Case Study - Intertrochanteric Hip Fracture

INTRODUCTION

Intertrochanteric femur fracture affects almost 13 million Americans, and one of the

leading fractures in the Philippines making it the most common form of fracture. An

intertrochanteric hip fracture occurs lower than a femoral neck fracture. Intertrochanteric hip

fractures have a different treatment because they do not have the issues with damage to blood

flow to bone seen with the femoral neck fractures. Because the bone blood flow is usually in tact,

these fractures can usually be repaired, and do not require the hip replacement procedure

described previously. The femur is one of the largest, and strongest bones in the body. The femur

is the thigh bone--it extends from the hip joint down to the knee joint. Because the femur is such a

strong bone, it can take tremendous force to cause a femur fracture. The cause of femur fracture

as stated previously, the femur is a tremendously strong bone--in order for a femur fracture to

occur, either a large force must be applied or something is wrong with the bone. In patients with

normal bone strength, the most common causes of femur fractures include car accidents and falls

from a height.

The femur is the largest and strongest bone and has a good blood supply. Because of this and its

protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a

fracture does occur, this same protective musculature usually is the cause of displacement, which

commonly occurs with femoral shaft fractures.

As with many orthopedic injuries, neurovascular complications and pain management are the

most significant issues in patients who come to the ED. The rich blood supply, when disrupted,

can result in significant bleeding. Open fractures have added potential for infection.

The 3 types of femoral shaft fractures are as follows:

Type I - Spiral or transverse (most common)

Type II - Comminuted

Type III - Open

Associated injuries are common.

History of Past and Present

Past History

There is no illness and fracture after accident happen.

Family History

Hypertention (Father side)

Asthma (Father side)

Present History

Few hours PTC

Patient slipped at the bathroom landed on her hips

Physician findings: positive pain on pelvis

Pelvis AP

Lumbosacral APL

For SPI

Secure Onset

Doctors Order:

Endorsing the case of Rosalia De Leon 85 years old admitted December 13, 2008 with case of

fall

Subjective

(+) pain on inguinal area

( - ) DOB

Able to seat without difficulty

Objective

Patient on BST at 14 x 17 Lbs

Intast Steinmann pin at inguinal area

OBJECTIVES

A. General

It has been universally known that the primary task of health care is patient's care and

concern, as quoted also by the DOH Manual,  "The primary function of the nursing

service is the promotion, protection, preservation or restoration of the health of the

people through the provision and delivery of health services and through the regulation

and encouragement of health goods and services."  (E.O. 119, Sec. 3).

Fracture of the hip (Intertrochanteric Femur Fracture) is common and may occur at any

age and with changing levels of severity.

This study was undertaken to determine the assessment of Fracture of the hip

(Intertrochanteric Femur Fracture).

B. Specific

Fracture of the hip range from easily treated to life-threatening disorders.  Some

disorders required surgical intervention.

Accordingly, the student-nurse who cares for patients with fracture of the hip  must

have a clear understanding of its fracture and clinical outcomes.  Specifically, this study

was undertaken to answer and understand the the fracture of the hip.  Alongside with

this, this study aimed to require the student-nurse to manage symptoms and facilitate

patients' and families' understanding of the fracture. This study also aimed to equip the

student-nurse the appropriate medical and nursing management.  In the medical

management, the study focused on medications and laboratory examinations.  In the

nursing management, the study tackled the long term objective, the nursing care plan

(NCP) and the discharge plan as this may affect the patient's comfort, functional

independence and self-esteem.

Basically, this case study will help the student-nurse in the teaching of patients of what

they are supposed to know, do and not do based on the needs of patient found by this

study.

This study is also very essential in guiding the patients identify their weaknesses and

limitations, in order to minimize them.  Understanding the condition of their sicknesses,

the patient can have opportunity to choose a plan more suited to his self-care ability, as

this promotes self-dependence and self-reliance, as one of the missions, goals of Alma

Mata (primary health care delivery).

PERSONAL DATA

A 80 year-old female named Rosario Fuentes Regalado, was admitted at Philippine

Orthopedic Center Emergency Room on the 18th of December 2008, placed in a

stretcher. Upon admission, the patient was immediately interviewed and the following

data was acquired; Born in Tondo, Manila on the day of March 27, 1952, Mrs.

Regalado was raised as a Roman Catholic along with her five siblings. Her highest

educational attainment is high school graduate and is presently residing at 1232

Naraso St. Pandacan Mnla, with her husband and children. She rents the house which

they are staying in and her daily activities include watching TV, cooking and other

household chores. Her average sleeping time is around 2 to 3 hours of continuous

sleep at night and takes 30 minute naps in the afternoons. Her bowel time usually

occurs in the morning and she then bathe herself in cold water afterwards. Oral

hygiene was also being practiced everyday by the patient. Taking down the patient’s

family history, it was noted that the she has a history of Hypertension. She has an

allergy in eggs and chicken and takes Penicillin as her medication. Upon getting the

vital signs, the patient was determined to be hypertensive, afebrile during admission

and with normal pulse rate and respiratory rate. After interviewing the patient, physical

examination was done and the following assessments were gathered; the patient’s

physical body built is slender, she is neat and has smooth skin integrity. Her mental

status was alert and coherent and she was calm in her emotional status. After several

examinations, the attending physician diagnosed the patient with intertrochanteric

femur fracture.

DEFINITIONS

Etiology/Causes

Car accidents

Fall from height

A hip fracture is a fracture in the proximal end of the femur (the long bone running through the

thigh), near the hip joint.

The term "hip fracture" is commonly used to refer to four different fracture patterns and is often

due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall

or minor trauma in someone with weakened osteoporotic bone. Most hip fractures in people with

normal bone are the result of high-energy trauma such as car accidents.

In the Philippines, the mortality following a fractured neck of femur is between 25% and 45%

within one year in patients aged 82, ± 7 years, of which 80% were women.

AP Hip projection demonstrating an Intertrochanteric fracture

Intertrochanteric fracture denotes a break in which the fracture line is between the greater and

lesser trochanter on the intertrochanteric line. It is the most common type of 'hip fracture' and

prognosis for bony healing is generally good if the patient is otherwise healthy.

MEDICAL AND SURGICAL MANAGEMENT

Surgery for intertrochanteric fracture

Intertrochanteric hip fracture in a 17-year-old male

Fracture supported by dynamic hip screw

An intertrochanteric fracture, below the neck of the femur, has a good chance of healing.

Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two

fragments in position. A large screw is inserted into the femoral head, crossing through the

fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place.

The fracture typically takes 3-6 months to heal. As it is only common in elderly, removal of the

dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation

and the increased risk of re-fracture after implant removal. The most common cause for hip

fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well

reduce the risk of further fracture. Only young patients tend to consider having it removed; the

implant may function as a stress riser, increasing the risk of a break if another accident occurs.

SIGNS AND SYMPTOMS

SWELLING IN THE AFFECTED AREA

PAIN IN THE LOCATION OF FRACTURE

IMMOBILITY

INFLAMMATION

COMPLICATIONS

General medical complications

Many of patients are unwell before breaking a hip; it is not uncommon for the break to have been

caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the

injury, and a likely surgery, does increase the risk of medical illness including heart attack, stroke,

and chest infection.

Blood clots may result. Deep venous thrombosis (DVT) is when the blood in the leg veins clots

and causes pain and swelling. This is very common after hip fracture as the circulation is

stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without

causing symptoms. A pulmonary embolism (PE) occurs when clotted blood from a DVT comes

loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs are cut off

which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may

contribute to illness and mortality in other cases.

Mental confusion is extremely common following a hip fracture. It usually clears completely, but

the disorienting experience of pain, immobility, loss of independence, moving to a strange place,

surgery, and drugs combine to cause or accentuate dementia.

Urinary Tract Infection (UTI) can occur. Patients are immobilized and in bed for many days; they

are frequently catheterised, commonly causing infection.

Prolonged immobilization and difficulty moving make it hard to avoid pressure sores on the

sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is

advocated; otherwise, alternating pressure mattresses should be used.

Drug StudyDrug Name Classification/

IndicationAction Adverse Effect Nursing

ConsiderationCelecoxib Anti-

Inflammatory Inhibits prostaglandin synthesis. Primarily by inhibition cyclo oxygenase 2 (cox – 2)

CNS: dizziness, headache, insomia, stroke,

Cx: hypertension, MI, peripheral Edema

EENT: pharyngitis, rhinitis, sinusitis,

GI: abdominal Pain, diarrhea, dyspepsia, flatulence, nausea,

masculoSkeletal: Backpain

monitor patient for signs and symptoms of liver toxicity cefeloxib may be hepatotoxic.

Advice patient to immmidiatly report to prescribe rash, unexplained weight gain or edema.

Instruct patient to immediately report to prescriber signs of GI bleeding such as: bloody vomitus, bloon in urine, or stool and black farry stool.

Drug Name Classification/ Indication

Action Adverse Reaction Nursing Consideration

Omeprazole Gastric ulcer and reflux oesophagitis 20 mg OD for 4 -8 wks. And 10 mg for long term of reflux oesophagitis.

Chemical Effect: inhibits acid (proton) pump and binds to hydrogen potassium adenosine triphosphatase on secretory surface of gastric parietal cell to block formation of gastric acid

Therapeutic Effect: relieves symptoms caused by excessive gastric acid.

CNS: headache, dizziness,

GI: diarrhea abnormal pain, nausea and vomiting, constipation,

Musculoskeletal: back pain

Respiratory: cough Skin: rash

Full stomach

Check for rushes

Discharge Summary

Advice the patient to maintain personal hygiene everyday

Teach the patient proper wound cleaning.

Advice the relatives to assist patient if patient want to go to bathroom or do things that can caused fracture again.