral line of the femur)
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• The Body or Shaft (corpus femoris).The body,
  almost cylindrical in form, is a little broader
  above than in the center, broadest and somewhat
  flattened from before backward below. it is
  strengthened by a prominent longitudinal ridge,
  the linea aspera.

The distal extremity of the femur (or lower
extremity) is larger than the proximal
extremity It consists of two oblong eminences
known as the condyles
Anteriorly, the condyles are slightly prominent
and are separated by a smooth shallow called the
patellar surface.
posteriorely they project considerably and a
deep notch, the Intercondylar fossa of femur, is
present between them.
The lateral condyle is the more prominent and is
the broader both in its antero-posterior and
transverse.
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• The lateral condyle is the more prominent and is
  the broader both in its antero-posterior and
  transverse.

• Each condyle is surmounted by an elevation, the
  epicondyle

• The medial epicondyle is a large convex eminence
  to which the tibial collateral ligament of the
  knee-joint is attached.

• The lateral epicondyle, smaller and less
  prominent than the medial, gives attachment to
  the fibular collateral ligament of the knee-joint.

• The articular surface of the lower end of the
  femur occupies the anterior, inferior, and
  posterior surfaces of the condyles. Its front
  part is named the patellar surface and
  articulates with the patella.

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BLOOD SUPPLY TO THE FEMUR

• THE FEMORAL ARTERY PASSES roundthe medial aspect
  of the femur to enter the popiliteal space where
  it becomes the popiliteal artery .it supplies
  blood to the structures of the thigh.
• Branches from the femoral artery
• Deep artery of the thigh (arteriaprofunda
  femoris) is the largest and main branch of the
  femoral artery and branches off the femoral
  artery about 2 to 5 cm below the inguinal
  ligament.
• Medial circumflex artery and lateral circumflex
  artery may arise from the deep artery or directly
  from the femoral artery.
• Great saphenous vein joins the femoral vein about
  3 cm below the inguinal ligament
• Deep vein of the thigh (profunda femoris vein)
  joins the femoral vein about 8cm below the
  inguinal ligament.

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MUSCLES

• The muscles in the front of the thigh are the
  sartorius and the quadriceps femoris.
• T he quadriceps is actually a powerful muscle
  made of 4 parts the rectus femoris, vastus
  lateralis, vastus medialis and vastus
  intermedius. While the sartorius flexes both the
  hip and knee joints, the quadriceps femoris is an
  extensor of the knee joint.
• The muscles in the inner aspect of the thigh are
  the pectineus, gracilis, adductor longus,
  adductor magnus, adductor brevis, obturator
  externus The adductor muscles also help rotate
  the thigh in an inward direction while the
  iliopsoas flexes the hip joint .
• The back of the thigh holds the powerful
  hamstring muscles, the biceps femoris,
  semitendinosus and semimembranosus. nd the
  iliopsoas. The hamstrings are all flexors of the
  knee joint.

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The important nerves of the thigh are the femoral
and the sciatic nerves
The femoral triangle is an anatomical region of
the upper inner human thigh.

• It is bounded by
• (superiorly) the inguinal ligament
• (medially) the medial border of the adductor
  longus muscle
• (laterally) the medial border of the sartorius
  muscle

• The three compartments of the femoral sheath
  (From lateral to medial)
• femoral artery and its branches
• femoral veins and its tributaries
• femoral canal, Which contains lymphatic vessels
  and some lymph nodes (Specifically, the deep
  inguinal lymph nodes

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ETIOLOGY

• due to a fall (usually from a height and often
  on to hard surface)
• due to direct blow to femur such as rta
• osteo porosis or malignan

• SIGNS AND SYMPTOMS
• Common Symptoms Are
• BLEEDING
• DEFORMITY OF THE LEG
• INABILITY TO MOVE THE AFFECTED LEG
• MUSCLE SPASMS
• NUMBNESS Or TINGLING
• SEVERE PAIN
• SWELLING

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• SERIOUS SYMPTOMS THAT MIGHT INDICATE A LIFE
  THREATENING CONDITION ARE.
• CONTUSION OR LOC EVEN FOR A BRIEF MOMENT
• HEAVY UNCONTROLLABLE BLEEDING
• INAVBILITY TO MOVE LEG
• HYPOTENSION
• PROTRUDING FRAGMENTS OF BONE THROUGH THE sKIN

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TREATMENT

• Nonsurgical Treatment
• Most femoral shaft fractures require surgery to
  heal. It is unusual for femoral shaft fractures
  to be treated without surgery. Very young
  children are sometimes treated with a cast.
• For the time between initial emergency care and
  surgery, doctor will place leg either in a
  long-leg splint or in skeletal traction. This is
  to keep broken bones as aligned as possible and
  to maintain the length of leg.
• (Skeletal traction is a pulley system of weights
  and counterweights that holds the broken pieces
  of bone together. It keeps leg straight and
  often helps to relieve pain.)
• EXTERNAL FIXATION
• External fixation is usually a temporary
  treatment for femur fractures. This device is
  stabilizing frame that holds the bones in the
  proper position so they can heal.
• Extensive comminution and open fractures
  were considered to be relative indications for
  the use of femoral external fixation as a
  definitive treatment for femoral shaft fractures.

Surgical Treatment
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INTRAMEDULLARY NAILING.It is the most common
treatment for femoral shaft fractures in
adults,An intramedullary nail can be inserted
into the canal either at the hip or the knee
through a small incision. It is screwed to the
bone at both ends. This keeps the nail and the
bone in proper position during healing. to
determine how
PLATE AND SCREWS
EXTERN AL FIXATION

• PLATE AND SCREWS
• The use of plate fixation for the routine
  treatment of femoral shaft fractures has
  decreased with the increased use of
  intramedullary nails.
• The main disadvantages associated with plate
  fixation when compared with intramedullary
  nailing are the need for an extensive surgical
  approach with its associated blood loss,
  infectious complications, and soft tissue insult.
• Because the plate is a load-bearing implant,
  implant failure is expected if union does not
  occur.

IM NAILING
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COMPLICATIONS

• Complications from Femoral Shaft Fractures
• The ends of broken bones are often sharp and can
  cut or tear surrounding blood vessels or nerves.
• Acute compartment syndrome may develop.
• (This is a painful condition that occurs when
  pressure within the muscles builds to dangerous
  levels. This pressure can decrease blood flow,
  which prevents nourishment and oxygen from
  reaching nerve and muscle cells. Unless the
  pressure is relieved quickly, permanent
  disability may result. This is a surgical
  emergency.)
• Open fractures expose the bone to the outside
  environment. Even with good surgical cleaning of
  the bone and muscle, the bone can become
  infected. Bone infection is difficult to treat
  and often requires multiple surgeries .
  
• Complications from Surgery.
• Infection.
• Injury to nerves and blood vessels.
• Blood clots.
• Fat embolism (bone marrow enters the blood stream
  and can travel to the lungs this can also happen
  from the fracture itself without surgery).
• Malalignment or the inability to correctly
  position the broken bone fragments. 
• Delayed union or nonunion (when the fracture
  heals slower than usual or not at all).
• Hardware irritation (sometimes the end of the
  nail or the screw can irritate the overlying
  muscles and tendons.)

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NURSING INTERVENTIONS

• 1.Provide emergency care if requires
  (hemostasis, respiratory care, prevention of
  shock).2. Provide fracture fixation to prevent
  following injury of tissues.3. Observe signs of
  fat embolism (especially during first 48 hours
  after the fracture).4. Monitor fluids input and
  output continuously, insert IV catheter, urinary
  catheter. 5. Monitor clients vital signs.6.
  Monitor clients laboratory tests results for
  abnormal values.7. Administer IV therapy,
  analgesics, antibiotics, and other medications as
  prescribed.8. Prepare client and his family for
  surgical intervention if required.9. For client
  after surgical intervention provide routine
  postoperative care and teach about possible
  postoperative complications.10. Provide care to
  client with cast (observe signs of circulatory
  impairment change in skin color and
  temperature, diminished distal pulses, pain and
  swelling of the extremity protect the cast from
  damage).11. Provide care to client in traction
  (check the weights are hanging freely, observe
  skin for irritation and site of skeletal traction
  insertion for signs of infection use aseptic
  technique when cleaning the site of
  insertion).12. In case of hip fracture and hip
  replacement maintain the adduction of the
  affected extremity.13. Provide respiratory
  exercises to prevent lung complications.14.
  Observe for signs of thrombophlebitis, report
  immediately.15. Provide appropriate skin care to
  prevent pressure sores.16. Encourage fluid
  intake and high-protein, high-vitamin,
  high-calcium diet.

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NURSING MANAGEMENT

• CLOSED FRACTURES
• Instruct the patient regarding the proper
  methods to control pain and edema (elevate
  extremity to heart level,take analgesia as
  prescribed etc).
• Teach patient how to use assistive devices
  safely.
• teach exercises to maintain the health of
  unaffected muscles and to strengthen muscles
  needed for transferring and for using assistive
  devices (crutches,walker).
• provide health teaching regarding self care
  ,medication information,monitoring potential
  complications .
• need for continuing health care supervision .
  
• OPEN FRACTURES
• Administer IV antibiotics immediately upon the
  patients arrival in hospital
• Perform wound irrigation and debridement .
• Asses neurovascular status frequently
• Take the patient temperature regularly and
  monitor signs of infection.
  
  (The
  objective of the management is to prevent
  infection and promote healing of bone and
  tissue.)

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PRIORITIZATION OF NURSING PROBLEMS

• 1.Acute Pain Related To Fracture And Surgery.
• 2. Impaired Physical Mobility Secondary To
  Fracture And Surgery.
• 3.Knowledge Deficit Regarding Treatment Regimen
  And Disease Condition.
• 4.Risk For Fat Embolism Due To Fractutre Of Long
  Bones.
• 5.Risk For Infection Due To Surgical Intervention
  And Injury .

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ASSESSMENT ASSESSMENT PLANNING IMPEMENTATION IMPEMENTATION EVALUATION
CUES/EVIDENCE NURSING DIAGNOSIS GOALS AND DESIRED OUTCOME NURSING ORDER/ACTION RATIONAL FOR ACTION EVALUATION
Subjective I have severe pain while moving my lower limb as verbalized by the patient Pain scale - 5/10 as 0 is the lowest and 10/10 is the highest objective Facial grimace Verbal report of pain. Acute Pain Related To Fracture And Surgery. After series of nursing interventions the client should manifest a decrease in pain scale from 5/10 to 0/10. 1.Asses the patients pain scale and perception. 2.Monitor vital signs and pain scale . 3.Maintain immobilization of affected part using cast,and skin traction. 4.Elevate and support injured extremity. 5.Teach divertional activities 6.Administer analgesia as prescribed . 1.To identify the onset ,intensity and duration of pain. 2.To obtain base line vital signs . (Vital signs changes during pain and for future comparison after intervention. 3.Relieves pain and prevents bone displacement and extension of tissue injury . 4.Promotes venous return, decreases edema, and may reduce pain. 5.To destract clients attention from pain. 6.To relieve the pain. After 12 Hrs Of Nursing Interventions The Goals Were Met As Evidenced By- Decrease in Pain scale from 5/10 to 0/10 No pain and discomfort Verbalize relief of pain. Positive response during evaluation. Display relaxed manner, able to participate in activities, and sleep and rest appropriately.Pain Control
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ASSESMENT ASSESMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/EVIDENCE NURSING DIAGNOSIS GOALS AND DESIRED OUTCOME NURSING ORDER/ACTION RATIONAL FOR ACTION EVALUATION
SUBJECTIVE I cannot move my leg properly and I have pain during motion as verbaluized by the patient. OBJECTIVE Limited range of motion. Inability to perform action as instructed. with cast on left leg . decreased IMPAIRED PHYSICAL MOBILITY ,ACUTE PAIN SECONDARY TO FRACTURE AND SURGERY Patient will be able to Perform his physical activity and free of complications as evidenced by . Participates in activities of daily living Performs physical activities independently Intact skin and abcence of thrombophlebitis Normal bowel pattern. 1.Support affected part using pillows. Provide footboard, wrist splints, trochanter. 2.Determine presence of complications related to immobility such as pneumonia ,elimination problem ,decubitus ulcer. 3.Encourage adequate intake of fluids 2-3L/day 4.Instruct /assist patient with active and passive ROM excercises of affected and unaffected limb like flexion,extension abduction and adduction.   1.To maintain position and function and reduce risk of pressure ulcers. . 2.To assess presence of complications 3.Promote well being and maximize and energy production... 4.Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility prevent contractures/atrophy and calcium resorption from disuse . 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 withassistance from the staff by the end of this shift. Pt did not complain of any pain associated with exercise session.
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• Conclusion
• A case of RTA patient with fracture of femoral
  shaft and was unable to move his left lower
  extremity.
• Initially patient was on skin traction.
• Surgical treatment Intra Medullary Nailing done
  on 18/12/12.
• Patient is able to move on walker.
• Health education given on home care including
  physiotherapy .
• Patient was discharged on 30/12/2012.
• Patient was told to come for follow-up after 2
  weeks.
• Bibiliography
• 1.Lippincott manual of nursing practices 9 th
  edition.
• 2.www.Local health.com.
• 3.ortho info.aas.org.
• 4.Grays femur anatomy and physiology of human
  body.
• 5.www.health type .com

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