DIPLOMA IN NURSING

CASE STUDY SEMESTER 6

TITLE:
CLOSE FRACTURE OF MIDSHARF RIGHT
FEMUR

NAME : ERNINA JOHNIOUS

ID NO : 03-200901-00391
GROUP :1
INTAKE : JANUARY 2009
CI NAME : MDM NANCY LO
 CONTENT
TITLE
A. INTRODUCTION OF THE CASE PATIENT

1.1 Patient information data

1.2 History of present injury

1.3 Patient progress notes

B. INTRODUCTION OF THE CASE STUDY

2.1 Definition

2.2 Types of fracture

2.3 Causes

2.4 Clinical manifestation

2.5 Immediate Managment

2.6 Medical managment

2.7 Complication

C. NURSING CARE PLAN

3.1 Nusing diagnosis & intervention

3.2 Health education

3.3 Discharge plan

SUMMARRY

CONCLUSION

REFERENCE
A. INTRODUCTION OF THE CASE PATIENT

1.1 Patient information data

Name : Mr. X-ray

Ic no : 031119-12-1371

Sex : Male

Age : 7 years

Race : Murut

Religion : Kristian

Address : Kg. saga

Nationality : Malaysia

Social status : NIL

Allergic : NIL

Date of addmission : 15 October 2010

Date of discharge : 20 October 2010

1.2 History of present injury

Patient fall from the tree and he cannot stand up.after that he feels right leg very
painful and swelling.He parents bring to the hospital and after take x-ray he diagnosis is
close fracture midsharft of right femur.
1.3 Patient progress notes

15 / 10 / 2010 ( On Addmission)

7.30 PM

Admitted by Dr. B, A&E warded at 7.30 pm on streacher and thomas splint,case

escorted by PPK.Patient complaint swelling and pain in the right leg.

Vital sign

BP : 118 / 82

Pulse : 112

Temp : 37.5 0c

Spo2 : 97%
Plan

1. Splinting
2. BUSE
3. Tab. PCM 250 mg
4. X-ray

10 PM

Patient complain pain and cannot sleep well.

Blood pressure high and level of pain is 6.

BP : 123 / 89

Plan

1. Tab. PCM 250 mg

2. Admitted in children ward

Reacheck BP after 30 minutes BP : 109 / 79

16 / 10 / 2010

8 AM

Close Fracture Midsharf of Femur

- No active complaint
- Sleep well
- No SOB

Plan

1. Monitor vital sign

2. KIV antibiotic
3. On skin traction today

Vital sign

BP : 101 / 80

Pulse : 102

Temp : 37.1 0c

Spo2 : 98%
10 AM

- On skin traction 2 kg with thomas splint

- On medication
- Allow orally
- Monitor pain score
- Arrangment physiotherapy

Medication

1. Tab PCM 250 mg

17 / 10/ 2010

8 AM

- Cont skin traction 2 kg

- No complaint
- Sleep well
- Off medication

10 AM

- Patient comfort, tolerance orally well

- No skin breakdown
- Positioning 2 hourly

Vital sign

BP : 98 / 68

Pulse : 105

Temp : 36.8 0c

Spo2 : 98%
Physiotherapy noted

- No active c/o today

- Patient sitting on the bed, alert and coperative
- Both upper limb actively more
- No coughing noted
- Breathing pattern (symmetrical & diaphramatic)
18 / 10/ 2010

8 AM

- Cont skin traction 2 kg

- No complaint
- Sleep well

10 AM

- Patient comfort, tolerance orally well

- No skin breakdown
- Positioning 2 hourly

Vital sign

BP : 100 / 78

Pulse : 98

Temp : 36.6 0c

Spo2 : 99%
Physiotherapy noted

- No active c/o today

- Patient sitting on the bed, alert and coperative
- Both upper limb actively more
- No coughing noted
- Breathing pattern (symmetrical & diaphramatic)
19 / 10/ 2010

8 AM

- Cont skin traction 2 kg

- No complaint
- Sleep well

10 AM

- Patient comfort, tolerance orally well

- No skin breakdown
- Positioning 2 hourly

Vital sign

BP : 99 / 75

Pulse : 115

Temp : 37.7 0c

Spo2 : 99%
Fever today and tepid sponging apply

Repet temperature after 30 minuts

Temp : 36.9 oc

Physiotherapy noted

- No active c/o today

- Patient sitting on the bed, alert and coperative
- Both upper limb actively more
- No coughing noted
- Breathing pattern (symmetrical & diaphramatic)
20 / 10/ 2010

8 AM

- Cont skin traction 2 kg

- No complaint
- Sleep well

10 AM

- Patient comfort, tolerance orally well

- No skin breakdown
- Positioning 2 hourly
- Discharge today
- Go to hospital Keningau to do POP

Vital sign

BP : 108 / 70 mmHg

Pulse : 106

Temp : 36.7 0c

Spo2 : 96%
B. INTRODUCTION OF THE CASE STUDY
Fractures of the femur are common childhood injuries and among the most common
causes of hospitalization for pediatric orthopedic injuries. The strong blood supply of
the fracture femur allows for rapid healing and generally favorable outcomes. The
treatment for fractures fracture varies based on the child's age and injury with a trend
towards operative stabilization.

Several observational studies have identified a bimodal age distribution for fractures
femur with peaks in the toddler age group, where falls are the predominant cause of
injury, and in the adolescent age group, where motor vehicle collisions cause most of the
fractures. Across all age groups, boys have higher rates of femoral shaft fractures than
girls.

Fracture femur is one of the most common fracture treated at tertiary level centre's
requiring adequate radiological assistance. Providing distal locking zig arm support in
the nail has made it possible to treat fracture femur at primary level with acceptable
locking, without the additional support with added benefits on surgeons part of less
expertise, less surgery time, and good to excellent union rates and at the same time on
patients part, avoidance of radiological exposure, being economical availability at the
next door itself.

Complications were the same as seen with closed interlocking nail involving limb length
discrepancy malrotoation infection with added complication failure to lock distal end in
few cases.

Mortality from a femur fracture has been estimated at 1 per 600 patients but is most
often due to associated injuries sustained as a result of high energy.
2.1 Definition

A break in the femur bone. The femur is also known as the thighbone and is the main
bone that runs from the knee to the hip. It is one of the body's strongest bones in the
body and a lot of force is required to break it. A fractured femur is also known as a
femoral fracture.
2.2 Types of fracture

 Transverse
 Oblique
 Spiral
 Angulated
 Displaced
 Angulated & displaced
2.3 Causes

 Direct trauma
 Accident
 Falls
 Pressure
 Esp. In athletics
 Pathological fracture
 Decrease of density of the bones
 Others
 Osteoporosis
 Paget’s disease
2.4 Clinical manifestation

 Pain
 Loss of normal function
 Obvious deformity
 Excessive motion at sites
 Crepitus/grating sounds (crakling sounds produced by rubbing of the bones)
 Soft tissue edema
 Warmth over injured area
 Ecchymosis of the skin surrounding injured area (bluish black discoloration)
of the skin
 Loss of the sensation/ paralysis distal to injury
 Signs of shock
 Evidence of fracture on x-ray film
2.5 Immediate Managment

 Splinting & body alignment

 Elevation of body part

 Application of cold packs (1st 24 hours) to reduce hemorrhage, edema & pain

 Observe f0r change in colour, sensation & body temperature of injury part

 Observe for signs of shock

2.6 Medical managment

 Analgesics are given to treat the pain

 Antibiotics when there is open fracture or surgical intervention

 Maintenance of fragments in correct alignment thourgh immobilization

 Tetanus to toxoid IM ATT

 Prevention of excessive loss of joint mobility & muscle tone

Secondary managment

 Optimal reduction (replace bone fragments in their correct anatomy

position)
* Manual manipulation/closed reduction (traction pressure applied to
distal fragment
* Traction (application of the pulling force as means of contracting
the nautral tension in the tissue)
* Open reduction (surgical intervation that may use internal fixation
device
 Immobilization
*Traction –skin traction, skeletal traction
*Internal fixation –pins, screw,wires
Skin Traction
2.7 Complication

 Hypovolemic shock
* Control must be rapid
* Blood for grouping and X match (GXM)
* IV-Hartman’s, N/saline , Gelofundine
* Vital signs monitoring
* Blood transfusion
 Fat embolism (24-72 hours)
* Microglobules of fat from the bone marrow at the fracture sites normally
Femoral shaft and pelvis
* Contributing factors can also be the excessive movement of fracture sites
Sign & Symptoms
1.Respiratory Insufficiency
- Increased respiratory rate (Tachypnea)
- Use of accessory muscles
- Tachycardia, fever, chest pain
2.Petechial haemorrhage into the skin expecially at axilla, anterior chest wall
and conjunctiva
 Knee stiffness
* Early surgery and mobilization
* Gradual knee bending exercises
 Wound infection
* Common in compound fracture & surgical wound
 Osteomyelitis
* Inflammation of the bone
C. NURSING CARE PLAN

3.1 Nusing diagnosis & intervention

Nursing diagnosis Goal Intervention Evaluation

Pain related to Patient pain will be 1.Monitor level of Patient verbalized
fracture reduce. pain with pain less pain.
score. Observe facial
2. Administer expression.
analgesics as Level of pain less
ordered by doctor from 10 to 0.
to relieve pain.
3.Advise patient to
rest in bed.
4.Less movement
5.Inform doctor if
pain no less.

Anxiety related to Patient verbalized 1.Assess the severity Patient verbalized

fracture no anxiety. of the anxiety. less anxiety.
Sleep pattern and 2.Explain to patient Observed sleep
appetite good. recarding process pattern and apptiet.
to fracture.
3.Give spiritual
support.
4.Collaborate with
family members
to give emotional
support.

Nursing diagnosis Goals Intervention Evaluation

Potential impaired Patient skin remain 1.Assess condition Skin condition
skin integrity intact no signs of of skin for normal.
related to skin breakdown. breakdown.
immobility 2.Relieve pressure
by using ripple
bed, gloves filled
with water.
3.Maintain personal
hygiene.
4.Protect the skin
from moisture by
applying.
protective cream.
5.Change position
of patient 2
hourly.

Knowledge deficit Patient will be able 1.Assess the depth Patient understand
related to fracture explain the nature of knowledge. about the fracture
of the fracture, 2.Explain the and treatment.
treatment and patient the
complication. process and
Patient give Good effect of the
feedback when ask treatment.
the question. 3.Encourge patient
And family to ask
Question.
4.Give health talk
Repeatedly.

3.2 Health education

 Less movement
 Don't try to realign the bone or push a bone that's sticking out back in

When use cast

 Always keep the cast clean and dry

 If the cast become very loose as the swelling goes down, call the doctor
Especially if the cast is rubbing againts the skin
 Cover the cast with a plastic bag or wrap the cast to bath.Avoid shower
 Do not lean on or push on the cast, it may break
 Do not try to remove cast

3.3 Discharge plan

 Name : Mr. X-ray

Age : 7 years

Ward : Children ward

Sex : Male

Race : Murut

Date of addmission : 15 / 10 / 2010 @ 7.30 PM

Date of discharge : 20 / 10 / 2010 @ 2 PM

Diagnosis

Close fracture midshaft of right femur

No medication prescribed

Transfer to hospital Keningau to do POP

Follow up clinic appointment at 18 / 11 / 2010

CONCLUSION
The femur is the most commonly fractured long bone. It is undisputed that majority of
these fractures can be satisfactorily treated by close inter locking nail.

Femoral fractures in nonambulating infants are generally felt to be attributable to abuse

in the absence of significant trauma or underlying organic pathology. The investigation
of such fractures includes a report to appropriate social service and law enforcement
agencies, and legal involvement.

This paper describes  nonambulatory infants who sustained identical midsharftl femoral
metaphyseal fractures extending through the growth plate after playing in an infant
stationary activity center called an Exersaucer. It is possible that the twisting motion
provided by the Exersaucer (Evenflo, Picqua, OH) might be consistent with the
generation of forces necessary to cause these fractures.

REFERENCE
 1. Pati BN , Bansal VP , Krisnan LG , Ahmed A , Garg S . Interlocking nail of
femur. A review of 90 classes. Ind J Orthop. 2001, 35: 1, 49-51.
2. Clawson DK, Smith RF, Hansen ST. Closed intramedullary nailing of the femur.
J Bone Joint Surg (Am). 1971;50:681-69.
3. Hunter, JB. Femoral shaft fractures in children. Injury 2005; 36 Suppl 1:A86
4. Loder, RT ,O’Donnell, PW ,Feinberg, JR. Epidemiology and mechanisms of
Femur fracture in children. J Pediatr Orthop 2006;26:561.
5. Rewers, A, et al. Childhood femur fracture, associated injuries , and
sociodemographic risk factor; a population-based study. Pediatrics 2005;
115;e543

Summarry Patient
Mr. X-ray was addmitted to A&E department on 15 october 2010 with complaint pain
and swelling at right leg.During in A&E department the patient vital sign was taken BP
118 / 82 mmHg, Pulse rate 112/min and spo2 97%.During at home this patient no take
anything medication.

Mr. X-ray was admitted at children ward by Dr. B around 7.30 am.1st day Mr. X-ray in
the ward he still in the pain.ain the ward treatments and investigation has taken.Nursing
care have been done to this patient.This patient no have special treatment bescause he
no complaint pain and allow orally.Vital sign is normal.

This patient on skin traction and no complain pain.Patient stable and

comfortable.Patient discharge because transfer to hospital Keningau to do POP.