KPJ UNIVERSITY COLLEGE, NILAI

Problem Based
Learning 1
Human Anatomy & Physiology
Lecturer: Dr. Muneerah Jamil

Cohort 2
Intake September 2013
Year 1 / Semester 1
Group Members:
Mohd Alfam Shamin bin Ashraf Alisha
2062141033
Vinith Prabu s/o Perabakaran
2062141014
Nazim Muhamad Arif bin Abdullah
2062141033
Putri Noor Syamimi binti Mohd Ridza
2062141011
Siti Athirah binti Nordin
2062141012
Anis Nadzirah binti Noor Azam
2062141001

Table of Contents
INTRODUCTION
ABSTRACT.............................................................................................................. 3
FRACTURE DEFINITION........................................................................................... 3
COMMON TYPES OF FRACTURES............................................................................3
PLAN
COMPLICATIONS..................................................................................................... 5
EVALUATION........................................................................................................... 6
History................................................................................................................ 6
Physical Examination.......................................................................................... 6
Diagnostic Imaging............................................................................................. 7
MANAGEMENT
IMMOBILIZATION.................................................................................................... 8
What is fiberglass?.............................................................................................. 8
Why fiberglass cast is more preferable over plaster cast?.................................9
Further Precautions............................................................................................ 9
Primary (provisional) fracture immobilization with a cast...................................9
Duration of Recovery........................................................................................ 10
THE REPAIR PROCESS OF BROKEN BONES...........................................................10
MEDICATION........................................................................................................ 11
REFERENCES...................................................................................................... 13

INTRODUCTION
ABSTRACT
A middle 40s housewife had been admitted to the emergency room after being
reported that she was unable to get up and walk after finding herself falling into
an accident when she was pushed from her back during skating. She complained
of having pain at her left lower leg with limited range of motion.

FRACTURES
Definition
Fracture is the act of breaking, or something that has broken, especially that in
bone or cartilage. Fractures are named according to their severity, the shape or
position of the fracture line, or even the physician who first described them. In
this case, the affected area is known as a long bone fracture. Fractures of the
"long bones" are one of the most common injuries associated with a variety of
accidents. Long bones are long, cylindrical and hollow in the middle, and have a
joint at each end. These bones can be injured (fractured) at any place along the
course of the bone. The tibia, or shinbone, is the most common fractured long
bone in the body. The long bones include the femur, humerus, tibia, and fibula. A
tibial shaft fracture occurs along the length of the bone, below the knee and
above the ankle.

Common Types of Fractures

Types of fractures

Description

An open fracture, also called a compound

fracture, is an injury that occurs when there is a
break in the skin around a broken bone. The
broken ends of the bone protrude through the
skin. Conversely, a closed (simple) fracture does
not break the skin.

Open (compound) fracture

A bone injury that results in more than 2

separate bone components is known as a
comminuted fracture. The bone is splintered,
crushed, or broken into pieces at the site of
impact, and smaller bone fragments lie between
the two main fragments.

Comminuted fracture

An impacted fracture is a fracture in which the

bone breaks into multiple fragments which are
driven into each other. One of the fractured
bones is forcefully driven into the interior of the
other. This type of fracture is usually caused by
something like a fall, especially if someone
breaks a fall with the arms or legs.

Impacted fracture
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Fracture of the distal end of the lateral leg bone

(fibula), with serious injury of the distal tibial
articulation. A Pott's fracture often occurs in
combination with other injuries such as an
inversion injury, a dislocation of the ankle or
other fractures of the foot, ankle or lower leg.
Pott's fractures can vary in location, severity and
type including displaced fractures, un-displaced
fractures, bimalleolar fractures or compound
fractures.

Pott fracture

Greenstick fracture

A partial fracture in which one side of the bone is

broken and the other side bends; occurs only in
children, whose bones are not fully ossified and
contain more organic material than inorganic
material. In some cases, a greenstick fracture
can be difficult to diagnose because there may
not be much pain or swelling and the child is
using the limb and has full motion. Mild
greenstick fractures sometimes are thought to
be sprains.

PLAN
COMPLICATIONS
Fractures, joint dislocations, ligament sprains, muscle strains, and tendon injuries
are common injuries that vary greatly in severity and treatment. Limbs are most

often affected, although any part of the body can be. Injuries may be open (in
communication with a skin wound) or closed.
Complications may
threatening such as:

be

serious.

Some

complications

are

potentially

life

Rapid blood loss: Bleeding can be external or internal. Sometimes

transfusion is required.
Fat embolism or Nonthrombotic Pulmonary Embolism: This rarely
happen, possibly preventable, complication usually may occur when a long
bone is fractured.

Complications may also threaten limb viability or cause permanent limb

dysfunction. Such complications occur in only a small percentage of limb injuries.
The greatest threats come from open injuries that predispose to infection and
injuries that disrupt the vascular supply (causing ischemia), primarily by directly
injuring arteries or occasionally veins. However, some closed injuries (eg,
posterior knee dislocations, hip dislocations, displaced supracondylar humeral
fractures) can also disrupt the vascular supply, causing ischemia. The following
can threaten a limb:

Compartment syndrome: Tissue pressure increases in a closed fascial

space, disrupting the vascular supply and reducing tissue perfusion. Crush
injuries or markedly comminuted fractures are a common cause.
Compartment syndrome can lead to rhabdomyolysis and thus infection,
which threatens limb viability and, if untreated, survival.
Nerve or spinal cord injuries: A penetrating injury may sever a
peripheral nerve. A blunt, closed injury may result in neuropraxia (bruised
peripheral nerve) or axonotmesis (crushed nerve), which is more severe.

Dislocations: The bones in a joint are completely separated, sometimes

disrupting the vascular supply and injuring nerves. Vascular and nerve
injuries are more likely when reduction (realignment of fracture fragments
or dislocated joints) is delayed. Partial dislocation, termed subluxation, can
also result in significant sequelae.
Infection: Open injuries can become infected, potentially leading to
osteomyelitis, which can be difficult to cure.

For this case, which seems to be a closed injury do not involve any blood vessels
or nerves, including fractures, sprains, strains, and tendon tears, are least likely
to result in serious complications.

EVALUATION
History
The patient is a 45 years old housewife that had not been skating for at least 10
years but having a healthy lifestyle and known to have no medical history
6

involving fractures nor serious medical illness throughout her life. She was
admitted into the emergency room after reporting that she was unable to get up
and walk after she was pushed from the back during skating.

Physical Examination
A physical examination is an evaluation of the body and its functions using
inspection, palpation by feeling with the hands, percussion by tapping with the
fingers, and auscultation by listening. A complete health assessment also
includes gathering information about a persons medical history and lifestyle,
doing laboratory tests, and screening for diseases.
Examination includes vascular and neurologic assessment, inspection for
deformity, swelling, ecchymoses, and decreased or abnormal motion and
palpation for tenderness, crepitation, and gross instability. Motor or sensory
deficits suggest neurologic injury. Paresthesias or sensory deficits alone suggest
neuropraxia; motor plus sensory deficits suggest axonotmesis.
Deformity suggests dislocation, subluxation (partial separation of bones in a
joint), or fracture. Swelling commonly indicates a significant musculoskeletal
injury but may require several hours to develop. If no swelling occurs within this
time, fracture or severe ligament disruption is unlikely. Some fractures, swelling
may be subtle but is rarely absent.
Nearly all injuries are tender, and for many patients, palpation anywhere around
the injured area causes discomfort. However, a noticeable increase in tenderness
in one localized area (point tenderness) suggests a fracture or sprain. Localized
ligamentous tenderness and pain with stressing the joint are consistent with
sprain.
Crepitation (a characteristic cracking or popping sound) may be a sign of
fracture. Gross joint instability suggests dislocation or severe ligamentous
disruption. Stability of an injured joint is evaluated by stress testing. However, if
fracture is suspected, stress testing is deferred until x-rays exclude fracture.

There are two factors that might cause tibial fractures to occur; high energy
collisions and lower energy injuries. The high-energy collisions, such as an
automobile or motorcycle crash, are common causes of tibial shaft fractures. In
cases like these, the bone can be broken into several pieces (comminuted
fracture). Meanwhile, sports injuries, such as a fall while skiing or running into
another player during soccer, are lower-energy injuries that can cause tibial shaft
fractures. These fractures are typically caused by a twisting force and result in an
oblique or spiral type of fracture.
The most common symptoms of a tibial shaft fracture are:

Pain
Inability to walk or bear weight on the leg
Deformity or instability of the leg
Bone "tenting" the skin or protruding through a break in the skin
Occasional loss of feeling in the foot

After physical examination from head to toe was done unto the patient, any
abrasion or laceration must primarily be observed to prevent any infection.
Abrasion is an injury caused by something that slightly rubs or scrapes against
the skin compared to laceration that causes deep cut or tear in skin. However,
there is no abrasion or laceration wound present to be observed on the
superficial area of the patients left lower limb. It can be assumed that the part of
her body that is affected is the left lower leg as the patient complain of having
pain at her left lower leg with limited range of motion. The patient also said to
experience pain when she walks with her left leg. As a result from the physical
examination, there is a localized tenderness detected over the tibial shaft and
along its medial border. Tenderness is known to be a discomfort when the
affected area is touched. A tibial shaft fracture occurs along the length of the
bone, below the knee and above the ankle. Shaft of tibia is triangular in cross
section. It consists of three surfaces. The medial border descends from anterior
end of medial condyle to posterior margin of medial malleolus. The patients
range of motion is limited. She has severe pain when walking with her left leg.

Diagnostic Imaging
X-ray has a wavelength range between 0.01 to 10 nanometres, 3 x 10 16Hz- 3 x
1019Hz range of frequency and about 12k eV. This type of radiation is able to
penetrate through most soft matters, such as muscle and tissue, however is
stopped by bones and tendons. This therefore provides us with a good visual on
the skeletal structure where we can determine whether there are any fractures
or dislodged bones present. It is a more preferable option in diagnostic imaging
as it is not a complex fracture and less radiation will be exposed to the patient
compared to CT scan and MRI.
Tibial shaft (diaphyseal) fractures can be classifieds by:
Location; proximal, middle or distal third
fracture pattern; transverse, spiral/oblique, comminuted/open
involvement in fibula
8

Fractures of the tibial shaft can be result from a direct blow or rotational force. As
from the previous physical examination, the suspected area of fracture might
involve on the distal part of the tibia. Therefore, anteroposterior (AP) and lateral
x-rays of the tibial shaft to include knee and ankle joints should be ordered.
However, CT scan of the fracture will be needed if near knee or ankle. The image
of x-rays shows that the simple transverse fracture of tibia at the near end
segment of the bone has not resulted in any angulations, rotation, shortening,
distraction and impaction to the bone. The fracture is proximal to the talus, not
entering the articular surface and considered as simple fracture as it is only has
a single line. Also there is no pathological fracture arise from the abnormal bone
such as osteoporosis since the patients has a healthy lifestyle.

MANAGEMENT
IMMOBILIZATION
After a bone is broken it needs rest and support to heal properly. Orthopedics use

casts to support and protect injured bones. A cast in other word, is one of the
preferred techniques to immobilize the bone of a limb that has been injured by
fracture, dislocation or break. While cast can be uncomfortable and cumbersome,
it is an effective and efficient method to treat fractures. Casts are custom-made
to fit and support injured limbs. There are two main types of casts:

Fiberglass casts. Fiberglass is a type of plastic that can be shaped.

Fiberglass casts are typically lighter and more durable than traditional plaster
casts. Air circulates more freely inside a fiberglass cast. Also, X-rays penetrate
fiberglass casts better than plaster casts. This is helpful if your child's doctor
wants to use an X-ray to examine your child's bones while he or she is still
wearing the cast. Fiberglass casts are available in different colors.

Plaster casts. Plaster casts are easier to mold for some uses than are
fiberglass casts. Also, plaster casts are typically less expensive than fiberglass
casts.
9

What is fiberglass?
A fiberglass cast type is used which is a lighter, synthetic alternative to the more
traditional plaster version. It is created by padding the extremity with cotton or
waterproof padding material, followed by wrapping several layers of knitted
fiberglass bandages impregnated with a water-soluble, quick-setting resin. It is
lighter and more durable than plaster, so fiberglass has quickly become the
preferred type of casting with many patients and medical care providers.

10

Why fiberglass cast is more preferable over plaster cast?

Fiberglass has many advantages over a plastic cast. The first thing most
patients notice is that the cast weighs less and is more comfortable. It is made of
water-activated polyurethane resin combined with bandaging materials, so this
material offers greater strength and less time for setting, as well. Casts made of
this material require less maintenance than those made with plaster and often
are used after the healing process already has begun.
The fiberglass bandages on the outside of the cast are waterproof, but typically,
most of the padding materials inside the cast are not. Waterproof materials have
been developed to replace this inside padding with a waterproof alternative. This
offers an option that would allow patients the ability to bath or shower, wash
hands, do chores and even swim while wearing a cast. The material also is
reported to cut down on odor and itching by helping to wick moisture away from
the skin under the cast.

Further Precautions
Medical professionals advise patients wearing fiberglass casts to report any
rough spots that snag clothing or chafe skin immediately to their medical care
facility for repair. Cracks are easily repaired but are not very likely to occur.
Experts also encourage patients to report any foul odor or damage to the
padding of the cast.
This cast is appropriate for tibial shaft fractures just like in this case that are not
badly displaced and are well aligned. Patients need to be in a cast that goes
below the knee and below the ankle. The advantage of casting is that these
fractures tend to heal well and casting avoids the potential risks of surgery such
as infection. Patients with casts must be monitored to ensure adequate healing
of the tibia and to ensure the bones maintain their alignment.
During the discharge the patient was also advice to inspect the skin around the
edges of the cast for inflammation. Inflammation is defined as a localized
reaction that produces redness, warmth, swelling, and pain as a result of
infection, irritation, or injury. Inflammation can be external or internal. A broken
bone can trigger an inflammatory response and dispatch cells and chemicals to
the site to repair the damage.
Inflammation is categorized into two categories which is acute and chronic.
Acute usually last for few days while chronic may last for weeks. Inflammation
process begins with the vasoconstriction of small vessels in the injured area
followed by rapid vasodilation of the arterioles and venules that supply the area.
Inflammatory may leads to congestion in the area causing redness and warmth
followed by increased capillary permeability which leads to swelling, pain, and
impaired function.

Primary (provisional) fracture immobilization with a cast

Unless an indication for immediate surgery is identified, the following approach is
recommended. Most low-energy closed tibial fractures can be aligned quite well
11

by closed reduction in a dependent position and application of a long leg cast.

Such a cast usually provides better immobilization than do splints made of
plaster or fiberglass slabs or those that are available commercially. Radiographs
of the fracture are then obtained, rotational alignment is reconfirmed by visual
comparison, and unless a major problem with misalignment is noted, the
reduction is accepted, at least temporarily. The patient is usually hospitalized
with the leg elevated slightly above heart level and observed for comfort and
neurovascular status. Outpatient care is possible if comfort, monitoring, and gait
training can be ensured. If the cast becomes too tight or the surgeon has serious
concern about impending circulatory compromise, the plaster is loosened and
the cast padding divided. If these measures do not maintain or restore
satisfactory neurovascular status, arterial perfusion and compartmental pressure
are checked, with further immediate surgical treatment as indicated. With a
satisfactory reduction and no evidence of neurovascular compromise, it is
expeditious to leave the provisional cast intact. If the reduction is not satisfactory
or closed treatment is, for some other reason, less desirable, definitive fixation
may be carried out electively after the initial swelling has begun to resolve, but
without excessive delay.

Duration of Recovery
Duration time taken for patient to return to daily activities varies with different
types of fractures. Some tibial shaft fractures heal within 4 months, yet many
may take 6 months or longer to heal. This is particularly true with open fractures
and fractures in patients who are less healthy.
Early motion: Many doctors encourage leg motion early in the recovery
period. For example, if soft tissue injury is present with a fracture, the
knee, ankle, foot, and toes may be mobilized early in order to prevent
stiffness.
Physical therapy: While you are wearing your cast or splint, you will
likely lose muscle strength in the injured area. Exercises during the healing
process and after your cast is removed are important. They will help you
restore normal muscle strength, joint motion, and flexibility.
Weightbearing: When you begin walking, you will most likely need to use
crutches or a walker.
Fracture pain usually stops long before the bone is solid enough to handle the
stresses of everyday activities. If the bone is not healed and you put weight on it
too soon, it could fail to heal. If that occurs, you may need a secondary surgical
procedure, such as bone grafting or revision fixation.

12

THE REPAIR PROCESS OF BROKEN BONES

When a person subjects himself to physical blow, with strength that overcomes
the bone itself, it will results a bone fracture. Bones are made up of connective
tissue that is fortified by calcium and a combination of bone cells. They have a
soft center where blood is formed, and its main function in the body is support
the body, protect the internal organs and allow mobility.
Bones can fracture in several ways and healing that will follow will be dependent
on the kind of fracture that the bones incurred. There are several stages bone
healing process and all bones need to successfully undergo each stage in order
to completely heal.
It's important to remember that your bones are constantly changing. Cells
called osteoclasts constantly break down old bone so that osteoblasts can
replace it with new bone tissue -- a process called bone remodeling. Another type
of cell called a chondroblast forms new cartilage. These are three of the
primary cells responsible for bone growth and not just the bone growth
experienced during early stage of life. This constant bone remodeling gradually
replaces old bone tissue with new tissue during the course of months.
Almost immediately after the break, the body begins to try and put itself back
together again. The overall processes are divided into four phases:
1. When a bone breaks, the fissure also severs the blood vessels running
down the length of the bone. Blood leaks out of these veins and quickly
forms a clot called a fracture hematoma. This helps to stabilize the bone
and keep both pieces lined up for mending. The clot also cuts off the flow
of blood to the jagged bone edges. Without fresh blood, these bone cells
quickly die. Swelling and inflammation follow due to the work of cells
removing dead and damaged tissue. Tiny blood vessels grow into the
fracture hematoma to fuel the healing process.
2. After several days, the fracture hematoma develops tougher tissue,
transforming it into a soft callus. Cells called fibroblasts begin producing
fibers of collagen, the major protein in bone and connective tissue.
Chondroblasts then begin to produce a type of cartilage called fibro
cartilage. This transforms the callus into a tougher fibro cartilaginous

13

callus, which bridges the gap between the two pieces of bone. This callus
generally lasts for about three weeks.
3. Next, osteoblasts move in and produce bone cells, transforming the callus
into a bone callus. This hard shell lasts three to four months, and it
provides necessary protection and stability for the bone to enter the final
stage of healing.
4. At this point, the body establishes the position of the bone within the flesh,
begins reabsorbing bits of dead bone, and creates a hard callus to bridge
the gap between the two pieces of bone. However, this bulge of tissue
needs a lot of work before the bone can take any strain. Osteoclasts and
osteoblasts spend months remodeling bone by replacing the bone callus
with harder compact bone. These cells also decrease the callus bulge,
gradually returning the bone to its original shape. The bone's blood
circulation improves and the influx of bone-strengthening nutrients, such
as calcium and phosphorus, strengthen the bone.

MEDICATION
Other than that upon discharging, patient also complaint of having a severe pain
at the site of injury thus the patient is will be prescribed with some medication to
reduce the pain. Medication that is suggested to be prescribed to the patient is
non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs work by reducing the
production of prostaglandins. Prostaglandins are chemicals that promote
inflammation, pain, and fever. They also protect the lining of the stomach and
intestines from the damaging effects of acid, promote blood clotting by
activating blood platelets, and promote normal function of the kidneys. The
enzymes that produce prostaglandins are called cyclooxygenases (COX). There
are two types of COX enzymes, COX-1 and COX-2. Both enzymes produce
prostaglandins that promote inflammation, pain, and fever; however, only COX-1
produces prostaglandins that activate platelets and protect the stomach and
intestinal lining. NSAIDs block COX enzymes and reduce production of
prostaglandins. Therefore, inflammation, pain, and fever are reduced. Since the
prostaglandins that protect the stomach and promote blood clotting also are
reduced, NSAIDs that block both COX-1 and COX-2 can cause ulcers in the
stomach and intestines, and increase the risk of bleeding.
In this case Capsule Celebrex (celecoxib) is being prescribed with a dose of
200mg twice daily for 3 days to the patient to reduce the pain or any swelling if it
is occurring.

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Plan

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Management

What is inflammation? What causes inflammation? - Medical News Today. 2014.

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Inflammatory response definition - Exercise and Fitness Center: Tips and Facts on
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Novimmune -- Science: Inflammation. 2014. Novimmune -- Science: Inflammation.

[ONLINE] Available at: http://www.novimmune.com/science/inflammation.html.
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Bonesfracture.com, (2014). Stages of Bone Healing after fracture. [online] Available

at: http://bonesfracture.com/stages-of-bone-healing-after-fracture/ [Accessed 17 Nov.
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Jonathan Cluett, M. (2014). How Is a Cast Made for a Broken Bone?. [online] About.
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