Femoral Fracture Case Study

• Femoral fracture refers to a break or fracture of the thighbone, or femur.
• Femoral fractures can occur in the: -Upper part (proximal femur) -Middle part (femoral shaft) -Lower part near the knee (distal femur)

Patient Profile: Queque Villanueva

• 33 years old
• Female
• Police Officer
• The chief complaint is severe pain in the left thigh and inability to bear weight.

Medical History

• No prior history of fractures or significant musculoskeletal injuries.
• Reports being in good health with no chronic medical conditions or ongoing medications.
• No prior fractures or major orthopedic injuries.

Family History

• Maternal: Diagnosed with osteoporosis at age 50 and experienced a hip fracture at age 60 following a minor fall, and has vertebral compression fractures.
• Paternal: No known history of fractures or osteoporosis.
• Siblings: One older sister had a wrist fracture at age 25 due to a sports injury; no other siblings with a history of fractures.
• Maternal grandmother: Had a hip fracture at age 70.
• Paternal grandparents: No known history of fractures.

Risk Factors for Femoral Fracture

• Age
• Female gender
• Osteoporosis
• Falls
• Trauma
• Medical conditions like Parkinson’s disease, stroke, diabetes, and thyroid problems.

Causes of Femoral Fracture

• High-speed trauma, like motor vehicle accidents.
• Falls from a high place.
• Injuries during extreme or contact sports.
• Gunshot wounds.
• Osteoporosis.
• Child abuse.
• Overuse.

Signs and Symptoms of Femoral Fracture

• Intense pain.
• Inability to bear weight.
• Deformity or shortening of the leg.
• Swelling and bruising.
• Open fracture.
• Difficulty moving the leg.
• Tenderness to touch.
• Bleeding.

Potential Complications of Femoral Fracture

• Infection.
• Blood clots.
• Nerve damage.
• Malunion.
• Nonunion.
• Hardware failure.
• Fat embolism.
• Compartment Syndrome.

Pathophysiology of Femoral Fracture

• Femoral fracture happens when the femur experiences a disruption in its structural integrity, usually from high-energy trauma or repetitive stress exceeding the bone's strength.
• An inflammatory response is initiated after the fracture, leading to the formation of a hematoma at the injury site, providing a scaffold for healing.
• Soft callus formation occurs via chondrocyte activity is replaced by hard callus as osteoblasts generate new bone tissue.
• Bone remodeling is the culmination of the healing process.
• Influencing factors in the speed and effectiveness include age, overall health, and nutritional status.

Diagnostic Tests for Femoral Fracture

• Physical Assessment: A thorough examination of the injured leg is crucial to identify any signs of a fracture
• Fulcrum Test: This helps diagnose femoral shaft stress fractures; the examiner uses their forearm as a fulcrum under the thigh, applying pressure to the front of the knee, causing sharp pain at the fracture site.
• X-rays: The first-line imaging test to evaluate a suspected fracture, providing clear images of the bone to help determine if a bone is intact or broken, the type of fracture, and its location.
• CT Scans: Computed tomography (CT) scans better classify the fracture pattern, delineate subtle fracture lines, or assess the extent of damage, especially if the fracture is near a joint or if there's a concern about fragmentation.
• MRI: Used in specific cases, like evaluating small or stress fractures not visible on X-rays or assess soft tissue damage.
• Bone Scans: Helps in identifying stress fractures or other subtle bone changes not visible on X-rays.

Nursing Care Plan Problem 1: Acute Pain

• Assessment: Patient's verbalization of pain at the fracture site; tachycardia, tachypnea, elevated blood pressure, and facial grimacing.
• Nursing Diagnosis: Acute pain related to a bone fracture. -Rationale: Femoral fractures are extremely painful due to nerve damage, muscle spasms, and the injury itself.
• Goals and Objectives: NOC: Pain Control. -Expected Outcome: The client will report that the pain management regimen achieves comfort-function goal without side effects in 8 hours.
• Nursing Interventions: NIC: Pain Management.
  • Independent Nursing Interventions: Provide alternative comfort measures (massage, back rub, position changes).
  • Dependent Nursing Interventions: Administer medications as indicated.
• Rationale with Reference:
  • Independent: Improves general circulation and reduces areas of local pressure and muscle fatigue (Vera, 2024) -Dependent: Reduces pain or muscle spasms; administer analgesics around the clock for 3-5 days. Studies of ketorolac (Toradol) have proven effective in alleviating bone pain, with longer action and fewer side effects than narcotics agents (Vera, 2024).
• Evaluation: The client reported that pain management regimen achieved comfort-function goal without side effects after 8 hours.

Nursing Care Plan Problem 2: Risk for Infection

• Assessment: Patient's reports of increased redness, swelling, or warmth around the wound site. Patient's verbalization of feeling unwell or fever; fever, tachycardia, tachypnea, and elevated WBC.
• Nursing Diagnosis: Risk for infection related to an open fracture or surgical site. -Rationale: Open fractures, where the bone protrudes through the skin, are at high risk for infection.
• Goals and Objectives: NOC: Risk Control. -Expected Outcome: The client will identify interventions to prevent or reduce the risk of infection in 8 hours.
• Nursing Interventions: NIC: Infection Protection. -Independent Nursing Interventions: Monitor vital signs, noting the presence of chills, fever, malaise, changes in mentation. -Dependent Nursing Interventions: Administer IV and topical antibiotics and tetanus toxoid as indicated.
• Rationale with Reference:
  • Independent: Hypotension and confusion may be seen with gas gangrene. Septicemia is shown through tachycardia, chills and fever
  • Dependent: Tetanus toxoid is given prophylactically because the possibility of tetanus exists with any open wound.
• Evaluation: The client can identify interventions to prevent and reduce the risk of infection after 8 hours.

Nursing Care Plan Problem 3: Impaired Physical Mobility

• Assessment: Patient's expressions of pain or discomfort when attempting to move. Patient's report of feeling weak or unable to bear weight on the affected limb; Limited range of motion, decreased muscle strength, postural instability.
• Nursing Diagnosis: Impaired physical mobility related to fracture and immobilization. -Rationale: A femoral fracture limits the patient’s ability to move and bear weight, potentially leading to complications like blood clots and atrophy.
• Goals and Objectives: NOC: Ambulation. -Expected Outcome: The client will verbalize understanding of the situation and individual treatment regimen and safety measures.
• Nursing Interventions: NIC: Exercise Therapy.
  • Independent Nursing Interventions: Teach the patient or assist with active and passive ROM exercises of affected and unaffected extremities.
  • Dependent Nursing Interventions: Consult with a physical, occupational therapist, or rehabilitation specialist.
• Rationale with Reference:
  • Independent: Increases blood flow to muscles and bone to improve muscle tone, preserve joint mobility, prevent contractures or atrophy, and calcium resorption from disuse.
  • Dependent: Useful in creating individualized activity and exercise programs. The patient may require long-term assistance with movement, strengthening, and weight-bearing activities, as well as the use of adjuncts.
• Evaluation: The client can verbalize understanding of the situation and individual treatment regimen and safety measures after 8 hours.

Nursing Care Plan Problem 4: Impaired Skin Integrity

• Assessment: Patient's verbalization of pain or tenderness around the surgical site. Patient's reports of increased pain when moving or touching the area; Redness and swelling, bruising, warmth to touch, fever, elevated WBC.
• Nursing Diagnosis: Impaired skin integrity related to surgical incision. Rationale: A surgical incision disrupts the epidermis and dermis, compromising the skin’s primary role as a protective barrier against pathogens, creating a direct entry point for bacteria, and increases the risk of infection.
• Goals and Objectives: NOC: Tissue Integrity. -Expected Outcome: The client will demonstrate understanding of the plan to heal skin and prevent reinjury in 8 hours.
• Nursing Interventions: NIC: Skin Surveillance. -Independent Nursing Interventions: Reposition frequently, encourage the use of a trapeze if possible. -Dependent Nursing Interventions: Help the client learn stress reduction and engage in alternate therapy techniques.
• Rationale with Reference:
  • Independent: Lessens constant pressure on the same areas and minimizes the risk of skin breakdown, and may reduce the risk of abrasions to elbows and heels.
  • Dependent: To control feelings of helplessness and deal with the situation.
• Evaluation: The client demonstrated understanding the plan to heal skin and prevent reinjury after 8 hours.

Nursing Care Plan Problem 5: Impaired Gas Exchange

• Assessment: Patient's verbalization of feeling short of breath or experiencing labored breathing. The patient reports discomfort or pain when taking deep breaths and feeling tired or weak; Tachypnea, tachycardia, hypoxemia, shallow breathing, use of accessory muscles, presence of wheezes or rhonchi, hypercapnia
• Nursing Diagnosis: Impaired gas exchange related to pain, immobility, and shallow breathing caused by a fracture which leads to pain-induced shallow breathing to avoid pain and reduced volume of air and leads to hypoventilation.
• Goals and Objectives: NOC: Respiratory Status. -Expected Outcome: The client will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters within 8 hours.
• Nursing Interventions: NIC: Airway Management.
  • Independent Nursing Interventions: Instruct and assist with deep breathing and coughing exercises and reposition frequently. -Dependent Nursing Interventions: Administer supplemental oxygen.
• Rationale with Reference:
  • Independent: Promotes alveolar ventilation and perfusion, and repositioning promotes drainage of secretions and decreases congestion.
  • Dependent: Decreased Pao2 and increased Paco2 indicate impaired gas exchange or developing failure.
• Evaluation: The client demonstrated improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters after 8 hours.

Medical Management of Femoral Fracture

• Physical Therapy: Essential for regaining:
  • Strength
  • Range of motion
  • Function in the affected leg
• Pain Management: Medications like:
  • Acetaminophen.
  • NSAIDs.
• Stronger analgesics as needed.
• Stabilization of the fracture: Maintain normal leg function by: -Keeping the bone in the correct position to heal properly
• Infection Prevention:
  • Use of antibiotics, especially for open fractures, and monitoring for signs of infection

Surgical Management of Femoral Fracture

• Intramedullary Nailing (IMN):
  • The gold standard for femoral shaft fractures. -A nail is inserted into the bone's medullary canal to stabilize the fracture.
• Open Reduction and Internal Fixation (ORIF):
  • Surgically realigning the bone. -Securing it with plates, screws, or other fixation devices.
• External Fixation:
  • Used in open fractures, polytrauma, or when early definitive care is not possible. -Provides temporary stabilization.
• Skeletal Traction:
  • A pin is placed through the bone distal to the fracture to apply traction. -Helps to reduce the fracture and relieve pain.