Fracture Mechanism In Osteogenesis Imperfecta Patient: Case Study

1.Science: Critically discuss the mechanism of injury of falls in a younger patient. In your answer explain how it is possible that Harriet sustained a fractured femoral shaft, a fracture requiring significant force, despite the mechanism being a simple fall. Identify the significance of observing for limb length disparity and external rotation that is documented in the nursing progress notes?

2.Science: Identify the medications, both routine and those prescribed for this admission, and discuss their pharmacology. Explain their indication for use in this patient.

3.Nursing: Based on the assessment data discuss the immediate nursing priorities for this patient (i.e. within the ED).

4.Nursing: Critically analyse the ongoing holistic nursing care for this patient linking to both the acute and chronic diagnoses and possible post-operative complications for this patient.

Reason behind femur fracture in Harriet's case

Fracture is a medical term which is used for broken bone. It happens due to effect of physical force on bone. This can happen because of car accident, falls or sports injuries. Osteogenesis imperfecta is the brittle bone disease. In this type of disease even mild fall can lead to breakage of bones. Femur shaft fracture is the breaking of body of femur bone found in thigh. This type of fracture can lead to deformity in legs hip pain and other fractures related to stress. Person having osteogenesis imperfecta are very prone to fractures.

This study is based on a case study in which a 8 year old child Harriet Potter suffering from osteogenesis imperfecta had a fall and then fractured the shaft of femur. Her mother admitted her in hospital for further treatment in ED. This report consists of answers of questions related to Harriet’s injury cause and effects and the pharmacodynamics of medicines involved. Nursing priorities of her is also included along with the holistic nursing care of Harriet and complications after surgery.

Falls is one of the most common mechanisms which is found in young age children. Falls can be like simply tripping or slipping on wet floor. The mechanics of the fall and the position of landing can give clues regarding the injury sustained. In the case of intentional injury the help of Psychiatric official should be taken. Normally simple falls result in fractures or head injury depending on the type of surface and if any sharp or blunt object is hit while falling. Simple ground falls leads to femur shaft fracture are normally uncommon in young patients, as simple fall can’t have so much force that can break thigh bone. But in this case of a 8 year old girl named Harriet Potter she is suffering from fracture of femur shaft by simple ground fall only. The reason behind this is that she is suffering from osteogenesis imperfecta which is also known as Brittle bone disease. This type of disease is genetic disorder which affects bone of patients. In this disease the bones become very fragile and break easily with even with mild impact (Duhaime,1992). Many fractures are common in whole lifetime. Other symptoms of this disease are short height, loose joints loss of hearing and problems with teeth. Osteogenesis imperfecta occurs due to lack of type 1 collagen which may occur due to mutations. This disease is of 8 types in which type 1 is mild but type 2 is the severe condition. Diagnosis can be done by checking of symptoms and by collagen testing. The mild form of this disease (type 1) has characteristics of bone fracture during childhood that can result from mild impact. But the severe form (type 2) can result into small breakable rib cage and underdeveloped lungs(Rauch & Glorieux, 2004). Thus this is the reason why Harriet had fracture of femur with simple fall. The shaft of femur is the long straight part of the thigh bone. It requires lot of force for breakage but in Harriet’s case it broke because of brittle bone disease. This fracture can cause serious pain and it will be difficult to put weight on leg and it can be looking as deformed like shorter than other leg. In such fracture doctor checks some features like deformity in leg, breaks formed in skin, bruises and bone pieces if any pushing through the skin. The imaging techniques which are used to check femur fracture are x ray and computed tomography (CT scan). As per progress notes limb length disparity and external rotation has to be checked. Limb length disparity is the difference between the structures of both legs. Due to femur fracture in the case of Harriet it may so happen that the leg affected becomes shorter than the other. If not treated this leg deformity can lead to hip pain, stress fractures or low back pain. Even the external rotation has to be checked to find out that she is able to move her leg external to the midline. The leg movement outside the axis of the body is also check in external rotation. These are checks to be done while checking for femur fracture and its consequences.

Medication used in Harriet's case

Other medications included are pamidronate, oxycodone and morphine.

It is a common analgesic and antipyretic drug for the management of mild to moderate pain in children and is the first line therapy for the treatment. Paracetamol is highly effective for pain reduction when administered at a dose of 15 mg per kg of body weight. It is safe and effective for children. Paracetamol is a highly lipid soluble compound which absorbs easily through gut. It is highly polarized in stomach with very low gastric absorption (Majidi et al., 2015). Paracetamol has several PD targets in the brain. It inhibits the COX and reduces the prostaglandin synthesis. It acts as a reduction factor donating electrons to the iron radical within COX peroxidase site and prevents the generation of tyrosine radicals and also prevents arachidonic acid oxygenation. Paracetamol is also involved in serotonergic pain control system by indirectly activating serotonin receptors like 5 hydroxytrptamine 3 subtype on opioidergic interneuron which reduces the excitement of dorsal horn neurons projecting to thalamus (Berde & Sethna, 2002).

It is administered to Harriet at dose of 30 mg. It is a class of drugs called bisphosphonates which can reduce breakdown of the bones. Its main work is to inhibit resorption of bone. It adsorbs to calcium phosphate crystals in bone and it directly blocks dissolution of this mineral component of bone. The inhibition of bone resorption depends on osteoclasts activity. Pamidronate targets FPP synthetase. Inhibition of this enzyme in osteoclasts prevents the biosynthesis of isoprenoid lipids which all are required for post translational farnesylation and geranylation of small GTPase signaling proteins. Thus this activity inhibits osteoclasts activity and reduces bone resorption (Lee et al. 2016)

It is used in case of moderate to severe pain. For Harriet its dosage is 3 mg per 4 hours. Maximum limit is 18 mg a day. Effects of oxycodone are pain relief with feelings of relaxation and also relief from respiratory depression (Chamey et al., 2008). Side effects are slow heart rate, slow breathing along with low BP if it is administered in high dose. Oxycodone is highly selective target of µ- opioid receptor (MOR). It binds with MOR which then inhibits the release of neurotransmitters by the cell which is done by reducing the amount of cAMP produced, which closes the calcium channels and opens potassium channels(Chen, Zhu & Zhou, 2014).

 Morphine is given to Harriet at 3 mg every 4 hours. Maximum limit is 12 mg. Morphine is a product of opium and is used as a great pain reliever. Side effects are nausea, constipation itching and respiratory problem. Morphine binds to opioid receptors and then molecular signaling activates the receptors for certain activity. The receptors are Mu receptors, kappa receptors and delta receptors which are found in different parts of brain. Morphine binds to it and provides relief from pain and sedation (Cremers et al, 2002)

for a patient with femoral fracture are plastered in a casting or placed in traction to prevent the complications during healing. A nursing staff can handle the patient’s pain by nursing the patient at a regular basis. On emergency the basic care is provided which includes maintaining airway, breathing, protection of the cervical spine and blood circulation (Christie, 2015)

Pharmacodynamics of the medication

These are the following ways of nursing care plans for the fracture patients:

Rate of the increase of vulnerability to falling may cause physical harm.

• Movement of bone is lost
• Weakness at the part of the fracture

• To maintain stabilization and align the fracture(s).
• To indicate body mechanism that will provide stability to the fractured bone.

• To maintain rest of the limb as instructed by the doctor by providing support to the joints at the fracture site, while moving. This will provide stability, by minimizing the chances of disturbing the arrangement which will improve the healing.

It is a type of pain that is troublesome sensory and emotional experience which rises from the damaged tissue and stays for more than a time period of 6 months.

• Muscle spasms
• Movement of bone fragments and injury to soft tissue
• Traction device
• Stress, anxiety

• Reports of pain
• Distraction, griming(pain on the face)
• Protective behavior, changes in muscle tone

• Relief from pain
• Will be able to participate in activities

• To maintain the movement of affected part by providing rest, cast or traction this will give relief from pain and prevents bone movement.
• To avoid using plastic sheets or pillows under the plastered limbs as they can increase discomfort by releasing the heat from the drying the cast.

The patient with fracture is very prone to infection to the dermis or epidermis.

• Puncture of the injury, repair by the surgical ways, introducing traction pins, wires screws.
• Alteration of blood circulation associated with secretions.
• Physical immobilization.

• Itching, pain, invasion of body structures such as boils and other types of abrasions.
• Disruption of skin surface, damage of layers of tissue.

• To diagnose the skin if there is any open wounds, foreign bodies, rashes, bleeding or discoloration. This provides information about skin condition and problems that are caused by the casting of the plaster, splint or traction.

Orthopaedic nursing and trauma care is a different but various ways to be focused on the patient care with musculoskeletal problems. These problems are associated with tissues which are the main system for the movement of the human being. Orthopaedic and trauma physiologist must have a deep knowledge and skills which help in providing expert specialist care based on various and highly specific need. The orthopaedic physiologist has his own role together with skills and knowledge. Nursing theory which is applied for the patient with musculoskeletal trauma is dealt with nursing and healthcare. Nursing care for this type of patient includes a professional care on the basis if holistic assessment (Clarke & Tomlinson, 2014).

The dominant work of nursing is incorporated by the four main elements:

• The person
• Environment in which the person is living.
• The health status of the person.
• Nursing care of the patient.

Complications from fractures

The fractures caused in femoral shaft are too delicate and they can cause further complications (Yu & Guo, 2017).

• The fractured bones have broken ends which are sharp and can tear the blood vessels or nerves surrounding it.
• A condition developes known as acute compartment syndrome, which is too much painful and it occurs when too much of pressure is created within the muscle builds. This pressure decreases the blood flow which prevents the oxygen to reach the nerve cells and the muscle cells. If the pressure is not released immediately it can cause permanent disability.
• Open fractures can become infected as they are exposed to the environment and this condition is too much difficult to treat. For this treatment multiple surgeries can be done with a regular intake of long term antibiotics (Smith et al., 2015).

Commonly the risks of surgeries are blood loss, problem associated with anesthesia (RU et al., 2013). In addition to this there are some other complications, those are:

• Infection of the bone
• Injury to the blood vessels and nerve cells
• Clotting of blood
• Embolism of fat
• The broken bone fragments may be misaligned or cannot be able to position correctly.
• Delaying of the attachment of the bone where the bone heals slower than usual.
• Irritation from the hardware caused from casting or traction.

Conclusion:-

From the given answers it can be concluded that Harriet who is suffering from fracture in shaft of femur due to simple ground fall was due to the fact that she had a medical history of brittle bone disease. She was administered with lot of medications to remove pain and X-ray was done to check level of fracture. The immediate nursing care was taken for the patient and are plastered in a casting or placed in traction to give the patient relief. Holistic approach includes orthopedic nursing and trauma care, for which an expert physiologist is needed who can take care of Harriet.

References 

Berde, C. B., & Sethna, N. F. (2002). Analgesics for the treatment of pain in children. New England Journal of Medicine, 347(14), 1094-1103.(ans2)

Charney, R. L., Yan, Y., Schootman, M., Kennedy, R. M., & Luhmann, J. D. (2008). Oxycodone versus codeine for triage pain in children with suspected forearm fracture: a randomized controlled trial. Pediatric emergency care, 24(9), 595-600.(ans2)

Chen, Y., Zhu, L. L., & Zhou, Q. (2014). Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients. Therapeutics and clinical risk management, 10, 437-448.(ans2)

Christie, J. (2015). Interventions for Treating Femoral Shaft Fractures in Children and Adolescents. Orthopaedic Nursing, 34(5), 309-310.(ans3)

Clarke, S., & Santy-Tomlinson, J. (2014). Orthopaedic and Trauma Nursing: An Evidence-based Approach to Musculoskeletal Care. John Wiley & Sons.(ans4)

Cremers, S., Sparidans, R., den Hartigh, J., Hamdy, N., Vermeij, P., & Papapoulos, S. (2002). A pharmacokinetic and pharmacodynamic model for intravenous bisphosphonate (pamidronate) in osteoporosis. European journal of clinical pharmacology, 57(12), 883-890.(ans2)

Duhaime, A. C., Alario, A. J., Lewander, W. J., Schut, L., Sutton, L. N., Seidl, T. S., ... & Loporchio, S. (1992). Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics, 90(2), 179-185.(ans 1)

Lee, Y. S., Baek, C. W., Kim, D. R., Kang, H., Choi, G. J., Park, Y. H., ... & Woo, Y. C. (2016). Comparison of hemodynamic response to tracheal intubation and postoperative pain in patients undergoing closed reduction of nasal bone fracture under general anesthesia: a randomized controlled trial comparing fentanyl and oxycodone. BMC anesthesiology, 16(1), 115.(ans2)

Majidi, A., Dinpanah, H., Ashoori, S., Motamed, H., & Tabatabaey, A. (2015). Comparison of morphine–midazolam versus morphine injection for pain relief in patients with limb fractures-a clinical trial. Ulus Travma Acil Cerrahi Derg, 21(1), 22-26.(ans2)

Osborne, R., Joel, S., Trew, D., & Slevin, M. (1988). Analgesic activity of morphine-6-glucuronide. The Lancet, 331(8589), 828.(ans2)

Rauch, F., & Glorieux, F. H. (2004). Osteogenesis imperfecta. The Lancet, 363(9418), 1377-1385.(Ans1)

RU, C., ZHANG, Y., ZHAO, J., & ZHANG, Y. (2013). Nursing experience of minimally invasive internal fixation with locking plate in the treatment of elderly patients with femoral intertrochanteric fracture [J]. Journal of Clinical Medicine in Practice, 4, 028.(ans4)

Smith, T., Pelpola, K., Ball, M., Ong, A., & Myint, P. K. (2014). Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age and ageing, 43(4), 464-471.(ans4)

Yu, W., & Guo, X. (2017). Teriparatide treatment of femoral fracture nonunion that autogenous bone grafting failed to heal: a case report. Archives of osteoporosis, 12(1), 15.(ans4)