This case study relates to a client who sustained a pelvic fracture from a road crash. The client was a 29 year old Chinese female who was six months pregnant. The case study consists of three parts: interpretation of the pathophysiology, analysis of diagnostic data, and discussion of medications used to assist this patient. The aim of the study is to explore the impact of this pelvic fracture for the patient and consider the implications for nursing practice.
Pathophysiology and the client adaptation
"Fractures of the pelvis and acetabulum are among the most serious injuries treated by orthopaedic surgeons" (Helfet, 2002). The complex nature of pelvic fractures can be better understood by looking at the anatomy that is involved. The pelvis consists of the ilium (i.e., iliac wings), ischium, and pubic bones, which form an anatomic ring meeting at the pubic symphysis in the front and the sacrum in the back. Together with a number of ligaments and muscles, the bones of the pelvis support the weight of the upper body and rest on the hip joints (Phipps, Sands, & Marek, 1999).
The pelvis is supplied with a rich venous plexus as well as major arteries. Shearing forces from the impact of trauma may cause significant bleeding due to rupture of the blood vessels and hemorrhage is usually the cause of death (Sheppard, 2001). If Grey-Turner's sign (Wright, 1997) presents, i.e. a bluish discoloration of the lower abdominal flanks and lower back, it may indicate pelvic fracture has caused retroperitoneal bleeding. The retroperitoneal space can accommodate up to 4 litres of blood (Phipps et al, 1999), thus ongoing monitor vital signs and Grey-Turner's sign at the early stage of the case is necessary.
The sciatic nerve is the thickest and longerst nerve in the body. Two nerves (tibial and common peroneal) wrapped in a common sheath make up the sciatic nerve. Because of its anatomical location, the sciatic nerve injury is common in the pelvis fracture. It arises from lumbrosacral plexus (L4, L5, S1, S2, and S3) and passes through the greater sciatic notch of the pelvis (Marieb, 1995). Its injury may lead to partial or complete loss of leg movement and sensation. Nurses should be familiar with neurological assessment of sciatic nerve through its major branches; patient with intact tibial and peroneal nerve function should have normal sensation in sole and first web space of foot and foot can point upward and downward (Hackett, 1983).
Sheppard (2001) points out that disruption of pelvic ring requires significant energy. Mary was hit by a car traveling 50km/hr, while she was walking on a pedestrian crossing. Because of the significant forces involved, complications to bladder, leg length discrepancy (because of abnormal rotation of femurs), and lacerations of perineum, vagina, or rectum are common. In this case, CT scans found partial placental devascularisation and that her baby would not survive.
Tile's classification of pelvic fracture is based on the mechanism of injury (Orthoteers, 2004). This case fits in Type B3 (lateral compression and contra-lateral), because the car hit on Mary's right side, and led to predominantly right-sided pelvic fractures with left acetabulum fracture. Tile's classification (Orthoteers, 2004) indicates this type of pelvic fracture is rotational unstable and vertically stable. In this case, instability is further increased because of pregnancy. As Lee (1999) stated, the locking mechanism of the pelvic girdle is less effective during pregnancy due to relaxation of the ligament of the sacroiliac joints and the pubic symphysis.
Bone regenerates rather than simply repaired through fibrous tissue (Porth and Gaspard, 2004). Bone healing process starts with the formation of hemtoma at the fracture site. The formation of fibrocartilage tissue occurs in 3 days to 2 weeks after fracture. Fibrous tissue has to first stabilize the fracture fragment before cartilage can form into healing process. Early bone formation is often called primary callus and progressively stabilizes the fracture site. The mechanical factors of treatment such as immobilization or internal fixation are important features to facilitate the healing process.
Mary underwent surgeries to stabilize her pelvis. The orthopaedic surgeons first stabilized the fracture by using an external frame to temporarily hold the bones in proper alignment, which allowed Mary to deliver a stillborn baby in the natural way. The further surgery was ORIF (open reduction internal fixation). The fractured bones are rigidly fixed with cannulated screws and external fixator to prevent future displacement and allow for rehabilitation to begin as quickly as possible.
Bone formation takes much longer time. Callus formation (2 to 6 weeks) occurs as the maturing of the granulation tissue continues. The outcome of ossification (3 weeks to 6 months) is that the gap at the fracture site is united or bridged. The final stage is consolidation and remodeling (Altizer, 2002a). Most likely, Mary has to have several months of temporary disability.
Several factors may influence bone healing, including age, hormones, functional activity, nerve function, nutrition, drugs, and local fractured bone condition (Orthoteers, 2001). Because of delivery of baby and large surface area of fractures, nutrition is significant in the case. As Marieb (1995) stated, bone is the storehouse of calcium in body. If blood calcium level is low, bone will demineralize to compensate and may delay bone healing. Diary food is the best source of calcium. However, it is not the usual food for Chinese people. Mary eats small meals and dislikes diary product, thus she is provided 'Ensure Plus' which has high calcium, high protein, and multiple minerals and vitamins as her diet supplement.
It is important that Mary is guided and encouraged to move and weight bear. Researches indicates that controlled cyclical loading produces a hypertrophic response and increases bone mineral content (Sheppard, 2001), i.e. exercise and loading facilitates bone healing.
Interpretation of the diagnostic data
Radiography is the most important diagnostic data for an orthopaedic patient. Also as infection is a common complication of trauma and surgery, early recognition of a local infection is an object of nursing, as it may prevent patient from developing sepsis and, thus, decrease morbidity; further to visual observation of local swellings, redness and warmth in her wound and her pin sites, a white blood cell count (WBCs) is an important diagnostic data for potential infection. Radiography and WBC will be discussed in this section.
* Computerized Tomography (CT )scan
The only specialized diagnostic test Mary underwent was CT scan. The CT scanner produces a narrow x-ray beam that examines body sections from many different angles. CT scanning of bone provides a series of tomograms to represent cross-sectional images of various bone layers, which can be translated by a computer and displayed on a monitor. The traditional x-ray takes only a flat or frontal picture. The CT scanner is about 100 times more sensitive than the x-ray machine. Thus, it is a much more effective but costly diagnostic test. CT scanning is crucial in this case, as the pelvis consists of irregular shape bones, and fractures of the posterior elements of pelvis are not easy to be seen on the plain X-ray (Chipno, 1982).
CT scan can visualize internal structure of body; it is the most important diagnostic data for orthopaedic surgery. The findings of Mary 's CT accurately confirm her pelvic fracture. There is a fracture through the right sacral ala which is minimally displaced, and the fracture extends into the sacroiliac joint inferiorly. There is slight widening of the anterior aspect of the right sacroiliac joint. Comminuted minimally displaced fractures of the superior and inferior pubic rami are present on the right. On the left, there is a mildly comminuted fracture involving the anterior margin of the acetabulum. The fracture fragments are minimally displaced. No gap is present in the articular surface. These findings demonstrate the position and displacement of the fracture fragments, which help surgeons to get as much information as possible about the fracture before beginning surgery. Additional, Mary's CT scans help to exclude some complications from the trauma: i.e. no abdominal bleeding, bladder injury, bowl injury, and spinal cord injury was detected.
As a result, interpretation of CT scans is an important complement to physical assessment. As a part of orthopaedic team, nurses need to learn how to read the radiographs. Though Mary was not keen to see her radiographs, nurses may need to explain the findings of her CT scans, so that Mary can better understand and cooperate with her treatment.
* White blood cell count (WBC)
Mary was at high risk of osteomyelitis (bone infection) due to traumatic pelvic fracture and post orthopaedic surgeries. Ostoemyelitis can be caused by bacteria or by fungus. The acute infection needs to be treated promptly and adequately to prevent the development of chronic osteomyelitis, which usually needs surgical removal of dead bone (Porth et al., 2004).
The blood test of WBC is one of the diagnostic data that may indicate osteomyelitis. There was a sequence of elevated WBC in Mary's case, i.e. 17.28, 14.12, 10.14, 11.26, and 11.05. High WBC usually indicates an imflammatory and immune response, however, nurses need to know the diagnose of osteomylitis needs to consider acompanying signs and symptoms of infection (e.g. pain in bone, local redness, or fever) and combine with other examinations (e.g. blood culture). As there were no physical signs of infection and no other tests support infection, osteomyelitis was not diagnosed. But this still needed to be considered until WBC went back to normal. Luckily, Mary's WBC was elevated only five days, thus it probably related to trauma and acute stress (Hendler et al., 2002).
Pharmacological interventions and implications to nursing practice
Pain control and embolism prevention are the major concerns for post orthopaedic surgery patients. This section will discuss nursing interventions for the use of Morphine and Warfarin.
Morphine is a strong analgesic, but only has action on central nervous system (CNS), i.e. alteration of the perception of and response to painful stimuli. Morphine is mostly metabolized by the liver, finally excreted via kidney, thus, Morphine should be cautiously used for patients with kidney disease and liver disease (Deglin & Vallerand, 2001). Mary is a Hepatitis B carrier, she can be prescribed Morphine as her liver function has been normal.
Morphine is a controlled drug. There is a general principles pertaining to the administration and storage and there is specific legislation for prescription (Galbraith, Bullock, and Manias, 1997). Nurses should be aware of only doctors are entitled to prescribe Morphine and complete the drug chart.
Mary felt convenient and secure to use Morphine through PCA (patient controlled analgesia). Only Mary could push PCA button, and she would not overuse Morphine since the maximize dosage has been prescribed and locked into PCA.
The nursing interventions focus on observation of Morphine's side effects. Morphine produces generalized CNS depression. Respiratory depression is the leading side effect, thus it is very important to regularly monitor respiratory rate and oxygen valuations. Nurses should encourage Mary to practice deep breathing and cough. Also, nurses need to help Mary to realize Morphine's other side effects, including confusion, blurred vision, hypotension, bradycardia, constipation, nausea, vomiting, urinary retention (Deglin et al., 2001), so that effective nursing interventions can be provided.
Mary is at high risk of deep vein thrombosis (DVT) due to pelvic fracture, surgeries, and prolonged immobilization. DVT refers to the formation of a thrombus (blood clot) within a deep vein, commonly in the thigh or calf. it is limb-threatening. If the thrombus breaks free and travels through the veins, it can reach the lungs, where it is called a pulmonary embolism (PE). PE is a potentially fatal condition that can kill within hours. Both DVT and PE may be asymptomatic and difficult to detect. Thus, prophylaxis is very important (Orthopaedic surgery, 2004).
Anticoagulant, Warfarin acts indirectly to prevent synthesis in the liver of vitamin K-dependent clotting factors. Warfarin is administered orally and metabolized by liver (Galbraith et al., 1997). If Mary's liver function is diminished, Warfarin may need to be stopped or decrease its doses.
Side effects include GI tract reaction and bleeding (Deglin et al., 2001). Bleeding is a major concern as Mary has several operation wounds and pin sites, and she still has post-natal bleeding. Nurses should check for excessive bleeding from these areas regularly. Also, nurses need to educate Mary to report unusual bleeding or bruising, e.g. bleeding gum or nose, black stools, red or brown urine.
Dosage is highly individualized based on the International Normalized Ratio (INR) system, which is the best means of standardizing measurement of prothrombin time to monitor oral anticoagulant therapy. Mary needs to do daily blood test to provide INR to doctors. Nurses should check oral anticoagulant therapy chart diligently and instruct Mary to take Warfarin exactly as directed. Vitamin K is a useful antidote to Warfarin in case of hemorrhage (Galbraith et al., 1997), however, Mary needs to avoid excess Vitamin K, such as broccoli (Booth, 2000) in her food which overcome Warfarin effect.
Pelvic fracture is a serious injury, involving significant force, may have severe complications, and surgical fixation is usually needed. The bone healing will take months or years; it is a hard process for the patient. Orthopaedic nurses should be able to read relevant radiograph and lab test and familiar with pharmacological interventions, so that to effectively promote health care.