Our Lady of Fatima University

(Jose Reyes Memorial Medical Center)

Femoral Neck Fracture Nursing Management to Patient with Femoral Neck Fracture

Submitted by:

Vjhay Shon
Submitted to:

Maam Miguel

Introduction A fracture is a break in the continuity of bone and is defined according to its type and extent. Fractures occur when the bone is subjected to stress greater that it can absorb. Fractures are caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle contractions. When the bone is broken, adjacent structures are Also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood vessels. Body organs maybe injured by the force that cause the fracture or by the fracture fragments. There are different types of fractures and these include complete fracture, incomplete fracture, closed fracture, open fracture and there are also types of fractures that may also be described according to the anatomic placement of fragments, particularly if they are displaced or nondisplaced. Such as greenstick fracture, depressed fracture, oblique fracture, avulsion, spinal fracture, impacted fracture, transverse fracture and compression fracture. A comminuted fracture is one that produces several bone fragments and a closed fracture or simple fracture is one that not cause a break in the skin. Comminuted fracture at the right femoral neck is a fracture in which bones of the right femoral neck has splintered to several fragments. By choosing this condition as a case study, the student nurse expects to broaden his knowledge understanding and management of fracture, not just for the fulfillment of the course requirements in medical-surgical nursing. It is very important for the nurses now a day to be adequately informed regarding the knowledge and skill in managing these

conditions since hip fracture has a high incidence among elderly people, who have brittle bones from osteoporosis (particularly women) and who tend to fall frequently. Often, a fractured hip is a catastrophic event that will have a negative impact on the patients life style and quality of life. There are two major types of hip fracture. Intracapsular fractures are fractures of the neck of the femur, Extracapsular fracture are fractures of the trochanteric region and of the subtrocanteric region. Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may die. Many older adults experience hip fracture that student nurse need to insure recovery and to attend their special need efficiently and effectively. Through the knowledge of this condition, a high quality of care will be provided to those people suffering from it.

Nursing Management of Patient with Femoral Neck Fracture Patient AP, a male client, 34 years old residing at Antipolo City was brought to a nearly hospital where first aid was done due to chief complaint of right LE pain . His initial vital signs are 100/60mmhg for his blood pressure, 23bpm for his respiratory rate, 87bpm for his heart rate and 37.6for his temperature. The patient was diagnosed with fracture displaced on his right femur. The patient smoke and he drinks alcohol. According to familydoctor.org, too much alcohol can damage the liver and contribute to some cancers, such as

throat cancer and liver cancer. Alcohol also contributes to deaths from car wrecks, murders and suicides. According to www.oshmanlaw.com The femur, located in the thigh or upper leg and extending from hip to knee, is one of the strongest and largest bones in the body. Due to its strength, the femur is difficult to fracture and requires significant force to injure. The most common causes of femur fracture include vehicle accidents and falls from height. Patients with illnesses such as tumor, infection, or osteoporosis may be at an increased risk for femur fracture because of weakened bones. In such cases, a fracture is known as a pathological femur fracture.

Anatomy and Physiology Lower Limb Each lower limb has 30 bones in four locations: (1) the femur in the thigh; (2) the patella; (3) the tibia and fibula in the leg; (4) and the 7 tarsals in the tarsus, the 5 metatarsals in the metatarsus, and the 14 phalanges in the foot. The femur, or thigh bone, is the longest , heaviest and strongest bone in the body. Its proximal end articulates the acetabulum of the hip bone. Its distal end articulates with the tibia and patella. The patella, or kneecap, is a small, triangular bone located anterior to the knee joint. It is a sesamoid bone that develops in the tendon of the quadriceps

femoris muscle.The patella functions to increase the leverage of the tendon of the quadriceps femoris muscle, to maintain position of the tendon when the knee is bent, and to protect the knee joint. The tibia, or shin bone, is the larger, medial, weight-bearing bone of the leg. The tibia articulates at its proximal end with the femur and fibula, and its distal end with the fibula and the talus bone of the ankle. An interosseous bone connects the tibia and fibula. The fibula is parallel and lateral to the tibia, but it is considerably smaller than the tibia. The proximal end, the head of the fibula, articulates with the inferior surface of the lateral condyle of the tibia below the level of the knee joint to form the proximal tibiofibular joint. The distal end has a projection called the lateral malleolus that articulates with the talus bone of the ankle. The tarsus is the proximal region of the foot and consists of seven tarsal bones. They include the talus and calcaneus, the cuboid, the three cuneiform bones called the first, second, and third cuneiforms. The metatarsus is the intermediate region of the foot and consists of five metatarsal bones numbered I to V, from the medial to the lateral position. The first metatarsal is thicker than the others because it bears more weight. The phalanges comprise the distal component of the foot and resemble those of the hand both in number and arrangement. They are numbered I to V being with the great toe, which is medial.

Signs and Symptoms are as follows: Symptoms includes pain, loss of function, deformity, shortening, crepitus, swelling and discoloration, paresthesia and tenderness. The pain is continuous and increases in severity until the bone fragments are immobilized. The muscle spasm that accompanies fracture is a type of natural splinting designed to minimize further movement of the fracture fragments. After fracture, the extremity cannot function properly, because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present. Displacement, angulations, or rotation of the fragments in the fracture of the right femoral neck causes deformity that is detectable when the limb is compaired with the uninjured extremity. Deformity also results from soft tissue swelling. In fractures of long bones, there is actual shortening of the extremity because of the contraction of the muscles that are attached above and below the site of the fracture. The fragments often overlap by a muchas 2.5 to 5 cm (1 to 2 inches). When the extremity is examined with the hands, a grating sensation called crepitus can be felt. It is caused by the rubbing of the bone fragments against each other. Localized swelling and discoloration of the skin (echymosis) occurs after as a result of trauma and bleeching into the tissues. These signs may not develop for several hours after

the injury. After fracture, any subjective sensation experienced as numbness, tingling, or a pins and needles may be felt. These often fluctuate according to such influences as posture, activity, rest, edema, congestion, or underlying disease, it is sometimes identified as acroparesthesia. Mostly, the affected part responds with a sensation of pain to pressure or touch that would not normally cause discomfort. This happens due to the bones splintered into fragments.

Pathophysiology Femoral neck fractures occur most commonly after falls. Factors that increase the risk of injuries are related to conditions that increase the probability of falls and those that decrease the intrinsic ability of the person to with stand the trauma. Physical deconditioning, malnutrition, impaired vision and balance, neurologic problems, and shower reflexes all increase the risk of falls. Osteoporosis is the most important risk factor that contributes to hip fractures. This condition decreases bone strength and, therefore, the bones ability to resist trauma. Femoral neck fractures can also be related to chronic stress instead of a single traumatic event. The resulting stress fractures can be divided into fatigue fractures and insufficiency fractures. Fatigue fractures are a result of an increased or abnormal stress placed on a normal bone. Whereas insufficiency fractures are due to normal stresses placed on diseased bone, such as an osteoporotic bone. Trauma sufficient to produce a fracture can result in damage to the blood supply to an entire bone, e.g., the femoral neck

in femoral fracture. With seer circulatory compromise, avascular (ischemic) necrosis may result. Particularly vulnerable to the development of ischemic are intracapsular fractures, as occur in the hip. In this location, blood supply is marginal ad damage to surrounding soft tissues may be a critical factor since better results are obtained in cases of hip fracture reduced with in 12 hr. than in those treated after that time period. In fractures of the femoral neck, bone scans have been recommended as diagnostic tools to determine the orability of the femoral need.

History Patient AP, male and a 34 years old was admitted at Philippine Orthopedic Center, the initial diagnosis was Fracture of complete comminuted multifragmented disteltered femur right. In his family history, the patient has negative history in hypertension and diabetes mellitus. And in his personal and social history, the patient is positive in alcohol beverage intake.

Nursing Physical Assessment Patient AP, a male client, 34 years old was admitted due to chief complaint of Right LE pain at Philippine Orthopedic Center. His initial vital signs are 100/60mmhg for his blood pressure, 23bpm for his respiratory rate, 87bpm for

his heart rate and 37.6for his temperature. Patient skin is warm and eyes are pink palpebral conjunctiva. Lungs with symmetrical chest wall expansion. Heart is on normal rate, regular rhythm and adynamic precordium. And positive lower extremity deformity and multiple abrasions.

Related Treatments Treatment of a fracture of complete comminuted multifragmented disteltered femur right depends on several factors. The most important criteria to consider are the amount of displacement of the fracture and the age of the patient. In younger patients, those under 60 to 65 years old, every effort will be made to avoid a partial hip replacement. Hip replacements work very well for less active patients, but they tend to wear out in younger, more active patients. Therefore, in young patients, a chance may be taken to avoid hip replacement even if there is a high risk of a non healing fracture. The patient was given Cefuroxime 750mg/1L every 8 hours. Cefuroxime according to www.emedexpert.com, is a bactericidal antibiotic, which exerts antibacterial activity by inhibition of bacterial cell wall synthesis in susceptible species. Cefuroxime has good stability to several bacterial beta-lactamase enzymes and, consequently, is active against many resistant strains of susceptible species.

Another drug given was Nanitidine 50mg/IV every 12 hours while on NPO. According to www.medicinenet.com, Ranitidine is a drug prescribed for promoting the healing, and prevention recurrence of ulcers of the stomach and duodenum. It is also used to treat occasional heartburn, and in healing ulcers and inflammation of the esophagitis; and Zollinger Ellison syndrome. Side effects, drug interactions, dosing, and warnings and precautions should be reviewed prior to taking any medication. Ranitidine may be taken with or without food. Ranitidine may be taken with or without food.

Nursing Care Plan The nursing diagnosis for patient JS is impaired physical mobility related to bed rest and fractured right femoral neck. The nurse must assess pain on a scale of 0-10 before and after implementing measures to reduce pain. Assist patient to do active ROM exercises on the lower extremities to improve muscle strength and joint mobility. Perform neurovascular assessment every 2 to 4 hours and document findings. Apply straight leg traction per physicians order. Encourage deep breathing and relaxation techniques. Teach the purpose of traction and surgery. Teach the purpose of and the procedure of performing isometric and flexion/extension exercises. After all the nursing interventions and techniques, the patient will be out of bed and in a chair. He will verbalize a decrease in pain. There should be no abnormal neurovascular assessments.

Recommendations Adults with a femur fracture are best treated with immediate operative fixation, typically intramedullary nailing. Young children typically are treated with skeletal or skin traction for approximately 4 weeks, followed by a body spica cast.Depending on the stage of skeletal maturity, some adolescents may be treated with initial external fixation, intramedullary nailing, or compression screw plate fixation. In the presence of contraindications to surgery, this repair may be delayed for days without significant complications if leg length is maintained with traction. Open fractures require immediate operative debridement followed by delayed intramedullary nailing. As a researcher in this case study, the student nurse recommends the patient to adjust in usual lifestyle and responsibilities to accommodate limitations imposed by fracture and to prevent recurrent fractures safety considerations, avoidance of fatigue and proper footwear. The patient is instructed about exercises to strengthening upper extremity muscles. If crutch walking is planned, methods of safe ambulation walker, crutches, care, emphasizes instructions concerning amount of weight bearing that will be permitted on fractured extremity, teaches symptoms needing attention, such as numbness, decreased function, increased pain and elevated temperature and explains basis for fractu retreatment and need for patient participation in therapeutic regimen. The

patient and the family were also informed that the patient must have an adequate balanced diet to promote bone and soft tissue healing.

References Brunner and Suddarths Textbook of Medical-Surgical Nursing www.oshmanlaw.com www.familydoctor.org http://www.emedexpert.com http://www.medicinenet.com