FRACTURE, CLOSED COMMINUTED

LEFT TIBIA,

Presented by:

Dela Torre, James

Grepo, Paul
Ignacio, Jerick
Lacanlale, Mart
Taguba, Mark
 CASE ABSTRACT

This is a case of a 27 y/o male, a resident of B17 L41 Barnabas St. – Annex 35
Better Living Paranaque City. He was admitted last January 16, 2010 under the service of
Dr. Grageda. He has a chief complaint of Vehicular Accident with admitting diagnosis of
fracture closed comminuted left tibia
Few minutes PTA, around 9:00 pm, while driving a motorcycle at La Huerta
Paranaque City, the patient was outbalanced due to pothole. He fall on his left side
sustaining multiple abrasion, tenderness on his left leg prompted to consult at Olivarez
General Hospital ER for medical advice and decided to admit for surgical operation.
Physical assessment revealed (+) pain and decrease limitation, ROM, and multiple
abrasion and hematoma on his left extremities. He has GCS of 15.
Laboratory procedures done to the patient are UA, CBC. Diagnostic procedure
done was X- Ray leg APL.
Medication prescribed by the doctor assigned are cefazolin sodium 1g I.V.,
Ketorolac tromethamine 30mg I.V, coamoxiclav TID PO, 620 mg, Mobic 30 mg 1 tab
BID, Paracetamol 500mg PO.
PATIENTS DATA
Name: Mr. RA
Age: 27 y/o
Gender: M
Civil status: Married
Address: B17 L41 Barnabas St. – Annex 35 Better Living Paranaque City
Date of Birth: January 03, 1983
Place of Birth: Pasay City
Religion: Roman Catholic
Nationality: Filipino
Occupation: Operator
Language Spoken: Tagalog
Weight: 145 lbs
Height: 5’8’’
Attending Physician: Dr. Grageda
Admitting Diagnosis: Fracture closed comminuted left tibia
Chief of Complaint: Vehicular Accident]
Surgical Operation: Arif Plate fixation

HISTORY OF PRESENT ILLNESS

Few minutes PTA, around 9:00 pm, while driving a motorcycle at La Huerta
Paranaque City, the patient was outbalanced due to pothole. He fall on his left side
sustaining multiple abrasion, tenderness on his left leg prompted to consult at Olivarez
General Hospital ER for medical advice and decided to admit for surgical operation.
Physical assessment revealed (+) pain and decrease limitation, ROM, and multiple
abrasion and hematoma on his left extremities. He has GCS of 15.

PAST MEDICAL HISTORY

(-) Asthma
(-) DM
(-) HPN
PATHOPHYSIOLOGY
Fracture
↓

Modifiable ← Risk factors → Non- Modifiable

• Behavior • Age
• Lifestyle ↓ • Gender
• Occupation physical trauma due to
• Environment vehicular accident

↓
traumatic force applied to left lower
extremities

↓
multiple abrasions and the tibial bone is broken → muscle
into fragments spasm form due
to fractured bone

↓ ↓ ↓
fibrous connective tissue or periosteum nerve at the site damaged pain
and blood vessels in the cortex, ↓
marrow, and surrounding soft tissues numbness
are disrupted and damaged

↓
bleeding occurs from the damaged
bone and from the neighboring
soft tissues

↓ decrease ROM and mobility

blood clot forms

↓
hematoma

↓
stimulate the inflammatory response
characterized by vasodilation, exudation of plasma
and leukocytes

↓
swelling