Case Study ON Tibial Fracture: University of Saint Louis

University of Saint Louis
Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
CASE STUDY
ON
TIBIAL FRACTURE
Jhoanna Mae T. Romias
BSN IV GROUP A
INTRODUCTION
I. DEFINITION
An incomplete or complete break in a bone caused by the application of too much force is
referred to as a fracture. A significant majority of bone fractures are caused by high force
impact or stress. The effects of crushing, which are brought on by direct hits, include soft tissue
edema, hemorrhage into the muscles and joints, joint dislocation, torn tendons, severe nerve
damage, and damaged blood vessels. Crushing also causes excessive muscle contraction and
rapid twisting motion. Any bone in the body is prone to fractures, and there are numerous
different ways that a bone mightbreak.
II. CLASSIFICATION OF FRACTURES
Closed fractures: If the injury doesn’t break open the skin, it’s called a closed fracture. This is
also called a simple fracture.
Open fractures: A fracture in which the bone breaks through the skin and can be seen outside
the leg. Or there is a deep wound that exposes the bone through the skin. This is also called a
compound fracture.
Complete fractures: The break goes completely through the bone, separating it in two.
Incomplete fractures: Bone cracks and bends but does not completely break.
Displaced fractures: There is a gap between the broken ends of the bone.
Non displaced: Which the bone cracks but retains its proper alignment.
Types of Bone Fractures
1. Transverse Fracture- Transverse fractures are breaks that are in a straight line across
the bone. This type of fracture may be caused by traumatic events like falls or
automobile accidents.
1. Spiral Fracture- This is a kind of fracture that spirals around the bone. Spiral fractures
occur in long bones in the body, usually in the femur, tibia, or fibula in the legs.
However, they can occur in the long bones of the arms. Spiral fractures are caused by
twisting injuries sustained during sports, during a physical attack, or in an accident.
1. Greenstick Fracture- This is a partial fracture that occurs mostly in children. The bone
bends and breaks but does not separate into two separate pieces. Children are most
likely to experience this type of fracture because their bones are softer and more
flexible.
2. Stress Fracture- Stress fractures are also called hairline fractures. This type of fracture
looks like a crack and can be difficult to diagnose with a regular X-rays. Stress fractures
are often caused by repetitive motions such as running.
3. Oblique Fracture- An oblique fracture is when the break is diagonal across the bone.
This kind of fracture occurs most often in long bones. Oblique fractures may be the
result of a sharp blow that comes from an angle due to a fall or other trauma.
4. Impacted Fracture- An impacted fracture occurs when the broken ends of the bone are
driven together. The pieces are jammed together by the force of the injury that caused
the fracture.
5. Segmental Fracture- The same bone is fractured in two places, leaving a “floating”
segment of bone between the two breaks. These fractures usually occur in long bones
such as those in the legs. This type of bone fracture may take longer to heal or cause
complications.
6. Comminuted Fracture- A comminuted fracture is one in which the bone is broken into 3
or more pieces. There are also bone fragments present at the fracture site. These types
of bone fractures occur when there is a high-impact trauma, such as an automobile
accident.
7. Avulsion Fracture- An avulsion fracture occurs when a fragment is pulled off the bone
by a tendon or ligament. These types of bone fractures are more common in children
than adults. Sometimes a child’s ligaments can pull hard enough to cause a growth plate
to fracture.
 A closed fracture is a bone break that does not cause skin or surrounding tissue injury.
Depending on how severe they are, fractures can heal in a few weeks to a few months.
The length of time depends on which bone is injured and whether there are any side
effects, like an infection or a blood supply issue.
 In a complete fracture, a bone breaks completely. It's snapped or crushed into two or
more pieces. Types of complete fracture include: single fracture, in which the bone is
broken in one place into two pieces and comminuted fracture, in which the bone is
broken or crushed into three or more pieces.
 A comminuted fracture is a break or splinter of the bone into more than two fragments.
Since considerable force and energy is required to fragment bone, fractures of this
degree occur after high-impact trauma such as in vehicular accidents or falls from a high
place.
 Displaced fracture are generally more complex because the bones are out of alignment,
or they may be in several pieces. The broken bone snaps out of place, and the broken
ends do not line up correctly.
III. STATISTICS
According to the Philippines Statistics

Authority (PSA), fractures accounted FRACTURE
for 8.8 percent of all occupational
injuries in 2016. Additionally, there
were 3,514 lower extremity fracture Lower Extremity
cases (or 19.7% of all injuries), 7,006 Wrist and Hand
arms and shoulder
cases of wrist and hand fractures (or
39.2% of all injuries), and then
fractures of the arms and shoulders
(16.7 percent or 2,979)
According to Internal Cause of Injury based on ONEISS 2014, fracture of patella, tibia or fibula,
or ankle had recorded a 0.579 case fatality rate or CFR with 1,036 total cases and reported 6
death cases in Philippines. According to ONEISS 2014, one of the most common internal causes
is the fracture of patella, tibia or fibula, or ankle. This kind of injury recorded 767 counts with a
percentage of 1.71 and a cum percentage of 88.25.
IV. RISK FACTORS
Age and Gender- Anyone are at risk for bone fractures. Studies stated that more men suffer
from fractures than women because of occupational hazards or physical activities.
Smoking- is a risk factor for fracture because of its impact on hormone levels. Women who
smoke generally go through menopause at an earlier age. Smokers, for example, often tend to
drink alcohol more, exercise less, and have poor diets.
Alcohol- Drinking alcohol in excess can influence bone structure and mass. Chronic heavy
drinking during a person’s earlier years can compromise bone quality and may increase the risk
of bone loss and potential fractures even after drinking has stopped.
Rheumatoid Arthritis- In this debilitating autoimmune disease which strikes two to three times
more women than men, the body attacks healthy cells and tissues around the joints, resulting in
severe joint and bone loss.
V. DIAGNOSIS
CT Scan (Computed tomography)- is a noninvasive diagnostic imaging procedure that uses a

combination of X-rays and computer technology to produce horizontal, or axial, images (often
called slices) of the body. CT scans of the bones can provide more detailed information about
the bone tissue and bone structure than standard X-rays of the bone, thus providing more
information related to injuries and/or diseases of the bone.
X-RAYS- Bone x-ray uses a very small dose of ionizing radiation to produce pictures of any bone
in the body. It is commonly used to diagnose fractured bones or joint dislocation. Bone x-rays
are the fastest and easiest way for the doctor to view and assess bone fractures, injuries and
joint abnormalities.
MRI (Magnetic Resonance Imaging)- These scans use a large magnet and a computer to take
pictures of the inner parts of the body from outside of the patient. The doctor will analyze
these pictures on a computer monitor to find any fractures.
VI. TREATMENT OR MANAGEMENT
INTERNAL FIXATION- Immobilization with a cast or splint heals most broken bones. However, a
person may need surgery to implant plates, rods or pins/screws to maintain proper position of
the bones called internal or external fixation, to hold the bone fragments together while they
heal. These might go inside or outside of the body.
EXTERNAL FIXATION- This is often a temporary solution that stabilizes the fracture while the
other injuries heal. The surgeon will put screws on either side of the fracture inside the body
then connect them to a brace or bracket around the bone outside the body.
SPLINT/CAST- Usually a splint or cast to keep an injured area in place, so that it will be
immovable. This will help the bone heal properly.
MEDICATION- A pain reliever such as acetaminophen or ibuprofen or a combination of the two,

can reduce pain and inflammation.
TRACTION- A person might need to use a pulley, string, weight, or metal frame to stretch the
muscles and tendons around the broken bone. This will help the ends of the bones stay in
position and heal properly.
BONE GRAFTING- A person might need bone grafting if a comminuted fracture is severely
displaced or if a bone isn’t healing back together as well as it should. The surgeon will insert
additional bone tissue to rejoin the fractured bone.
I. COMPLICATIONS
Blood loss- bones have a rich blood supply. A bad break can make a person lose a large amount
of blood.
Blood clots: Blockage of a blood vessel that can break free and move through the body.
Cast-wearing complications: Can include pressure ulcers (sores) and joint stiffness.
Compartment syndrome: Bleeding or swelling within the muscles surrounding the fracture.
Hemarthrosis: Bleeding into the joint, causing it to swell.
II. PREVENTION
To prevent for broken/fractured bones is by avoiding falls and other activities that have a risk
for accidents:
(For Indoors)
 Balance: Consider balance training and physical therapy if a person's body feels off.
 Clutter removal: Make sure home and workspace are free from clutter that could trip
you and others. Always use the proper tools or equipment at home to reach things.
Never stand on chairs, tables or countertops.
 Lights: Make sure the rooms all have good lighting.
 Rugs: Use skid-free mats under any rugs will be needed.
 Shoes: Wear shoes, not just socks when at home.
 Vision: Check eyesight with an eye exam by an optometrist.
(For Outdoors)
 Wear a seat belt on every trip

 Wear bicycle and motorcycle helmets
 Avoid using electronic devices or doing other activities in the car that distract you
from driving
 Don’t drink and drive or let others drive after drinking
 Walk facing oncoming traffic and wear highly visible reflective clothing if walking at
night
 Attention: Pay attention to every surroundings. Watch for anything that could turn into
an obstacle or cause to a trip.
 Balance: Use a cane or walker and wear rubber-soled shoes for a better grip.
 Curbs: Take care at curbs. Watch footing as taking a step.
 Lights: Leave a porch light on if coming home after dark.
 Staying fit- Weight-bearing exercise such as walking helps keep bones healthy and
strong. Exercises that build or maintain muscles can also improve balance.
PATIENT’S PROFILE
Name: Patient J.A.A
Age: 21
Gender: Male
Birth Date: September 19, 2020
Place of Birth:
Address: Alcala, Cagayan
Occupation: None
Civil Status: Single
Weight: 75kg (165.347 lbs)
Height: 5’9ft (175.26 cm)
BMI: 24.4 (Normal)
Nationality: Filipino
Language/s Used:
Religion: Roman Catholic
Educational Attainment:
Admission’s Date/Time: June 25, 2022 (12:40 am)
Chief Complaint: Vehicular Accident
Admitting Diagnosis: Fracture, Close, Complete, Comminuted, Displaced Tibial Plateau Right
Attending Physician: Dr. Alan Ryan Yu

Admitting vital signs
Temperature: 36.6
Pulse rate: 86
Respiratory rate: 18
Blood pressure: 120/80
Oxygen saturation:
Final vital signs
Temperature: 36.4
Pulse rate: 84
Respiratory rate: 20
Blood pressure: 110/70
Oxygen saturation: 98%
History of Present Illness
Patient J.A.A was involved in a car accident on the Baybayug a few hours prior to getting
admitted on June 25, 2022, while riding in a "kulong kulong." When a tire on the motor blew,
the patient tried to stop it, but the car began to sway and lose its balance. The patient's right
knee and leg were jammed between the vehicle and the ground. He was taken to the Alcala
municipal hospital right away, where he was given a pain reliever and referred to Divine Mercy
for an x-ray. He was then sent back to CVMC, where he was diagnosed with a Fracture, Close,
Complete, Comminuted, Displaced tibial plateau Right and is currently being treated there.
History of Past Illness
The patient J.A.A. received two doses of the Sinovac COVID vaccine in addition to receiving a
full course of vaccinations. He had never been in an accident before and had never had surgery.
The patient claims that although he was never admitted to the hospital, he was always able to
handle colds and fevers by getting lots of rest and taking over-the-counter drugs. Patient J.A.A
is has food alergy to eggs, poultry products and seafoods.
Family History
Mother Father
Age: Unknown Age: Unknown
(+) Hypertension Deceased
(+) Diabetes Meletus CKD (2019)
1st Child 3rd Child (Patient)

Age: 25 2nd Child Age: 21
No Known Disease Age: 23 Fractured Leg
No Known Disease
LEGENDS
- Female
- Male
- Patient (Male)
GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Health Pattern Before Hospitalization During Hospitalization
Health Perception-Health Patient J.A.A. defined health The patient defined his
Management as “Health, yun yung kapag health as “Di gaanong
wala kang sakit at kaya mong maganda kasi nga eto dahil
gawin ang trabaho mo” and sa disgrasya nasa hospital
believes to the statement ako imbes na tumutulong sa
that health is wealth. bahay”. The patient stated
According to the patient he that he can no longer do his
does not get sick very often usual activities due to his
before hospitalization thus, condition and rated is health
he rates his health as 10. He as 7 out of 10. Patient is
takes Vit. C to protect his currently taking Vitamin C
immunity and buys OTC and Vitamin D with calcium.
drugs such as paracetamol
and bioflu when he gets mild
fever or headache. He was
vaccinated with 1st and 2nd
dose of COVID-19 vaccines
without booster.
Nutritional-Metabolic Patient J.A.A eats three Patient J.A.A. eats three

Pattern meals a day—breakfast, times a day (breakfast, lunch,
lunch, and dinner—plus and dinner) with snacks in
snacks. He eats breakfast at between. “kapag nagugutom
eight in the morning, lunch at ako sa gabi, nagpapakuha
twelve in the afternoon, and ako kay mama ng cup
dinner at 6pm.in regular noodles yun yung kinakain
basis. Each day, the patient ko” as verbalized by the
drinks one liter of water. He patient. He eats breakfast at
typically eats 3-5 cups of rice 7a.m., lunch at 12p.m., and
with meat or fish, vegetables, dinner at 7p.m. The patient’s
and rice. The patient said, dietician has ordered diet as
"Madalas gulay at isda ang tolerated (DAT) for him.
ulam minsan lang mag ulam According to the patient, he
ng karne kasi mahal ang consumes more than a liter

presyo ng karne ngayon " The of water due to the high
patient stated that he hates temperature inside the
tangi, eggs, poultry products, hospital. The patient’s diet
and shellfish because of his consists of 1 cup of rice with
allergy. He doesn't have any meat or fish, vegetables, and
issues swallowing or eating fruits. When served with
his food. He does not smoke, chicken, he chose not to eat
and he does not consume it. He does not have any
alcoholic beverages. difficulty in chewing or
swallowing food. The patient
Weight: 75kg (165.347 lbs)
still has food allergy to
Height: 5’9ft (175.26 cm) seafoods, chicken, tangi, and
eggs.
BMI: 24.4 (Normal)
Elimination Pattern Patient J.A.A. usually voids 3 The patient voids 3x a day
times a day, once in the once in the morning and
morning, once in noon, and twice at noon. He describes
once at night, with an his urine as yellowish in color
amount of urine that is about and his urination was
3-5 glasses. He stated that his painless. The patient stated
urination was painless and is that he only defecated twice
clear white in color. Patient since admission because he
J.A.A. defecates once a day was shy to defecate in
and has no difficulty in hospital. He described his
defecating. He described his stool as brown in color and
stool as brown and slightly formed. He stated that he
formed. drank pineapple juice to
alleviate constipation.
Activity-Exercise Pattern Patient J.A.A. stated that he In attempt to rebuild his

exercises twice a week. He strength, patient J.A.A.
jogs from their house to their claimed that he performs
farm as his exercise. He also range-of-motion exercises in
plays basketball and rides his his unaffected area. He
bike. “ Naglalaro ako ng claimed that he doesn't have
basketball tsaka nagbibike any trouble breathing while

ako” as stated by the patient. exercising. The patient said
He has no breathing that his condition prevents
problems when exercising. him from moving extensively
He stated that he exercises to and that he spends much of
stay healthy. his time on his phone.
Sexuality-Reproduction When he was in fourth grade, The patient does not have
Pattern the patient underwent any sexual activities nor any
circumcision. When he was in experiences.
grade 9, he became aware of
the puberty-related changes.
He observed that the hair on
his face, genital region, and
armpits had grown. He has
never engaged in sexual
activity or had any sexual
encounters.
Sleep-Rest Pattern According to the patient During hospitalization,

J.A.A., he typically goes to Patient J.A.A. stated that he
bed at 4 am and gets up at 7 sleeps for 5 hours. He takes a
am. He said he takes two- nap for an hour and feels
hour naps around 4 or 5 irritated when he wakes up
o'clock in the afternoon and due to his condition. “Naiinis
that they leave him feeling ako kasi andito parin kami sa
sluggish. He doesn't have any hospital ang tagal na namin
trouble falling asleep and dito” as verbalized by the
doesn't take any sleep aids. patient. He stated that
The patient claimed that he sometimes he wakes up
occasionally wakes up during between sleeps because he
the night from nightmares. dreams about the accident
that he’s been through. He
does not use any sleep-
inducing drugs.
Cognitive-Perceptual Pattern Patient J.A.A. is oriented to Patient J.A.A. is oriented and

people, time and place, alert. He responds to

responses to stimuli verbally questions that are asked and
and physically. He can cooperates well.
understand and speak
Tagalog and Ilocano fluently.
Role-Relationship Pattern Patient J.A.A. belongs to a Patient J.A.A. stated that he

family of 6 which includes is getting his strength from
himself, his 2 siblings, her his family especially from his
mother and her 2 mother, and they have
grandparents from his always supported him and
mother side. He has a good showed their love for him by
relationship with is family giving him foods and calling
and she stated that they through phone. “Inaalagaan
always support each other ako nilang mabuti lalo na si
especially through hard mama kasi siya nagbabantay
times. When family problem sakin dito.” as verbalized by
occurs, he chooses to be the patient.
quiet. His role in the family is
to do simple house chores.
“Ako po yung nag huhugas ng
plato, nagwawalis sa bahay
at nagtitiklop ng mga damit.”
as verbalized by the patient.
They go to church and eat at

a restaurant as a form of
their family bonding. The one
who decides in the is their
mother. The patient stated
that he has a lot of friends
“kumakain po kami sa labas,
sa pancitan po at
nagmomotor” as their bond.
Self-perception – Self- Patient J.A.A. stated that he Patient J.A.A. stated that he
concept pattern perceived himself as a is still hopeful he would get

healthy person. He stated better. He was worried
that his negative trait was because his dream to be a
that he is “palasumbat sa policeman is at stake. He
magulang”. stated that he is currently not
satisfied with his body image
He described his positive trait
due to his leg fracture. The
as “masiyahin” and he also
patient stated that he wants
stated that he is satisfied by
to go home immediately and
his self-body image. He
finish his degree in
wants to be an engineer but
criminology.
chose to enter criminology
because he was unable to
pass the CSU entrance exam
and was also due to the
influence of his friends.
Coping-Stress Tolerance Patient JAA. verbalized that Patient JAA said that he is
Pattern the major cause of his stress currently stressed about his
is due to his studies. His way condition and his study
of relieving stress is through because he is an incoming 4th
cellphone or hanging out year this next school year.
with friends and jamming He copes up with his current
with them. stress by watching videos
using his cellphone and
playing mobile games.
Value-Belief Pattern Patient J.L. is a Roman Patient JAA. always prays

Catholic and he stated that that he will get better soon.
he always prays. He goes He believes that his faith will
with his family to the church help him recover from his
every Sunday. Patient claims condition. “Nag dadasal po
that he believes in ako na sana gumaling ako
superstitious belief like kaagad.” as verbalized by the
“magpagpag pagka galing sa patient. He always listens
patay” as verbalized by the every time there is a mass in
patient.
the hospital.
ANATOMY AND PHYSIOLOGY
Introduction
The skeletal system is composed of bones and cartilage connected by ligaments to form a
framework for the rest of the body tissues. There are two parts to the skeleton:
 Axial skeleton – bones along the axis of the body, including the skull, vertebral column
and ribcage;
 Appendicular skeleton – appendages, such as the upper and lower limbs, pelvic girdle
and shoulder girdle.
Function
 Support and movement
Bones are a site of attachment for ligaments and tendons, providing a skeletal
framework that can produce movement through the coordinated use of levers, muscles,
tendons and ligaments. The bones act as levers, while the muscles generate the forces
responsible for moving the bones.
 Protection
Bones provide protective boundaries for soft organs: the cranium around the brain, the
vertebral column surrounding the spinal cord, the ribcage containing the heart and
lungs, and the pelvis protecting the urogenital organs.
 Mineral homoeostasis
As the main reservoirs for minerals in the body, bones contain approximately 99% of the
body’s calcium, 85% of its phosphate and 50% of its magnesium. They are essential in
maintaining homoeostasis of minerals in the blood with minerals stored in the bone are
released in response to the body’s demands.
 Blood-cell formation (Haemopoiesis)

Blood cells are formed from haemopoietic stem cells present in red bone marrow.
Babies are born with only red bone marrow; over time this is replaced by yellow marrow
due to a decrease in erythropoietin, the hormone responsible for stimulating the
production of erythrocytes (red blood cells) in the bone marrow. By adulthood, the
amount of red marrow has halved, and this reduces further to around 30% in older age.
 Triglyceride storage
Yellow bone marrow acts as a potential energy reserve for the body; it consists largely
of adipose cells, which store triglycerides (a type of lipid that occurs naturally in the
blood).
Bone composition
Bone matrix has three main components:
 25% organic matrix (osteoid);

 50% inorganic mineral content (mineral salts);
 25% water.
Organic matrix (osteoid) is made up of approximately 90% type-I collagen fibers and 10% other
proteins, such as glycoprotein, osteocalcin, and proteoglycans It forms the framework for
bones, which are hardened through the deposit of the calcium and other minerals around the
fibers.
Mineral salts are first deposited between the gaps in the collagen layers with once these spaces
are filled, minerals accumulate around the collagen fibers, crystallizing and causing the tissue to
harden; this process is called ossification. The hardness of the bone depends on the type and
quantity of the minerals available for the body to use; hydroxyapatite is one of the main
minerals present in bones.
Figure 1 – Bone Structure
Structure
Bone architecture is made up of two types of bone tissue:
 Cortical bone;
 Cancellous bone.
Cortical bone
Figure 2 – Anatomy of cortical bone
Also known as compact bone, this dense outer layer provides support and protection for the
inner cancellous structure. Cortical bone comprises three elements:
 Periosteum
 Intracortical area;
 Endosteum.
The periosteum is a tough, fibrous outer membrane. It is highly vascular and almost completely
covers the bone. The periosteum has numerous sensory fibers, so bone injuries (such as
fractures or tumors) can be extremely painful. Tendons and ligaments attach to the outer layer
of the periosteum, whereas the inner layer contains osteoblasts (bone-forming cells) and
osteoclasts (bone-resorbing cells) responsible for bone remodeling.
The function of the periosteum is to:

 Protect the bone;
 Help with fracture repair;
 Nourish bone tissue.
Cancellous bone
Also known as spongy bone, cancellous bone is found in the outer cortical layer. It is formed of
lamellae arranged in an irregular lattice structure of trabeculae, which gives a honeycomb
appearance. The large gaps between the trabeculae help make the bones lighter, and so easier
to mobilize.
Trabeculae are characteristically oriented along the lines of stress to help resist forces and
reduce the risk of fracture. The closer the trabecular structures are spaced, the greater the
stability and structure of the bone.
Blood supply
Blood vessels in bone are necessary for nearly all skeletal functions, including the delivery of
oxygen and nutrients, homoeostasis and repair. Arteries are the main source of blood and
nutrients for long bones. The blood supply in long bones is derived from the nutrient artery
and the periosteal, epiphyseal and metaphyseal arteries. If the blood supply to bone is
disrupted, it can result in the death of bone tissue (osteonecrosis).
Growth
Bones are not fully developed at birth, and continue to form until skeletal maturity is reached.
By the end of adolescence around 90% of adult bone is formed and skeletal maturity occurs at
around 20-25 years.
Long, short and irregular bones develop from an initial model of hyaline cartilage (cartilage
models). Once the cartilage model has been formed, the osteoblasts gradually replace the
cartilage with bone matrix through endochondral ossification. Mineralization starts at the
center of the cartilage structure, which is known as the primary ossification center. Secondary
ossification centers also form at the epiphyses (epiphyseal growth plates).
Remodeling
Once bone has formed and matured, it undergoes constant remodeling by osteoclasts and
osteoblasts, whereby old bone tissue is replaced by new bone tissue. Bone remodeling has
several functions, including mobilization of calcium and other minerals from the skeletal tissue
to maintain serum homoeostasis, replacing old tissue and repairing damaged bone, as well as
helping the body adapt to different forces, loads and stress applied to the skeleton.
Calcium plays a significant role in the body and is required for muscle contraction, nerve
conduction, cell division and blood coagulation. As only 1% of the body’s calcium is in the blood,
the skeleton acts as storage facility, releasing calcium in response to the body’s demands.
Serum calcium levels are tightly regulated by two hormones, which work antagonistically to
maintain homoeostasis. Calcitonin facilitates the deposition of calcium to bone, lowering the
serum levels, whereas the parathyroid hormone stimulates the release of calcium from bone,
raising the serum calcium levels.
Osteoclasts are large multinucleated cells typically found at sites where there is active bone
growth, repair or remodeling, such as around the periosteum, within the endosteum and in the
removal of calluses formed during fracture healing. The osteoclast cell membrane has
numerous folds that face the surface of the bone and osteoclasts break down bone tissue by
secreting lysosomal enzymes and acids into the space between the ruffled membrane. These
enzymes dissolve the minerals and some of the bone matrix. The minerals are released from
the bone matrix into the extracellular space and the rest of the matrix is phagocytosed and
metabolized in the cytoplasm of the osteoclasts. Once the area of bone has been resorbed, the
osteoclasts move on, while the osteoblasts move in to rebuild the bone matrix.
Osteoblasts synthesize collagen fibers and other organic components that make up the bone
matrix. They also secrete alkaline phosphatase, which initiates calcification through the deposit
of calcium and other minerals around the matrix. As the osteoblasts deposit new bone tissue
around themselves, they become trapped in pockets of bone called lacunae. Once this happens,
the cells differentiate into osteocytes, which are mature bone cells that no longer secrete bone
matrix.
The remodeling process is achieved through the balanced activity of osteoclasts and
osteoblasts. If bone is built without the appropriate balance of osteocytes, it results in
abnormally thick bone or bony spurs. Conversely, too much tissue loss or calcium depletion can
lead to fragile bone that is more susceptible to fracture. The larger surface area of cancellous
bones is associated with a higher remodeling rate than cortical bone, which means osteoporosis
is more evident in bones with a high proportion of cancellous bone, such as the head/neck of
femur or vertebral bones.
As the body ages, bone may lose some of its strength and elasticity, making it more susceptible
to fracture. This is due to the loss of mineral in the matrix and a reduction in the flexibility of
the collagen.
Long bones
Typically, longer than they are wide (such as humerus, radius, tibia, femur), they comprise a
diaphysis (shaft) and epiphyses at the distal and proximal ends, joining at the metaphysis. In
growing bone, this is the site where growth occurs and is known as the epiphyseal growth
plate. Most long bones are located in the appendicular skeleton and function as levers to
produce movement
Tibia
The ‘tibia' is the Latin word for tubular musical instruments like the flute. They were sometimes
made from tibial bones of animals, so the length of the tibia was useful in many ways other
than just for bearing body weight while walking.
The tibia (shin bone) is a long bone of the leg, found medial to the fibula. It is also the weight
bearing bone of the leg, which is why it is the second largest bone in the body after the femur.
Like other long bones, there are three parts of the tibia: proximal, shaft, and distal. The
proximal part participates in the knee joint, whereas the distal part contributes to the ankle
joint. The tibial shaft on the other hand offers many sites for leg muscle attachment.
Figure 3 - Tibia
Proximal part
Figure 4 - Medial condyle of tibia
The proximal end of the tibia features several important landmarks which function as sites of
muscle attachment and articular surfaces: two tibial condyles (medial and lateral) separated by
intercondylar areas (anterior and posterior).
Figure 5 - Medial meniscus
The superior surface of the medial condyle is round in shape and somewhat concave, so it fits
perfectly into a joint with the medial condyle of the femur. The medial meniscus is sandwiched
between the tibia and femur in this joint with attachments to all margins except for the lateral
margin. Instead, the lateral margin extends to the medial intercondylar tubercle.
Figure 6 - Lateral meniscus

Figure 7 - Lateral condyle of tibia
On the other hand, the superior surface of the lateral condyle is pretty much a mirror image of
the medial condyle. It is round in shape, somewhat convex, and articulates with the lateral
condyle of the femur. The lateral meniscus attaches to all of its margins except for the medial
margin. The medial margin extends to the lateral intercondylar tubercle. Note that the lateral
and medial menisci are the pads of fibrocartilage inserted to ease the pressure that is
transmitted from the femur to the condyles.
Figure 8 - Intercondylar eminence of tibia
The superior surfaces of the condyles are flattened and together they form the superior
articular surface called the tibial plateau. Here, the tibial condyles articulate with the femoral
condyles within the knee joint. The articular surfaces are separated by two small prominences,
the medial and lateral intercondylar tubercles. These tubercles form the intercondylar
eminence, which is bordered by the anterior and posterior intercondylar areas.
Figure 9 - Tibial plateau
Figure 10 - Anterior cruciate ligament

 The anterior intercondylar area features attachment sites for many structures. Anterior
to posterior they are: the anterior horn of the medial meniscus, the anterior cruciate
ligament, and the anterior horn of the lateral meniscus.
Figure 11 - Posterior cruciate ligament
 The posterior intercondylar area also has facets for structures to attach. Anterior to
posterior these are: the posterior horn of the lateral meniscus, the posterior horn of the
medial meniscus, and the posterior cruciate ligament.
On the lateral surface of the proximal end of the tibia just inferior to the lateral condyle is the
bony prominence called the tubercle of iliotibial tract or Gerdy’s tubercle. Inferior and lateral
to it is the articular facet for the head of the fibula where the tibia and fibula articulate via the
superior/proximal tibiofibular joint.
Figure 12 - Tubercle of iliotibial tract

At the anterior surface of the proximal end is the tibial tuberosity. It is an attachment site for
the patellar ligament and you can easily spot and palpate this prominence just below your
knee. Inferiorly, the tibial tuberosity is continuous with the anterior border of the tibia.
Figure 13 - Tibial tuberosity

Joints
Two major joints in which the tibia takes part are the knee joint and the ankle joint.
Figure 14 – Knee Joint

The knee joint is certainly something that deserves special attention. Its articular surfaces are
the superior surfaces of lateral and medial condyles of the tibia, and the inferior surfaces of the
lateral and medial condyles of the femur.
Figure 15 – Superior tibiofibular joint
The tibia also has three articulations with the fibula. The superior/proximal tibiofibular joint is
where the proximal end of tibia articulates with the head of the fibula. The articulation site on
the tibia is found on the lateral side of its proximal part, while the fibula participates with the
medial surface of its head. This joint is reinforced by the anterior and posterior ligaments of
fibular head.
DRUG STUDY
Classification Brand-Generic Indication Mechanism of Contraindication Adverse Reaction Nursing Responsibilities

Name Action
Therapeutic Generic Name: Celecoxib is Thought to inhibit Contraindicated on CNS: headache, Assessment:
class: Celecoxib indicated for the prostaglandin patients dizziness, insomnia  Assess onset, type,
Nonsteroidal management of synthesis, hypersensitive to location, duration
anti- impending drug, CV: hypertension, pain/inflammation.
acute pain.
inflammatory Brand Name: cyclooxygease-2, sulfonamides, peripheral edema Inspect
drugs (NSAIDs) Cerebrex to produce anti- aspirin, or other appearance of
inflammatory, NSAIDs. EENT: pharyngitis, affected joints for
analgesic, and rhinitis, sinusitis immobility,
Pharmacologic antipyretic Contraindicated in deformity, skin
class: effects. patients who GI: abdominal conditions. Also,
Cyclooxygenase- experienced pain, diarrhea, assess patient for
2 inhibitors asthma, urticaria, dyspepsia, CV risk factors
or allergic-type flatulence, GI before therapy.
Dosage and reactions after reflux, nausea
Frequency: taking aspirin, or Intervention:
200mg/tab BID other NSAIDs. Metabolic:  Before starting
hyperchloremia drug therapy,
rehydrate
Musculoskeletal: dehydrated
back pain patient.
 Be alert for
Respiratory: patients allergic to
dyspnea, urinary or with history of

tract infection anaphylactic
reactions to
Skin: erythema sulfonamides,
multiforme, aspirin, or other
exfoliative, NSAIDs may be
dermatitis, toxic allergic to this
epidermal drug.
necrolysis, rash  Monitor patient’s
renal function.
 Watch for signs
and symptoms of
overt and occult
bleeding and rash.
 Watch for
immediately
evaluate signs and
symptoms of heart
attack (chest pain
shortness of
breath, trouble
breathing) or
stroke (weakness
in one part or side
of the body,
slurred speech).
Patient Teaching:
 Tell patient to
report history if
allergic reactions
to sulfonamides,
aspirin, or other
NSAIDs before
therapy.
 Instruct patient to
promptly report
sings of GI
bleeding, such as
blood in vomit,
urine, or stool; or
black, tarry stools.
 Advise patient to
immediately report
rash, unexplained
weight gain, or
swelling.
 Advise the patient
to avoid aspirin,
alcohol (increase
GI bleeding).
seek medical
attention
immediately if
chest pain,
shortness of
breath or trouble
breathing,
weakness in one
part or side of the
body, or slurred
speech occurs.

Name Action
Therapeutic Generic Name: Tramadol is Unknown. Contraindicated in CNS: dizziness, Assessment:
class: Tramadol indicated in Thought to bind patients headache,  Assess BP and RR
Analgesics moderate to to opioid hypersensitive to somnolence, before and
receptors and drug or opioids. vertigo, seizures, periodically during
moderately
Pharmacologic Brand Name: inhibit reuptake anxiety, asthenia, administration.
severe chronic
class: Ambidol of CNS stimulation,  Assess onset, type,
Synthetic pain. norepinephrine confusion, location, and
centrally active and serotonin. coordination duration of pain.

analgesics disturbance,  Assess previous
euphoria, malaise, analgesic history.
Dosage and nervousness, sleep Tramadol is not
Frequency: disorder, fever, recommended for
300mg/50ml paresthenia, patients
D5W 24° x 3 tremor, dependent on
doses depression, opioids.
insomnia,  Tramadol exposes
agitation, apathy patients to the risk
of addiction,
CV: vasodilation, abuse, and misuse.
hypertension, Assess each
peripheral edema patient’s risk
before prescribing.
EENT: visual
disturbances, Intervention:
nasopharyngitis,  Monitor CV and
pharyngitis, respiratory status,
rhinitis, sinusitis especially within
first 24 to 72 hours
GI: constipation, of therapy
nausea, vomiting, initiation and after
abdominal pain, dosage increases;
anorexia, diarrhea, adjust doses
dry mouth, accordingly.
dyspeptia,  Monitor patient
flatulence regularly for
development of
GU: proteinuria, abnormal
urinary frequency, behaviors.
urine retention,  Monitor bowel and
pelvic pain, UTI bladder function.
Anticipate need for
Metabolic: weight stimulant laxative.
loss  Monitor patient for
drug dependence
Musculoskeletal: similar to that of
hypertonia, codeine and thus
arthralgia, neck has potential for
pain, myalgia abuse.
Respiratory: Patient/Family Teaching:

bronchitis,  Instruct the patient
respiratory to immediately
depression report difficulty
breathing or other
Skin: diaphoresis, signs or symptoms
pruritus, rash of a potential
adverse opioid-
related reaction.
 Encourage patient
to report all
medications taken,
including
prescription, OTC
medications, and
supplements.
 Report severe
constipation,
difficulty
breathing,
excessive sedation,
muscle weakness,
tremors, chest
pain, and
palpitations.

Name Action
Therapeutic Generic Name: Used to treat Ascorbic acid, a Contraindicated in CNS: headache, Assessment:
class: Dietary Vitamin C vitamin C water-soluble patient dizziness  Assess
Supplements deficiency, vitamin that acts hypersensitive to hypersensitivity to
Brand Name: delayed wound as a cofactor and drug or any GI: nausea, drug.
Pharmacologic Ascorbic Acid and bone healing, as an antioxidant. component of this vomiting, diarrhea,  Assess patient for
class: and in general as It is essential for drug. heartburn signs and
Antioxidants an antioxidant. It connective tissue symptoms of
has also been synthesis, and Fe Vitamin C Hematologic: deep vitamin deficiency
Dosage and suggested to be absorption and supplementation is vein thrombosis, before beginning
Frequency: an effective storage. contraindicated sickle cell crisis, vitamin therapy.
200mg/tab OD antiviral agent. Additionally, it is in blood disorders hemolysis (in G6PD  Assess for
an electron donor like thalassemia, deficiency) debilitating
used for collagen G6PD deficiency, diseases and GI
hydroxylation, sickle cell disease, Musculoskeletal: disorders that may
carnitine and Fatigue disrupt the
biosynthesis, and hemochromatosis. absorption,
hormone or Vascular: flushing metabolism, and
amino acid excretion of
synthesis. vitamins.
Intervention:
 Evaluate the
patient for proper
dietary intake and
determine if
vitamin therapy is
having a
therapeutic effect.
Patient/Family Teaching:
 Tell patient to take
oral formulation
with a meal.
 Instruct the patient
that do not crush,
chew or break the
drug.
 Inform the patient
about the possible
side effects of the
drug.
 Alert patient to the
signs and
symptoms of
hypervitaminosis.
Hypervitaminosis A
causes nausea,
vomiting,
headache, loss of
hair, and cracked
lips.
Hypervitaminosis D
causes anorexia,
nausea, and
vomiting.

Name Action
Therapeutic Generic Name: To alleviate Ca and vitamin Contraindicated in CNS: headache Assessment:
class: Dietary Vitamin generalized body D administration patients  Assess the
Supplements D + Calcium weakness and to counteracts the hypersensitive to GI: nausea, patient’s blood
strengthen rise of PTH that is drug. abdominal pain, pressure and vital
Pharmacologic Brand Name: immune system. caused by Ca diarrhea signs q4h.
class: Vitamin D Calvit deficiency and
analogs increased bone Hematologic: Intervention:
resorption. eosinophilia,  Monitor for

Dosage and thrombocytosis, manifestations of
Frequency: Calcium leukopenia hypercalcemia. If it
200mg/tab OD carbonate is used occurs, discontinue
as a Musculoskeletal: until serum
supplementary weakness, usual calcium returns to
source of Ca to tiredness normal (9-10.6
help prevent or mg/dl).
decrease the rate Immune System:  Monitor serum
of bone loss. hypersensitivity calcium whenever
reactions dosage
Vitamin D is a fat- adjustments are
soluble sterol Renal and Urinary: made. Measure
essential for the hypercalciuria urinary calcium
proper regulation and phosphorus
of Ca and Skin: rashes, levels q24h.
phosphate pruritus, urticarial
homeostasis, Patient/Family Teaching:
bone metabolism  Tell patient to take
and oral formulation
mineralization. with a meal.
 Instruct patient on
foods that contain
Vitamin D and
encourage
adequate intake of
fluids.
avoid excessive use

of tobacco or
beverages
containing alcohol
or caffeine.
NURSING CARE PLAN
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective data: Acute pain related to After 8 hours of Independent: Independent: Goal met
“Sumasakit parin fracture on the right independent and  Assessed and  To determine
tong kanang paa ko leg as evidenced by collaborative nursing recorded the the After 8 hours of
kapag nagagalaw,” the patient’s interventions, the patient’s level effectiveness independent and
as verbalized by the verbalization of pain patient will be able of pain. of collaborative
patient. and guarding to: interventions nursing
behavior on lower . interventions, the
extremity.  Verbalize relief  Maintained patient was able
Objective data: of pain (pain immobilization  Relieves pain to:
 Pain scale of scale of 2 out of of affected and prevents

6 out of 10 10). part by means bone  Verbalized
 Facial of bed rest, displacement relief of pain
grimace  Appear relaxed, cast, splint, /extension of (pain scale of
 Guarding able traction. tissue injury. 2 out of 10).
behavior on to sleep/rest
right leg appropriately.  Ensured that  To promote  Appeared
 Restlessness the affected venous relaxed, able
 V/S taken:  Demonstrate use limb is return, to sleep/rest
BP – 110/80 of relaxation elevated and decreases appropriately.
PR - 85 skills and supported at edema and
RR – 20 diversional all times. may reduce  Demonstrate
O2 Sat – 99% activities. pain. d use of
Temp – 37.3 relaxation
 Elevated bed  To maintain skills and
covers; keep body warmth diversional
linens off toes. without activities.
discomfort.
 Provided  To improves
alternative general
comfort circulation;
measures reduces
(e.g., position areas of local
changes) pressure and
muscle
fatigue.
 Provided  Refocus
emotional attention,
support and promote
encourage stre relaxation,
ss and may
management enhance
techniques coping
(progressive abilities in
relaxation, the
deep- management
breathing of stress of
exercises, traumatic
visualization, injury and
or guided pain.
imagery).
 Encouraged  To prevent
adequate rest fatigue that
periods. can impair
ability to
manage or
cope with
pain.
Dependent: Dependent:
 Given  To reduce
Celecoxib as pain and/or
prescribed. muscles
spasms.
Subjective data: Impaired Physical After 8 hours of Independent: Independent: Goal met
“Hindi ko Mobility related to independent and  Determined  This will help
masyadong musculoskeletal collaborative nursing the level of in After 8 hours of
naigagalagaw yung impairment as interventions, the immobility determining independent and
paa ko,” as evidenced by patient will be able caused by the the collaborative nursing
verbalized by the verbalization of to: injury, appropriaten interventions, the
patient. reluctance to including the ess of the patient was able to:
attempt movement  Demonstrate patient’s interventions
and limited range of measures to perception. rendered.  Demonstrated
Objective data: motion. increase measures to
 Reluctance mobility.  Presented a  To promote a increase
to attempt safe safe, secure mobility.
movement  Perform environment: environment
 Difficulty activities of bed rails up, and may  Performed
turning in daily living bed in a down reduce risk activities of
bed with the least position, for fall. daily living
 Limited amount of important with the least
range of assistance, items close by. amount of
motion considering  To prevent assistance,
 Decreased the  Taught patient stiffness, considering
muscle condition. or assist with maintains the condition.
strength or active and muscle
control passive ROM strength and
 Remain free exercises of avoid  Remained free
of contractures. of
contractures unaffected contractures

from extremities.  To allow time from impaired
impaired to recover mobility.
mobility.  Allowed for and conserve
rest periods energy.
between
exercises.  To further
independenc
 Promoted e and
independence maximize
during patient’s
exercises and capabilities.
activities.
 Help reduce
burdening
 Repositioned pressure
the patient at points for
least every extended
two hours and period and
as needed. reduce
breakdown.
 This
enhances
 Set goals with sense of
patient with anticipation
patient or of progress
significant or
other for improvement

cooperation in and gives
activities or sense of
exercise and independenc
position e.
changes.
Dependent: Dependent:
 Given  To increase
analgesics patient
before performance
immobilizing, and ability to
as ordered. move.
Subjective data: Impaired mood After 8 hours of  Assess ability to  Mood Goal met
“Nakakalungkot regulation related to independent nursing understand disturbances are
lang tsaka nagsisisi functional interventions, the current situation. prevalent in many After 8 hours of
ako bakit ako impairement as patient will be able to: disorders and independent
nadisgrasya at nag evidenced by guilt many affect nursing
aalala ako baka di  Acknowledge individual’s interventions, the
ko na maituloy reality of mood cognitive patient was able to:
yung problems/needs. functioning and
pagcricriminology understanding of  Acknowledgedr
ko ” as verbalized  Identify areas of events. eality of mood
by the patient. concern.  discuss how problems/needs
client perceives  A negative .
Objective data: the current outlook is
 Regretfull situation and associated with  Identify areas of
about the how it is diffiulty in concern.
incident affecting cognitive control
emotions. and emotional
 Influenced regulation
self-esteem strategies.
 Encourage client
to pay attention  Awareness of
to emotional one’s emotions
states and helps the

feelings. individual to deal
appropriately
with them.
 clarify meanings
of feelings by  Validates and
checking ensures accuracy
meaning with of meaning of the
patient and communication.
provide
feedback.
 Discuss how  Individual

negative thinking differences can
and rumination affect the
intensify strategies the
depression. person uses to
recover from a
negative mood.

Case Study ON Tibial Fracture: University of Saint Louis

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Case Study ON Tibial Fracture: University of Saint Louis

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University of Saint Louis

Tuguegarao City, Cagayan 3500

Jhoanna Mae T. Romias

II. CLASSIFICATION OF FRACTURES

Types of Bone Fractures

According to the Philippines Statistics

IV. RISK FACTORS

CT Scan (Computed tomography)- is a noninvasive diagnostic imaging procedure that uses a

VI. TREATMENT OR MANAGEMENT

MEDICATION- A pain reliever such as acetaminophen or ibuprofen or a combination of the two,

 Wear a seat belt on every trip

Name: Patient J.A.A

Birth Date: September 19, 2020

Address: Alcala, Cagayan

Civil Status: Single

Weight: 75kg (165.347 lbs)

Height: 5’9ft (175.26 cm)

BMI: 24.4 (Normal)

Religion: Roman Catholic

Admission’s Date/Time: June 25, 2022 (12:40 am)

Chief Complaint: Vehicular Accident

Attending Physician: Dr. Alan Ryan Yu

Admitting vital signs

Final vital signs

History of Present Illness

History of Past Illness

1st Child 3rd Child (Patient)

GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Health Pattern Before Hospitalization During Hospitalization

Nutritional-Metabolic Patient J.A.A eats three Patient J.A.A. eats three

ng karne kasi mahal ang consumes more than a liter

Activity-Exercise Pattern Patient J.A.A. stated that he In attempt to rebuild his

basketball tsaka nagbibike any trouble breathing while

Sleep-Rest Pattern According to the patient During hospitalization,

Cognitive-Perceptual Pattern Patient J.A.A. is oriented to Patient J.A.A. is oriented and

people, time and place, alert. He responds to

Role-Relationship Pattern Patient J.A.A. belongs to a Patient J.A.A. stated that he

They go to church and eat at

concept pattern perceived himself as a is still hopeful he would get

Value-Belief Pattern Patient J.L. is a Roman Patient JAA. always prays

ANATOMY AND PHYSIOLOGY

 Blood-cell formation (Haemopoiesis)

 25% organic matrix (osteoid);

Figure 1 – Bone Structure

Figure 2 – Anatomy of cortical bone

The function of the periosteum is to:

Figure 4 - Medial condyle of tibia

Figure 5 - Medial meniscus

Figure 6 - Lateral meniscus

Figure 7 - Lateral condyle of tibia

Figure 8 - Intercondylar eminence of tibia

Figure 9 - Tibial plateau

Figure 10 - Anterior cruciate ligament

Figure 11 - Posterior cruciate ligament

Figure 12 - Tubercle of iliotibial tract

Figure 13 - Tibial tuberosity

Figure 14 – Knee Joint

Figure 15 – Superior tibiofibular joint

Classification Brand-Generic Indication Mechanism of Contraindication Adverse Reaction Nursing Responsibilities

dyspnea, urinary or with history of

Classification Brand-Generic Indication Mechanism of Contraindication Adverse Reaction Nursing Responsibilities

centrally active and serotonin. coordination duration of pain.