Anatomy and physiology
1. Complete / incomplete
a. Complete fracture, when the line is broken through the entire cross-section of
the bone or through both bone cortices as seen in the photograph.
b. Fracture is incomplete, if the fracture does not pass through the entire bone
cross section, such as:
1) Hairline fracture (broken cracked hair).
2) Buckle fracture or torus fracture, in the event of a fold of one cortex with
spongy bone compression underneath, usually on the distal radius of the
child.
3) Greenstick fracture, about one cortex with other cortical angulation that
occurs in the long bones of the child.
2. The shape of the broken line and its relationship to the mechanism of trauma.
a. Transverse line: angular or direct trauma
b. The oblique broken line: angular trauma
c. Broken spiral line: rotational trauma
d. Compression fracture: axial-flexion trauma to the spongious bone
e. Avulsion fracture: trauma of traction / muscle traction on insertion in bone, eg
patellar fracture.
3. Number of broken lines.
a. Comminutive fracture: broken lines more than one and interconnected.
b. Segmental fracture: broken lines more than one but not related. When two
broken lines are called bipocal fractures.
c. Multiple fractures: broken lines of more than one but on discontinuous bones,
eg femoral fractures, cruric fractures, and spinal fractures.
4. Shift / not shift.
a. The fracture is undisplaced, the line is completely broken but the two fragments
do not shift, the periosteum is intact.
b. Fraktur displaced (shifted), there is a fracture fragment fragment which is also
called the location of fragments, divided:
1) dislocation ad longitudinam cum contractionum (shift axis and overlapping)
2) dislocation ad axim (shifting angle shape)
3) dislocation ad latus (a shift in which both fragments away from each other).
5. Open-closed (see above).
6. Complications-no complications, if any should be called. Complications can
include early or late complications, local or systemic, by trauma or by treatment.
In establishing a diagnosis the fracture should be called a type of bone or part of
the bone having its own name, left or right, which part of the bone (proximal,
middle or distal), complete or not, broken line shape, number of broken lines, shift
not shifted, open or Closed and complicated if any. As an example:
a. Right proximal femur fracture of oblique, displaced, dislocated ad latus line
open one degree, neurovascular distal well
b. The lateral condyle of the lateral humeral humerus, displaced, covered with
radial nerve paralysis
1.1 Definitions
Fracture or fracture is the breakdown of continuity of bone tissue that is generally
caused by pressure or injury. Fractures are divided over open fractures, ie, if the
bone fractures penetrate the skin to be associated with outside air and closed
fractures, ie if the bone fragments are not related to the outside world, it is called a
clean fracture (because the skin is intact) without complications. In a closed
fracture there is a separate classification based on the soft tissue state around the
trauma, namely:
1.1.1 Level 0: Common fractures with little or no injury to surrounding soft
tissues.
1.1.2 Level 1: fracture with shallow abrasion or bruised skin and subcutaneous
tissue.
1.1.3 Level 2: more severe fractures with internal soft tissue contusions and
swelling.
1.1.4 Level 3: Severe injuries with apparent soft tissue damage and compartment
syndrome threats.
Tibial and fibular osteum (the shin and bone of the calf) is the largest pipe bone
after the femur that forms the knee joint with the femur OS, at the tip of which
there is a bulge called the OS of the lateral malleolus or outer ankle. The tibia's OS
is smaller than the base attached to the fibula OS at the end of the joints with the
leg bone and there is a taju called the maleolus medial OS. Fractures that occur
in the tibia and fibula bones are often called cruris fractures (Smeltzer, 2003). A
closed cruric fracture is a disconnect of the tibia and fibula bones without the open
wound bone fragment caused by injury from direct or indirect trauma affecting the
foot (Muttaqin, 2011).
A bone fracture can stand on its own (Tibia or Fibula) or it can have both fractures
together. Tranverse fracture (transverse fracture shape) or with displacement
(overlapping, angulation, rotation) either one level (fracture location is parallel) or
not one level (either a fracture line above or below).
1.2 Etiology
The causes of tibia fibula fractures include:
1.2.1 Trauma
1.2.1.1 Direct trauma: Impact on the fibular tibia bone.
1.2.1.2 Indirect Trauma: The pivot point of impact with the occurrence of
tibia fibula fracture far apart.
1.2.2 Pathological Fracture
Fractures are caused due to disease processes such as fibula tibia bone
cancer.
1.2.3 Degeneration
There is a pathological deterioration of the tissue itself: old age
1.2.4 Spontaneous
There is a very strong muscle pull like sports.
1.3 Symptom Signs
In general, according to Sjamsuhidajat (2010), the symptoms of cruris fracture
are the presence of pain and swelling in the fractured bone, deformity,
tenderness, crepitation, musculoskeletal dysfunction due to pain, bony continuity,
and neurovascular disorders.
1.4 Pathophysiology
When fractures, damage occurs in the cortex, blood vessels, bone marrow and
soft tissue. As a result of this there is bleeding, bone damage and surrounding
tissue. This condition causes the hematoma on the medullary canal between the
lower bony edge of the periostrium with the bone tissue that copes with the
fracture. The occurrence of an inflammatory response due to necrotic tissue
circulation is characterized by a vasodilation phase of plasma and leukocytes,
when bone damage occurs, the body begins the healing process to repair the
injury, this stage indicating the early stages of bone healing. The commonly
formed hematoma causes increased pressure in the bone marrow which then
stimulates the release of fat and the fat clots enter the blood vessels that supply
the other organs. The hematoma causes capillary dilatation in the muscle, thereby
increasing capillary pressure in the muscles, thus increasing capillary pressure,
then stimulating histamine in the ischemic muscle and causing the plasma protein
to disappear and entering the interstitial. This leads to edema. Edema is formed
will press the nerve endings, which if long lasting can cause
syndromcomportement.
Pathway
Trauma putar ataupun tir, trauma dengan gaya angulasi, cedera tidak langsung pada kaki
Fraktur kruris tertutup
Terputusnya Kerusakan
hubungan tulang jaringan lunak
Terapi imobilisasi
gipssirkular
Ketidakmampuan Terapi bedah
melakukan fiksasi interna dan Kerusakansarafs
pergerakan kaki fiksasi eksterna pasmeotot
Kerusakanvasku
Nyeri lar
HambatanMobili
tasFisik
Resiko tinggi
trauma
Pembengkakanl
Ketidaktahuantekn Pasca-bedah okal
ikmobilisasi
Port de entree
Responpsik Resikosindrom
Resikomalunion,
ologis kompatemen
delayed union, non
union, footdrop Resikoinfeksi
Ansietas
Pemenuhan informasi
1.5 Management
1.5.1 Conservative Management
1.5.1.1 Recognition
Recognition is performed in terms of diagnosis and fracture
assessment. The principle is to know the history of the accident, the
degree of severity, the type of power that plays and the description
of the events that occur by the patient himself.
1.5.1.2 Reduction
Reduction is the attempt / action of manipulation of fragments such
as the location of the origin. This action can be carried out
effectively in the emergency room or splint room. To reduce pain
during an action, the patient may be given IV drugs, sedatives or
local nerve blocks.
1.5.1.3 Retention
After the fracture is reduced, bone fragments should be mobilized
or maintained in the correct position and alignment until union
occurs. Immobilization can be done by external or internal fixation.
External fixation methods include casts, splints, traction and
external fixator techniques.
1.5.1.4 Rehabilitation
Represents the process of restoring to the original function and
structure by performing active and passive ROM as optimal as
possible in accordance with the ability of the client.Isometric
exercise and muscle setting. Seek to minimize disuse atrophy and
improve blood circulation.
1.5.2 Management of Surgery
Open Reduction and Internal Fixation (ORIF) or Open Reduction with
Internal Fixation is a form of surgery by fixing internal fixation on bone
fractures. ORIF function to maintain the position of bone fragments to
remain united and not shifted. This internal fixation in the form of Intra
Medullary Nail is commonly used for long bone fractures with a tranvers
fracture type.
ORIF will immobilize the fracture by performing surgery to insert nails,
screws or pens into the fracture site to fix bone sections at the fracture
simultaneously.
1.6 Investigations
1.6.1 X-rays: determine the location / extent of traumatic fracture
1.6.2 Bone scan, tomogram, Computed Tomography (CT) scan / Magnetic
Resonance Imaging (MRI): shows fractures, can also be used to identify
soft tissue damage.
1.6.3 Arteriogram: performed when vascular damage is suspected.
1.6.4 Complete area count: hematocrit and leukocyte may increase
(hemoconcentration) or decrease (white blood cell bleeding is a normal
stress response after trauma).
1.7 Complications
1.7.1 Complications early fractures include:
1.7.1.1 Shock
Hypovolemic or traumatic shock, due to bleeding (many external
and invisible blood losses that bias cause decreased oxygenation)
and extra fluid loss to damaged tissue, can occur in extreme
fractures, thorax, pelvis and vertebrae.
1.7.1.2 Fat embolism syndrome
At the time of fracture the fat globula may enter the blood vessels
because bone marrow pressure is higher than capillary pressure or
because catecholamines released by the patient's stress reaction
will mobilize fatty acids and facilitate the occurrence of fatty
globules in the bloodstream.
1.7.1.3 Compartement Syndrome
It is a problem that occurs when tissue perfusion in the muscle is
less than that required for network life. This may be due to a
decrease in the size of the muscle compartment because the fascia
that wraps the muscles is too tight, the use of gibs or bandages that
trap or increase the contents of muscle compatibility due to edema
or bleeding due to various problems (eg ischemia, and cracked
injuries).
1.7.1.4 Artery Damage
Rupture of the arteries due to trauma bias is characterized by no
pulse, decreased CRT, distal cyanosis, wide hematoma, and cold
in extremities caused by splinting emergency action, position
changes in the sick, reduction actions, and surgery.
1.7.1.5 Infection
The body's defense system is damaged when there is trauma to the
tissues. In orthopedic trauma the infection begins in the skin
(superficial) and goes inside. This usually occurs in the case of
open fractures, but also because of the use of other materials in
surgery such as pins and plates.
1.7.1.6 Avascular necrosis
Avascular necrosis (AVN) occurs due to blood flow to damaged
or disturbed bone that can cause bone necrosis and begins with
Volkman's Ischemia (Smeltzer and Bare, 2001).
1.7.2 Complications in prolonged or advanced fractures include:
1.7.2.1 Malunion
Malunion in a state where the broken bone has healed in an
unnecessary position.Malunion is a bone healing characterized by
increasing levels of strength and deformity. Malunion performed
with good surgery and reimobilization.
1.7.2.2 Delayed Union
Delayed union is a continuous healing process at a slower pace
than normal. Delayed union is a failure to consolidate fractures
according to the time it takes the bones to connect. This is due to
decreased blood supply to bone
1.7.2.3 Nonunion
Nonunion is a consolidated fracture failure and produces a
complete, strong, and stable connection after 6-9 months.
Nonunion is characterized by an excessive movement on the side
of the fracture that forms a false joint or pseuardoarthrosis. This is
also due to poor blood flow (Price and Wilson, 2006).
II. Client Care Plan with Close Fracture of Tibia Fibula
2.1. Assessment
In a focus assessment that needs to be noticed in fracture patients refers to the
theory according to Doenges (2002) there are various kinds include:
2.1.1. History of the disease now
Assess the chronology of the trauma that causes a crash fracture, what
help is obtained, whether it has been treated to a shaman fracture. In
addition, by knowing the mechanism of the occurrence of accidents,
nurses can find other injuries. The presence of knee injury is indicative of
a proximal tibial fracture. The presence of angular trauma will result in a
fracture of the conversal type or short oblique, while rotational trauma
will cause a spiral type. The main cause of the fracture is a road traffic
accident.
2.1.2. Past medical history
In some circumstances, clients who have previously gone to a traditional
shaman often experience mal-union. Certain diseases such as bone cancer
or cause pathological fractures so bones are difficult to connect. In
addition, diabetic clients with foot injuries are particularly at risk for
acute and chronic osteomyelitis and diabetes inhibits bone healing.
2.1.3. Family disease history
Family disease associated with cruris fractures is one of the predisposing
factors of fracture, such as bone cancers that tend to be genetically
inherited
2.1.4. Functional health patterns
2.1.4.1. Activity / Rest
Limitations / losses on function in the affected part (may be
immediate, fracture itself or occur secondary, from tissue
swelling, pain)
2.1.4.2. Circulation
a. Hypertension (sometimes seen as a response to pain or
anxiety) or hypotension (blood loss)
b. Tachycardia (stress response, hypovolemia)
c. Decreased / no pulse on the injured distal, slow capillary
refill, central to the affected part.
d. Network coverage or hematoma period on the injury side.
2.1.4.3. Neurosensori
a. Loss of movement / sensation, muscle spasms
b. Numbness / tingling (paresthesias)
c. Local deformity: abnormal angulation, shortening, rotation,
crepitation (creaking sound) Muscle spasms, visible weakness
/ loss of function.
d. Angitation (possibly pain / anxiety or other trauma)
2.1.4.4. Pain / comfort
a. Severe sudden pain at the time of injury (possibly localized to
tissue area / bone damage to immobilization), no pain due to
nerve damage.
b. Spasms / muscle cramps (after immobilization)
2.1.4.5. Security
a. Laseration of skin, tissue avulse, bleeding, discoloration
b. Local swelling (may increase gradually or suddenly).
2.1.4.6. Patterns of perception and self-concept
Impacts that arise from clients fraktur is arising fears and
disabilities due to fractures experienced, anxiety, the sense of
inability to perform activities normally and views against himself
is wrong.
2.1.5. Physical examination: focus data
2.1.5.1. Look
In the early phase of the trauma, the client's face is seen wincing
in a sneer. There is a clear deformity on the bottom. If swelling is
proximal to the cruris and there are severe pain complaints, it is
necessary to examine the presence of pulse changes, poor
perfusion (cold acral on the side of the lesion), and Cafilarry
Refill Time (CRT)> 3 seconds. These are important signs of
compartment syndrome.
In clinical conditions, nurses often find clients with closed
cruciate fractures with advanced complications (infections and
imperfect soft tissue cover).
2.1.5.2. Feel
Complaints of tenderness and crepitation.
2.1.5.3. Move
Movement in the broken limb area should not be performed as it
results in a traumatic response to the soft tissue around the end of
a broken bone fragment. The client seems unable to perform
movement on the broken lower leg.
2.2. Possible Nursing Diagnoses
Diagnosis 1: Acute pain (Wilkinson, 2011: 530)
2.2.1. Definition
Unpleasant and sensory and emotional experience resulting from actual or
potential tissue damage that is sudden or slow with mild to severe intensity
with anticipated or predictable end and duration of less than six months.
2.2.2. Limitations of characteristics
2.2.2.1. Subjective
Reveals verbally or reports pain with gestures
2.2.2.2. Objective
Positions to avoid pain, muscle tone changes, autonomic
responses, appetite changes, distraction behavior, expressive
behavior, mask faces, safeguarding or protective behavior,
narrowed focus, evidence of observable, self-focused and sleep
disorders.
2.2.3. Related factors
Injury-causing agents (eg biological, chemical, physical, and
psychological)
Diagnosis 2: Physical Mobility Barriers (Wilkinson, 2011: 472)
2.2.4. Definition
A limitation of independence, useful physical movement of the body or one
or more extremities.
2.2.5. Limitations of characteristics
2.2.5.1. Decrease reaction time
2.2.5.2. Difficulty flipping through
2.2.5.3. Perform other activities as a substitute for movement (eg:
increasing attention to other people's activities, controlling
behavior, focusing on prioritization / activity before
illness)
2.2.5.4. Dyspnea after the move
2.2.5.5. Changes in how it works
2.2.5.6. The movement vibrates
2.2.5.7. Limited ability to perform fine motor skills
2.2.5.8. Limited ability to perform rough motor skills
2.2.5.9. Limited range of movement of joints
2.2.5.10. Tremor due to movement
2.2.5.11. Posture instability
2.2.5.12. Slow movement
2.2.5.13. Uncoordinated movements
2.2.6. Related factors
2.2.6.1. Activity Intolerance
2.2.6.2. Changes in cell metabolism
2.2.6.3. Anxiety
2.2.6.4. Body mass index above the 75th percentile according to age
2.2.6.5. Cognitive impairment
2.2.6.6. Contractures
2.2.6.7. Cultural beliefs about age-appropriate activities
2.2.6.8. Physical not fit
2.2.6.9. Decreased endurance
2.2.6.10. Decreased muscle control
2.2.6.11. Decreased muscle mass
2.2.6.12. Decreased muscle strength
2.2.6.13. Lack of knowledge about the value of physical activity
2.2.6.14. Depressive mood state
2.2.6.15. Developmental delays
2.2.6.16. Inconvenience
2.2.6.17. Kaku Joints
2.2.6.18. Lack of environmental support (eg physical or social)
2.2.6.19. Limitations of cardiovascular endurance
2.2.6.20. Damage to the integrity of bone structure
Diagnosis 3: Risk of Infection (Herdman, 2015: 405)
2.2.7. Definition
Vulnerable to the invasion and multiplication of pathogenetic organisms
that can interfere with health.
2.2.8. Risk factor
2.2.8.1. Lack of knowledge to avoid pathogen exposure
2.2.8.2. Malnutrition
2.2.8.3. Obesity
2.2.8.4. Chronic illness (eg Diabetes mellitus)
2.2.8.5. Primary body defenses are inadequate
a. Impaired skin integrity
b. Peristalsis disorders
c. Decreased ciliary work
d. Change of secretary pH
e. Stasis of body fluids
2.2.8.6. Secondary body defenses are inadequate
a. Immunosuppression
b. Leukopenia
c. Decreased hemoglobin
2.3. Planning
Diagnosis 1: Acute pain
2.3.1. Goal and yield criteria (NOC)
After nursing actions during ....... x24 hours, the expected pain is reduced
by the criteria:
2.3.1.1. Comfort Level:
Level of positive perception of physical and psychological
convenience
2.3.1.2. Self-control :
Individual action to control pain
2.3.1.3. Pain rate:
The severity of pain that can be observed or reported
2.3.1.4. Shows pain control as evidenced by the following indicator (state
1-5: never, rarely, occasionally, often, or always)
2.3.1.5. Indicates the level of pain, as evidenced by the following indicators
(very severe, severe, moderate, mild or absent): Expression of
facial pain, anxiety or muscle tension, duration of pain,
whimpering and crying, anxiety.
2.3.2. Nursing and rational interventions (NICs)
2.3.2.1. Pain Management:
Relieve or reduce pain to the comfort level acceptable to the client
2.3.2.2. Giving Analgesics:
Use pharmacological agents to reduce or eliminate pain
2.3.2.3. Medication Management:
Facilitate the safe and effective use of prescription or over-the-
counter medicines
2.3.2.4. Analgesia Help:
Facilitate the handling of analgesic granting and arrangement by
clients
2.3.2.5. Sedation Management:
Provide sedatives, monitor client responses, and provide the
necessary physiological support during diagnostic or therapeutic
procedures
Diagnosis 2: Physical Mobility Barriers
2.3.3. Goal and yield criteria (NOC)
Shows mobility as evidenced by the following indicators (1-5: extreme,
severe, light, or non-interference):
2.3.3.1. Balance
2.3.3.2. Coordination
2.3.3.3. Performance of body position
2.3.3.4. Perge
2.3.3.6. Moves easily
2.3.4. Nursing and rational interventions (NICs)
2.3.4.1. Promotion of Body Mechanics
Facilitate the use of posture and movement in daily activities to
prevent fatigue and tension or musculoskeletal injuries
2.3.4.2. Promotion Physical Exercise: Strength Training:
Facilitate routine resistive muscle training to maintain or improve
muscle strength
2.3.4.3. Physical Exercise Therapy: Ambulation:
Improve and assist in walking to maintain or restore body functions
2.3.4.4. Physical Exercise Therapy: Balance
Use certain activities, postures, movements to maintain, improve, or
restore balance
2.3.4.5. Physical Exercise Therapy: Joint Mobility
Use active and passive body movements to maintain or restore joint
flexibility
2.3.4.6. Physical Exercise Therapy: Muscle Control
Use certain activities or appropriate exercise protocols to improve
restore controlled body movements
2.3.4.7. Position Settings
Regulate the client's or client's body position carefully to improve
physiological and psychological well-being
Diagnosis 3: The risk of infection
2.3.5. Goal and yield criteria (NOC)
Infection risk factors will disappear, as evidenced by Wound Healing: primary
and secondary; Immune Status; Infectious Severity.
2.3.6. Nursing and rational interventions (NICs)
2.3.6.1. Injury cure:
Prevent the occurrence of complications on the wound and facilitate
the wound healing process
2.3.6.2. Immunization / Vaccination Management:
Monitor immunization status, facilitate access to immunization, and
immunize against infectious diseases
2.3.6.3. Infection Control:
Minimize the spread and transmission of infectious agents
2.3.6.4. Infection Protection:
Preventing and detecting early infections in clients at risks
BIBLIOGRAPHY
Doenges. 2002. Tersedia dalam: http://digilib.unimus.ac.id /files/disk1/135/
jtptunimus-gdl-nurhidayah-6731-2-babii.pdf
Herdman, T. H. (Ed). (2015). Nanda International Inc. Diagnosis Keperawatan:
Definisi & Klasifikasi 2015-2017. Edisi 10. Jakarta: EGC.
http://digilib.unimus.ac.id/files/disk1/135/jtptunimus-gdl-nurhidayah-6731-2-
babii.pdf(Diakses 07 Agustus 2017)
http://eprints.ums.ac.id/20977/19/NASKAH_PUBLIKASI_ILMIAH.pdf (Diakses 07
Agustus 2017)
http://eprints.ums.ac.id/22037/23/NASKAH_PUBLIKASI.pdf (Diakses 07 Agustus
2017)
http://www.askepkeperawatan.com/2015/11/askep-fraktur-tibia-fibula.html (Diakses
07 Agustus 2017)
http://www.slideshare.net/wahyubudiPrasetyo/contoh-makalah-uap-wahyu-budi-p
(Diakses 07 Agustus 2017)
https://www.google.com/search?q=askep+close+fraktur+tibia+fibula&ie=utf-
8&oe=utf-8&client=firefox-b#q=askep+fraktur+tibia+pdf (Diakses 07 Agustus
2017)
Muttaqin, A. 2011. Buku Saku Gangguan Muskuloskeeletal: Aplikasi pada Praktik
Klinik Keperawatan. Jakarta: EGC.
Price & Wilson. 2006. Tersedia dalam: http://digilib. unimus.ac.id
/files/disk1/135/jtptunimus-gdl-nurhidayah-6731-2-babii.pdf Diakses 07
Agustus 2017
Sjamsuhidajat. 2010. Tersedia dalam: http://eprints.ums.ac.id /20977/19/
NASKAH_PUBLIKASI_ILMIAH. pdf Diakses 07 Agustus 2017
Smeltzer & Bare. 2001. Tersedia dalam: http://digilib. unimus.ac.id
/files/disk1/135/jtptunimus-gdl-nurhidayah-6731-2-babii.pdf Diakses 07
Agustus 2017
Smeltzer, 2003. Tersedia dalam: http://digilib.unimus.ac.id
/files/disk1/135/jtptunimus-gdl-nurhidayah-6731-2-babii.pdf Diakses 07
Agustus 2017
Wilkinson, J. M. (2011). BukuSaku Diagnosis Keperawatan: Diagnosis NANDA,
Intervensi NIC, KriteriaHasil NOC. EdisiRevisi. Jakarta: EGC.
