MEDICAL MANAGEMENT

IDEAL RATIONALE/ INDICATION ACTUAL REMARKS

Drugs, IV fluid/s, Blood
and/or Blood Products
Ideal medications for
Fracture, Open IIIA, complete,
comminuted, distal 3rd, femur
right: Medications:
1. Intravenous (IV) 1. To prevent infection of the wound, soft ▪ Gentamycin 80 mg IVTT q8H ANST - ▪ No untoward side-
antibiotics tissue, and bone, and to promote healing Administered on March 23, 2021 effects
of bone and soft tissue. ▪ Clindamycin 300mg 1 tab PO OD - ▪ No untoward side-
o First o Type III fractures often have Administered on March 23, 2021 effects
generation contamination from gram-negative
Cephalosporin organisms, and in the case of soil-
and contaminated wounds (i.e., farm
aminoglycosid injuries), additional coverage should
e (e.g., be added for anaerobic bacteria.
gentamicin) Typically, this would include penicillin
for the risk of a Clostridial infection. In
the treatment of open fractures in the
hospital setting, the surgeon must also
be concerned for nosocomial
infections, namely by Staphylococcus
aureus and aerobic gram-negative
bacilli such as Pseudomonas.
2. Intramuscular (IM) 2. Required if the patient is not fully up-to- ▪ It was not indicated in the case study if
tetanus toxoid date with their vaccination. Patient may there was any administration of IM tetanus
need tetanus vaccine if the injury has toxoid to the pt.
broken their skin. Tetanus is caused by
infection from Clostridium tetani, which is
an anaerobic bacterium commonly found in
soil, and the toxins produced by the
bacteria lead to severe and potentially life-
threatening muscular spasm.
3. IV opioid analgesic 3. Typically given to treat and manage pain ▪ Tramadol 50 mg IVTT PRN for pain - ▪ No untoward side-
agents (e.g., Administered on March 23, 2021 effects
morphine)

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Other medications and IVFs
given to the pt base on the
case:
4. Alfacalcidol 4. Management of hypocalcemia, secondary ▪ Alfacalcidol 100mg 1 tab PO OD - ▪ No untoward side-
hyperparathyroidism and osteodystrophy Administered on March 23, 2021 effects
associated with chronic renal failure.
5. PLR 5. Fluid substitution under the conditions of ▪ PLR 1L @30 gtts/min - Administered on ▪ No untoward side-
undisturbed acid-base balance or mild March 23, 2021 effects
acidosis; Isotonic and hypotonic
dehydration; Short-term intravascular
volume replacement; Vehicle solution for
compatible electrolyte concentrates and
drugs.
6. D5LR 6. Provides electrolytes and calories, and is a ▪ IVF to follow: (2-3-4) D5LR 1L @ 30gtts/min ▪ No untoward side-
source of water for hydration; Parenteral - Administered on March 23, 2021 effects
replacement of extracellular losses of fluid
and electrolytes, with or without minimal
carbohydrate calories, as required by the
clinical condition of the patient; Treatment
of shock; Persons needing extra calories
who cannot tolerate fluid overload
Home medications include: Home Medications:
7. Cefuroxime 7. Treatment of susceptible infections due to 1. Cefuroxime 500 mg 1 tab PO TID ▪ No untoward side-
group B streptococci, pneumococci, effects
staphylococci, H. influenza, E. coli,
Enterobacter, Klebisella, including
acute/chronic bronchitis, gonorrhea,
impetigo, early Lyme disease, otitis media,
pharyngitis/tonsillitis, sinusitis, skin/skin
structure, UTI, perioperative prophylaxis.
8. Celecoxib 8. Relief of signs/symptoms of osteoarthritis, 2. Celecoxib 200mg PRN for pain ▪ No untoward side-
rheumatoid arthritis (RA) in adults. effects
Treatment of acute pain, primary
dysmenorrhea. Relief of signs/symptoms
associated with ankylosing spondylitis.
Treatment of juvenile rheumatoid arthritis
(JRA).

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Diagnostic and Laboratory
Procedures
1. Basic blood test 1. Blood tests are another method used to ▪ Hematology and Urinalysis were performed. ▪ It was found on
diagnose certain bone diseases. One patient’s
example is osteoporosis, where blood tests hematology
are used to determine risk factors and rule results, that his
out other illnesses. For instance, blood WBC and
calcium levels can be measured to find out neutrophils count
whether someone is getting enough were beyond
calcium, but this does not provide any normal levels. It
information about how much calcium there could indicate
is in their bones. Other blood parameters bacterial infection.
may be used to detect signs of Neutrophils, which
inflammations, tumors or metabolic account for about
diseases which can affect the condition of 70% of white blood
the bones. cells, can increase
2. Clotting screen 2. This is a preoperative test since surgery in response to
can cause blood loss, so it’s important to bacterial
know if you have a clotting problem. infections. This
3. Urinalysis 3. Identify high bone turnover. condition is a
4. X-RAY 4. X-rays are usually used to confirm if a normal immune
bone is broken and to find the locations of response to an
any loose bony pieces. Your doctor will event, such as
order x-rays to help determine the extent of infection, injury,
the fracture. X-rays will show the number inflammation,
of breaks in the bone, as well as the some medications.
position and degree of separation ▪ There were few
(displacement) between the bony significant findings
fragments. found on the
5. CT-Scan 5. Computed tomography (CT) is not patient’s Urinalysis
indicated for the routine evaluation of results. His urine
common fractures. However, depending on transparency was
the bones involved and the degree of cloudy, RBC of
comminution, CT can be invaluable in the 20.3 which is
preoperative planning for complicated beyond normal,
fractures. This planning is paramount in WBC of 4.6 also
periarticular fractures in which intra- beyond the normal
articular involvement is suspected, such as range and his
in tibial plateau fractures. CT may also be urine was also
an important adjunct for assessing fracture protein positive.
Patient’s Name / Room No. | 3
 reduction and fixation.
6. MRI 6. To determine the MRI imaging patterns in
recent bone injuries following negative or
inconclusive plain radiographs. Few bony
injuries and most soft tissue injuries cannot
be detected on plain radiography.
Magnetic resonance imaging (MRI) can
detect such occult bony injuries due to
signal changes in bone marrow. In addition
to excluding serious bony injuries, it can
also identify tendon, ligament, cartilage
and other soft tissue injuries and thus help
in localizing the cause of morbidity.
7. Doppler ultrasound 7. Indicated to assess blood flow

Other ideal medical

management:
1. Wound irrigation 1. Washing the wound with large volumes of ▪ Performed preoperatively. ▪ No untoward side-
fluid will remove macro contamination and effects
clotting that may obscure the view of
deeper levels of contamination or
damaged tissue. Once the macro
contamination is eliminated, the irrigation
serves to diminish the residual bacterial
contamination of the remaining healthy
tissue. Irrigation is often done in
conjunction with surgical debridement
2. Skeletal traction 2. Skeletal traction is a pulley system of ▪ Traction care: Make sure that skeletal ▪ No untoward side-
weights and counterweights that holds the traction is never interrupted effects
broken pieces of bone together. It keeps
your leg straight and often helps to relieve
pain. This is to keep your broken bones as
aligned as possible and to maintain the
length of your leg.
3. Skeletal stabilization 3. Fracture stabilization is critical for
management of the injured extremity and
for the overall benefit of the patient. The
stability imparted to the bone helps
minimize ongoing trauma to the soft
Patient’s Name / Room No. | 4
 tissues and provides a stable scaffold for
tissue healing. Furthermore, bone stability
allows for early functional motion of the
extremity. Nursing care and mobilizing the
patient out of bed are facilitated as well.
4. Exercise the hip and 4. To preserve muscle strength; Active
the lower leg, foot, and muscle movement enhances healing by
toes on a regular basis increasing blood supply and electrical
potentials at the fracture site.
5. Physical therapy 5. This includes ROM and strengthening ▪ Discharge Orders ▪ Refer to Dr. Paul
exercises, safe use of assistive devices, Flores for rehab
and gait training. Performing specific (PT)
exercises both during and after the healing
process is essential to help restore muscle
strength, joint motion, and flexibility. Doctor
or a physical therapist will provide patient a
rehabilitation exercise plan.

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IDEAL
1. Debridement
2. Intramedullary bone
pins (Internal fixation)
SURGICAL MANAGEMENT
RATIONALE/ INDICATION ACTUAL REMARKS
1. Debridement is the removal of ▪ Debridement thigh, leg, application of delta ▪ Debridement was
devitalized tissue such as necrotic right leg and power transitional pin was performed on the
tissue, slough, bioburden, biofilm, and performed of March 23, 2021. day patient was
apoptotic cells. Debridement of an open admitted.
fracture must be done in a thorough
and systematic manner so as to avoid
leaving devitalized tissue or
contamination behind. The skin edges
of the traumatic wound should be
trimmed to a healthy bleeding edge.
Debridement is recognized as a major
component of wound management to
prepare the wound bed for re-
epithelialization. Devitalized tissue, in
general, and necrotic tissue, in
particular, serve as the source of
nutrients for bacteria. Devitalized tissue
also acts as a physical barrier for re-
epithelialization, preventing
applied topical compounds to make
direct contact with the wound bed to
provide their beneficial properties.
2. Currently, the method most surgeons ▪ Intramedullary bone pins are transversely ▪ Internal fixation is
use for treating femoral shaft fractures inserted on proximal 3rd right tibia with 10 kgs carried out
is intramedullary nailing. During this skeletal traction in place. immediately.
procedure, a specially designed metal
rod is inserted into the canal of the
femur. The rod passes across the
fracture to keep it in position. Screws
are placed above and below the
fracture to hold the leg in correct
alignment while the bone heals.
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