CASEPRESENTATIONONTIBIALFRACTURE：在脛骨骨折病例報(bào)告課件

1、CASE PRESENTATION ON TIBIAL FRACTUREPREPARED BY REMYA VISHWAMBARAN EMERGENCY ROOM 第1頁(yè)，共34頁(yè)。 DEMOGRAPHIC DATANAME : 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 : COMMINUTE

2、D TIBIAL SHAFT FRACTURE DISCHARGED ON :30/12/12第2頁(yè)，共34頁(yè)。PHYSICAL ASSESMENTGENERAL APPEARANCEPatient was drowsy for several minutesUnable 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%第3頁(yè)，共34頁(yè)。SKIN Skin is warm to touch. Tenderne

3、ss over rt ankle Laceration on rt toes Noted abrasions on rt lower limb. HEAD AND NECKHair Is Equally Disrtibuted.Absence Of Dandruff.EYESAble to move both eyes第4頁(yè)，共34頁(yè)。 EARSPatients pinna is same color as facial. Able to hear sounds clearly . No discharges NECK AND THROATLips are pink but dry. Teet

4、h is properly aligned with no dentures. No tenderness of node.THORAXThe Thorax Is Symmetric On Inspection第5頁(yè)，共34頁(yè)。 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 . CARDI

5、O VASCULAR第6頁(yè)，共34頁(yè)。 MUSCULO SKELETAL Unable To Mobilize His Lt Lower Limb. Has Pain During Examination. Tenderness at site of fracture Lower extremity appear shortenedNEUROLOGIC To Follow Commands. No neurovascular deficit.第7頁(yè)，共34頁(yè)。 Patient History PRESENT MEDICAL HISTORY Patient was brought to E.R

6、by REDCRESCENT ambulance after he was involved in R.T.A with complaints of : 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.PRESENT SURGICAL HISTORY He underwent external fixation of tibia on the sam

7、e day of admission as an emergency case PAST MEDICAL AND SURGICAL HISTORY No past history第8頁(yè)，共34頁(yè)。 Investigations Done For The Patient1.X-Ray skull ,chest ,hand and ankle2. CT Scan (lumbosacral spine,lower extremity)3.Blood investigations like PT INRSERUM ELECTROLYTES RH TYPING and ABOCBC第9頁(yè)，共34頁(yè)。 T

8、EST on 17/12/12 RESULT REFERENCE RANGECBC HB HCT RBC 11.1g/dl 33.8g/dl 4.02 13.7-17.5g/dl40.1-51.0gdl4.63-6.08 *106/ulPLT 254163-337/ulsodium 134135-150 mmol/lpottassium 3.83.5-5.0mm0l/lPT 13.1 10.0-17.0secAPTT 28.126.1-36.3secINR 1.22.4theraputicRH typingB+veLAB REPORTS 第10頁(yè)，共34頁(yè)。 TREATMENT DONE FO

9、R THE PATIENTSURGICAL INTERVENTION_ EXTERNAL FIXATION OF RT TIBIA. Medications IV FLUIDS N.S 0.9% Dextrose 5%ANALGESICS diclofenac 75mg im . pethedine 50 mg im.ANTIBIOTICSinj . augmentin 1.2 gm iv tid inj. flagyl 500mg iv bdinj .amikacin 500mg iv bd 第11頁(yè)，共34頁(yè)。Tibial shaft fractureThe tibia is the la

10、rger bone in your lower leg. Tibial shaft fractures occur along the length of the bone. 第12頁(yè)，共34頁(yè)。Types of Tibial Shaft FracturesThe 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 t

11、ypes of tibial fractures includeStable 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.Displaced fracture: When a bone breaks and is displaced, the b

12、roken ends are separated and do not line up. These types of fractures often require surgery to put the pieces back together.第13頁(yè)，共34頁(yè)。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: Th

13、is 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.第14頁(yè)，共34頁(yè)。Spiral fracture: This type of fracture is caused by a twist

14、ing 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

15、: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 bro

16、ken 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.第15頁(yè)，共34頁(yè)。ANATOMY AND PHYSIOLOGY Tibia is medial bone of the leg,

17、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-sect

18、ion of tibia is triangular in shape第16頁(yè)，共34頁(yè)。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. Ther

19、e is also a prominent tibialtuberosityCondyles: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 between the two condyles, which marks the separation between

20、the two. Both condyles are visible and palpable in living subjects.Lateral condyle has a fibular facet for attachment of fibula.ii. Tibial Tuberosity: Is a little projection in the area where the anterior condylar surface merge with each other.It is divided into a proximal smooth and a distal rough

21、region. To the smooth part of tibial tuberosity attaches the patellar tendon.第17頁(yè)，共34頁(yè)。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

22、(interosseous border). Surfaces:The surfaces of tibial shaft are named as: anteromedial surface, posterior surface and lateral surfaceC .Distal end of Tibia:Distal end is slightly expanded and has 5 surfaces namely anterior, medial, posterior, lateral and distalThe distal end of tibia is rotated lat

23、erally, 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

24、more posterior. Its main role is to deepen the articular surface for ankle joint.第18頁(yè)，共34頁(yè)。Tibia/Fibula - Anterior view Lateral tibial plateau Tibial tuberosity Fibular head Fibular shaft Lateral malleolus Tibia plafond Medial malleolus Tibia shaft 9.Medial tibial plateau 第19頁(yè)，共34頁(yè)。BLOOD SUPPLY TO T

25、IBIAProximal 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.The periosteal blood supp

26、ly to the shaft arises from anterior tibial artery.metaphysis receives its blood from anastomosis around the ankle joint.第20頁(yè)，共34頁(yè)。Muscles of tibia第21頁(yè)，共34頁(yè)。 The muscles of the leg may be divided into three groups: anterior, posterior, and lateral.The Anterior Crural Muscles Tibialis anterior.Extens

27、or digitorum longus.Extensor hallucis longus.Peronus tertiusThe Posterior Crural MusclesThe muscles of the back of the leg are subdivided two groupssuperficial and deep. TheSuperficialGroup Gastrocnemius.Soleus. Plantaris The Deep Group Popliteus. Flexor hallucis longus. flexor digitorius longus , t

28、ibialis posterior第22頁(yè)，共34頁(yè)。ETIOLOGY 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.

29、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 skinContusions (bruises)SwellingBony prominences under the skinInstability (some patients may reta

30、in a degree of stability if the fibula remains intact or the fracture is incomplete)第23頁(yè)，共34頁(yè)。.Treatment Nonsurgical TreatmentNonsurgical treatment may be recommended for patients who:Are poor surgical candidates due to their overall health problemsAre less active, so are better able to tolerate sma

31、ll degrees of angulation or differences in leg lengthHave 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 swel

32、ling 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

33、 healing is complete. 第24頁(yè)，共34頁(yè)。Surgical TreatmentIntramedullary Nailing. The current most popular form of surgical treatment for tibial fractures is imnailing.Plates and screwsThese tools are reserved for fractures in which intramedullary nailing may not be possible or optimal, such as certain frac

34、tures 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.第25頁(yè)，共34頁(yè)。 Complications Sharp fragments may cut or tear adjacent muscles, nerves, or blood vessels.Excessive swelling

35、 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 infect

36、ion has improved dramatically over the past generation.Surgical ComplicationsMalalignment, or the inability to correctly position the broken fragmentsInfectionNerve injuryVascular injury Blood clots (these may also occur without surgery)Nonunion (failure of bone to heal)Angulation (with treatment by

37、 external fixation第26頁(yè)，共34頁(yè)。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. Monitor fluids input and output continuously, insert IV catheter, urinary catheter. 4. Mon

38、itor clients vital signs.5.Monitor clients 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 circ

39、ulatory 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, hi

40、gh-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. 第2

41、7頁(yè)，共34頁(yè)。. 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.第28頁(yè)，共34頁(yè)。 ASSESSMENTNURSING DIAGNOSIS PLANNINGIMPLEMENTATION RATI

42、ONAL EVALUATION Subjective “I have severe pain while moving my lower limb” as verbalized by the patientPain scale - 7/10 as 0 is the lowest and 10/10 is the highestobjective Facial grimace Verbal report of pain. Acute Pain Related To Fracture After series of nursing interventions the client should m

43、anifest a decrease in pain scale from 7/10 to 2-3/10. with in 12 hrs. 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.5.Encouraged patient to discuss problems related to injury6.Taugh

44、t divertional activities like listening to music .7.Administerd analgesia as prescribed as per pain scale 1.To identify the onset ,intensity and duration of pain.2.Relieves pain and prevents bone displacement and extension of tissue injury .4.Promotes venous return, decreases edema, and may reduce p

45、ain.5.helps to relieve the anxiety6.To destract clients attention from pain.7.To relieve the pain. After 12 Hrs Of Nursing Interventions The Goals Were Met As Evidenced By-Decrease in Pain scale from 7/10 to 2-3/10Verbalize relief of pain.Positive response during evaluation.Display relaxed manner ,a

46、ble to participate in activities第29頁(yè)，共34頁(yè)。 ASSESMENT NSG DIAGNOSIS PLANNINGIMPLEMENTATIONRATIONAL EVALUATIONSUBJECTIVE I cannot move”as verbaluized by the patient.OBJECTIVELimited range of motion.Inability to perform action as instructed. IMPAIRED PHYSICAL MOBILITY SECONDARY TO FRACTURE Within 12 hr

47、s Patient will be able toPerform his physical activity and free of complications as evidenced by .Participates in activities of daily livingPerforms physical activities independently Intact skin and abcence of thrombophlebitis 1.Supported affected part using pillows. Provide footboard, wrist splints

48、, trochanter.2.Instruct ed/assist ed in collaboration with the physiotherapist patient with active and passive ROM excercises of affected and unaffected limb. 3.Determined presence of complications related to immobility such as pneumonia ,elimination problem ,decubitus ulcer.4.Encouraged adequate intake of fluids 2-3L/day 5.Provide d/assisted/helped mobility by use of wheel chair,crutches,walker as soon as possible.1.To maintain position and reduce risk of pressure ulcers. .2.Increases blood flow to muscles and bone to improve