Case Study: Tibial Fracture

CASE STUDY
ON
TIBIAL FRACTURE
Jhoanna Mae T. Romias
BSN V
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 for FRACTURE
8.8 percent of all occupational injuries in
2016. Additionally, there were 3,514
lower extremity fracture cases (or 19.7% Lower Extremity
of all injuries), 7,006 cases of wrist and Wrist and Hand
hand fractures (or 39.2% of all injuries), arms and shoulder
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

University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL IV
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 as The patient defined his health
Management “Health, yun yung kapag wala as “Di gaanong maganda kasi
kang sakit at kaya mong gawin nga eto dahil sa disgrasya nasa
ang trabaho mo” and believes hospital ako imbes na
to the statement that health is tumutulong sa bahay”. The
wealth. According to the patient patient stated that he can no
he does not get sick very often longer do his usual activities
before hospitalization thus, he due to his condition and rated is
rates his health as 10. He takes health as 7 out of 10. Patient is
Vit. C to protect his immunity currently taking Vitamin C and
and buys OTC drugs such as Vitamin D with calcium.
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 Pattern Patient J.A.A eats three meals a Patient J.A.A. eats three times a
day—breakfast, lunch, and day (breakfast, lunch, and
dinner—plus snacks. He eats dinner) with snacks in between.
breakfast at eight in the “kapag nagugutom ako sa gabi,
morning, lunch at twelve in the nagpapakuha ako kay mama ng
afternoon, and dinner at 6pm.in cup noodles yun yung kinakain
regular basis. Each day, the ko” as verbalized by the patient.
patient drinks one liter of water. He eats breakfast at 7a.m.,
He typically eats 3-5 cups of rice lunch at 12p.m., and dinner at
with meat or fish, vegetables, 7p.m. The patient’s dietician has
and rice. The patient said, ordered diet as tolerated (DAT)
"Madalas gulay at isda ang ulam for him. According to the
minsan lang mag ulam ng karne patient, he consumes more
kasi mahal ang presyo ng karne than a liter of water due to the
ngayon " The patient stated that high temperature inside the
he hates tangi, eggs, poultry hospital. The patient’s diet
products, and shellfish because consists of 1 cup of rice with
of his allergy. He doesn't have meat or fish, vegetables, and

any issues swallowing or eating fruits. When served with
his food. He does not smoke, chicken, he chose not to eat it.
and he does not consume He does not have any difficulty
alcoholic beverages. in chewing or swallowing food.
The patient still has food allergy
Weight: 75kg (165.347 lbs) to seafoods, chicken, tangi, and
Height: 5’9ft (175.26 cm) eggs.
BMI: 24.4 (Normal)

Elimination Pattern Patient J.A.A. usually voids 3 The patient voids 3x a day once
times a day, once in the in the morning and twice at
morning, once in noon, and noon. He describes his urine as
once at night, with an amount yellowish in color and his
of urine that is about 3-5 urination was painless. The
glasses. He stated that his patient stated that he only
urination was painless and is defecated twice since admission
clear white in color. Patient because he was shy to defecate
J.A.A. defecates once a day and in hospital. He described his
has no difficulty in defecating. stool as brown in color and
He described his stool as brown formed. He stated that he drank
and slightly formed. 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 jogs strength, patient J.A.A. claimed
from their house to their farm that he performs range-of-
as his exercise. He also plays motion exercises in his
basketball and rides his bike. “ unaffected area. He claimed
Naglalaro ako ng basketball that he doesn't have any
tsaka nagbibike ako” as stated trouble breathing while
by the patient. He has no exercising. The patient said that
breathing problems when his condition prevents him from
exercising. He stated that he moving extensively and that he
exercises to stay healthy. spends much of his time on his
phone.
Sexuality-Reproduction Pattern When he was in fourth grade, The patient does not have any
the patient underwent 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 J.A.A., During hospitalization, Patient

he typically goes to bed at 4 am J.A.A. stated that he sleeps for 5
and gets up at 7 am. He said he hours. He takes a nap for an
takes two-hour naps around 4 hour and feels irritated when he
or 5 o'clock in the afternoon wakes up due to his condition.
and that they leave him feeling “Naiinis ako kasi andito parin
sluggish. He doesn't have any kami sa hospital ang tagal na
trouble falling asleep and namin dito” as verbalized by the
doesn't take any sleep aids. The patient. He stated that
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 questions
responses to stimuli verbally that are asked and cooperates
and physically. He can 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 is

family of 6 which includes getting his strength from his
himself, his 2 siblings, her family especially from his
mother and her 2 grandparents mother, and they have always
from his mother side. He has a supported him and showed
good relationship with is family their love for him by giving him
and she stated that they always foods and calling through
support each other especially phone. “Inaalagaan ako nilang

through hard times. When mabuti lalo na si mama kasi siya
family problem occurs, he nagbabantay sakin dito.” as
chooses to be quiet. His role in verbalized by the patient.
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-concept Patient J.A.A. stated that he Patient J.A.A. stated that he is
pattern perceived himself as a healthy still hopeful he would get
person. He stated that his better. He was worried because
negative trait was that he is his dream to be a policeman is
“palasumbat sa magulang”. at stake. He stated that he is
currently not satisfied with his
He described his positive trait as body image due to his leg
“masiyahin” and he also stated fracture. The patient stated that
that he is satisfied by his self- he wants to go home
body image. He wants to be an immediately and finish his
engineer but chose to enter degree in criminology.
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 the Patient JAA said that he is
Pattern major cause of his stress is due currently stressed about his
to his studies. His way of condition and his study because
relieving stress is through he is an incoming 4th year this
cellphone or hanging out with next school year. He copes up

friends and jamming with them. with his current stress by
watching videos using his
cellphone and playing mobile
games.
Value-Belief Pattern Patient J.L. is a Roman Catholic Patient JAA. always prays that
and he stated that he always he will get better soon. He
prays. He goes with his family to believes that his faith will help
the church every Sunday. him recover from his condition.
Patient claims that he believes “Nag dadasal po ako na sana
in superstitious belief like gumaling ako kaagad.” as
“magpagpag pagka galing sa verbalized by the patient. He
patay” as verbalized by the always listens every time there
patient. is a mass in 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 anti- management of synthesis, hypersensitive to location, duration
inflammatory impending drug, sulfonamides, CV: hypertension, pain/inflammation.
acute pain.
drugs (NSAIDs) Brand Name: cyclooxygease-2, to aspirin, or other peripheral edema Inspect appearance
Cerebrex produce anti- NSAIDs. of affected joints for
inflammatory, EENT: pharyngitis, immobility,
Pharmacologic analgesic, and Contraindicated in rhinitis, sinusitis deformity, skin
class: antipyretic effects. patients who conditions. Also,
Cyclooxygenase-2 experienced asthma, GI: abdominal pain, assess patient for CV
inhibitors urticaria, or allergic- diarrhea, dyspepsia, risk factors before
type reactions after flatulence, GI reflux, therapy.
Dosage and taking aspirin, or nausea
Frequency: other NSAIDs. Intervention:
200mg/tab BID Metabolic:  Before starting drug
hyperchloremia therapy, rehydrate
dehydrated patient.
Musculoskeletal:  Be alert for patients
back pain allergic to or with
history of
Respiratory: anaphylactic
dyspnea, urinary reactions to
tract infection sulfonamides,
aspirin, or other
Skin: erythema NSAIDs may be

multiforme, allergic to this drug.
exfoliative,  Monitor patient’s
dermatitis, toxic renal function.
epidermal necrolysis,  Watch for signs and
rash 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. Thought Contraindicated in CNS: dizziness, Assessment:
class: Tramadol indicated in to bind to opioid patients headache,  Assess BP and RR
Analgesics moderate to receptors and hypersensitive to somnolence, vertigo, before and
inhibit reuptake of drug or opioids. seizures, anxiety, periodically during
moderately severe
Pharmacologic Brand Name: norepinephrine asthenia, CNS administration.
chronic pain.
class: Ambidol and serotonin. stimulation,  Assess onset, type,
Synthetic confusion, location, and
centrally active 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, tremor, patients dependent
D5W 24° x 3 depression, on opioids.
doses insomnia, agitation,  Tramadol exposes
apathy patients to the risk
of addiction, abuse,
CV: vasodilation, and misuse. Assess
hypertension, each patient’s risk
peripheral edema before prescribing.
EENT: visual Intervention:

disturbances,  Monitor CV and
nasopharyngitis, respiratory status,
pharyngitis, rhinitis, especially within first
sinusitis 24 to 72 hours of
therapy initiation
GI: constipation, and after dosage
nausea, vomiting, increases; adjust

abdominal pain, doses accordingly.
anorexia, diarrhea,  Monitor patient
dry mouth, regularly for
dyspeptia, flatulence development of
abnormal behaviors.
GU: proteinuria,  Monitor bowel and
urinary frequency, bladder function.
urine retention, Anticipate need for
pelvic pain, UTI stimulant laxative.
 Monitor patient for
Metabolic: weight drug dependence
loss similar to that of
codeine and thus has
Musculoskeletal: potential for abuse.
hypertonia,
arthralgia, neck pain, Patient/Family Teaching:
myalgia  Instruct the patient
to immediately
Respiratory: report difficulty
bronchitis, breathing or other
respiratory signs or symptoms of
depression a potential adverse
opioid-related
Skin: diaphoresis, reaction.
pruritus, rash  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, delayed vitamin that acts as hypersensitive to hypersensitivity to
Brand Name: wound and bone a cofactor and as drug or any GI: nausea, vomiting, drug.
Pharmacologic Ascorbic Acid healing, and in an antioxidant. It is component of this diarrhea, heartburn  Assess patient for
class: general as an essential for drug. signs and symptoms
Antioxidants antioxidant. It has connective tissue Hematologic: deep of vitamin deficiency
also been synthesis, and Fe Vitamin C vein thrombosis, before beginning
Dosage and suggested to be an absorption and supplementation is sickle cell crisis, vitamin therapy.
Frequency: effective antiviral storage. contraindicated hemolysis (in G6PD  Assess for
200mg/tab OD agent. Additionally, it is an in blood disorders deficiency) debilitating diseases
electron donor like thalassemia, and GI disorders that
used for collagen G6PD deficiency, Musculoskeletal: may disrupt the
hydroxylation, sickle cell disease, Fatigue absorption,
carnitine and metabolism, and
biosynthesis, and hemochromatosis. Vascular: flushing excretion of
hormone or amino vitamins.
acid synthesis.
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 patient’s
Supplements D + Calcium weakness and to counteracts the hypersensitive to GI: nausea, blood pressure and
strengthen rise of PTH that is drug. abdominal pain, vital signs q4h.
Pharmacologic Brand Name: immune system. caused by Ca diarrhea
class: Vitamin D Calvit deficiency and Intervention:
analogs increased bone Hematologic:  Monitor for
resorption. eosinophilia, manifestations of
Dosage and thrombocytosis, hypercalcemia. If it
Frequency: Calcium carbonate leukopenia occurs, discontinue
200mg/tab OD is used as a until serum calcium
supplementary Musculoskeletal: returns to normal (9-
source of Ca to weakness, usual 10.6 mg/dl).
help prevent or tiredness  Monitor serum
decrease the rate calcium whenever
of bone loss. Immune System: dosage adjustments
hypersensitivity are made. Measure
Vitamin D is a fat- reactions urinary calcium and
soluble sterol phosphorus levels
essential for the Renal and Urinary: q24h.
proper regulation hypercalciuria
of Ca and Patient/Family Teaching:
phosphate Skin: rashes,  Tell patient to take
homeostasis, bone pruritus, urticarial oral formulation
metabolism and with a meal.
mineralization.  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 tong fracture on the right leg independent and  Assessed and  To determine
kanang paa ko kapag as evidenced by the collaborative nursing recorded the the After 8 hours of
nagagalaw,” as patient’s verbalization interventions, the patient’s level effectiveness independent and
verbalized by the of pain and guarding patient will be able to: of pain. of collaborative
patient. behavior on lower interventions. nursing
extremity.  Verbalize relief of interventions, the
pain (pain scale of  Maintained  Relieves pain patient was able
Objective data: 2 out of 10). immobilization and prevents to:
 Pain scale of 6 of affected part bone
out of 10  Appear relaxed, by means of displacement  Verbalized
 Facial grimace able to sleep/rest bed rest, cast, /extension of relief of pain
 Guarding appropriately. splint, traction. tissue injury. (pain scale of 2
behavior on out of 10).
right leg  Demonstrate use  Ensured that  To promote
 Restlessness of relaxation skills the affected venous return,  Appeared
 V/S taken: and diversional limb is elevated decreases relaxed, able
BP – 110/80 activities. and supported edema and to sleep/rest
PR - 85 at all times. may reduce appropriately.
RR – 20 pain.
O2 Sat – 99%  Demonstrated
Temp – 37.3  Elevated bed  To maintain use of
covers; keep body warmth relaxation skills
linens off toes. without and diversional
discomfort. activities.
 Provided  To improves
alternative general
comfort circulation;
measures (e.g., reduces areas
position of local
changes) pressure and
muscle
fatigue.
 Provided  Refocus
emotional attention,
support and promote
encourage stres relaxation,
s management and may
techniques enhance
(progressive coping
relaxation, abilities in the
deep-breathing management
exercises, of stress of
visualization, or traumatic
guided injury and
imagery). pain.
 Encouraged
adequate rest  To prevent
periods. fatigue that
can impair
ability to
manage or
cope with
pain.
Dependent:
 Given Celecoxib Dependent:
as prescribed.  To reduce pain
and/or
muscles
spasms.
Subjective data: Impaired Physical After 8 hours of Independent: Independent: Goal met
“Hindi ko masyadong Mobility related to independent and  Determined the  This will help
naigagalagaw yung musculoskeletal collaborative nursing level of in determining After 8 hours of
paa ko,” as verbalized impairment as interventions, the immobility the independent and
by the patient. evidenced by patient will be able to: caused by the appropriatene collaborative nursing
verbalization of injury, including ss of the interventions, the
reluctance to attempt  Demonstrate the patient’s interventions patient was able to:
Objective data: movement and limited measures to perception. rendered.
 Reluctance to range of motion. increase  Demonstrated
attempt mobility.  Presented a  To promote a measures to
movement safe safe, secure increase
 Difficulty  Perform environment: environment mobility.
turning in bed activities of bed rails up, and may
 Limited range daily living bed in a down reduce risk for  Performed
of motion with the least position, fall. activities of
 Decreased amount of important items daily living with
muscle assistance, close by. the least
strength or considering  To prevent amount of
control the condition.  Taught patient stiffness, assistance,
or assist with maintains considering the
active and muscle condition.
 Remain free of passive ROM strength and
contractures exercises of avoid
from impaired unaffected contractures.  Remained free
mobility. extremities. of contractures
 To allow time from impaired
 Allowed for rest to recover and mobility.
periods conserve
between energy.
exercises.
 To further
 Promoted independence
independence and maximize
during exercises patient’s
and activities. capabilities.
 Help reduce
 Repositioned burdening
the patient at pressure
least every two points for
hours and as extended
needed. period and
reduce
breakdown.
 This enhances
 Set goals with sense of
patient with anticipation of
patient or progress or
significant other improvement
for cooperation and gives
in activities or sense of
exercise and independence.
position
changes.
Dependent:
Dependent:  To increase
 Given analgesics patient

before performance
immobilizing, as and ability to
ordered. move.
Subjective data: Impaired mood After 8 hours of Independent: Independent: Goal met
“Nakakalungkot lang regulation related to independent and
tsaka nagsisisi ako functional collaborative nursing After 8 hours of
bakit ako impairement as interventions, the independent and
nadisgrasya at nag evidenced by guilt patient will be able to: collaborative nursing
aalala ako baka di ko interventions, the
na maituloy yung Dependent: patient was able to:
pagcricriminology ko
” as verbalized by
the patient.
Objective data:
 Regretfull about
the incident
 Influenced self-
esteem

Case Study: Tibial Fracture

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CASE STUDY

Jhoanna Mae T. Romias

II. CLASSIFICATION OF 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

 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

of his allergy. He doesn't have meat or fish, vegetables, and

BMI: 24.4 (Normal)

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

circumcision. When he was in experiences.

Sleep-Rest Pattern According to the patient J.A.A., During hospitalization, Patient

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

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

support each other especially phone. “Inaalagaan ako nilang

They go to church and eat at a

cellphone or hanging out with next school year. He copes up

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

Skin: erythema NSAIDs may be

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

EENT: visual Intervention:

nausea, vomiting, increases; adjust