PNEUMOHEMOTHORAX and OPEN III-ACOMMINUTED TIBIAL FRACTURE

BSN-3B Group 1

OBJECTIVES
Presenter-centered
After 90 minutes of case presentation, the presenters will be able to:

Thoroughly discuss the overview of the case. Assess the clients condition, Formulate nursing diagnoses related to the clients condition, Plan appropriate nursing interventions that would aid in clients recovery, Implement the planned interventions;and Evaluate the effectiveness of the interventions provided.

OBJECTIVES
Audience-centered After 90 minutes of case presentation, the students will be able to: Obtain an overview of the case to be presented. Compare the normal anatomy of the organs involved from abnormal findings and diagnosis of the case. Understand the importance of laboratory tests in diagnosing the case. Learn nursing managements on how to handle clients with the same diagnosis. Formulate questions and asks clarification about the case presentation.

OBJECTIVES
Instructor-centered After 90 minutes of case presentation, the CIs will be able to: Share additional info about the case presentation. Ask clarifications or questions if some info presented were unclear. Give suggestions on how to improve the study.

INTRODUCTION

FRACTURES According to Porth, fracture, or discontinuity of the bone, is the most common type of bone lesion. Normal bone can withstand considerable compression and shearing forces and, to a lesser extent, tension forces. A fracture occurs when more stress is placed on the bone than it is able to absorb. Grouped according to cause, fractures can be divided into three major categories: fractures caused by sudden injury, fatigue or stress fractures, and pathologic fractures. The most common causing fractures are those resulting from sudden injury. The force causing the fracture may be direct, such as a fall of blow, or indirect, such as a massive muscle contraction trauma transmitted along the bone.

Diagnosis is the first step of fractures and is based on history and physical manifestations. X-ray examination is used to confirm the diagnosis and direct the treatment. Healing time depends on the site of the fracture, the condition of the fracture fragments, hematoma formation, and other local and host factors. In general, fractures of long bones, displaced fractures and, fractures with less surface area heal more slowly. Function usually returns with in 6 months after union is complete. However, return to complete function may take longer. Stress fractures usually require less time to heal, usually 2 to 4 weeks, during which the reduction in activity and protection of the are needed.

PNEUMOHEMOTHORAX This is the collection of blood and air in the spaces around the lungs. The build up of blood and air in the lungs puts pressure, so the lungs cannot expand normally as it should. Trauma or lung disease such as COPD, asthma, cystic fibrosis, and tuberculosis can increase the risk of having pneumohemothorax.

Diagnosis for pneumothorax is aided by x-rays and arterial blood gases or there is decreased or no breath sounds.
A small pneumothorax may go away on its own. You may only need oxygen and rest. The health care provider may use a needle to pull the extra air out from around the lung so it can expand more fully. If you have a large pneumothorax, a chest tube will be placed between the ribs into the space around the lungs to help drain the air and allows the lung to re-expand.

DEFINITION OF TERMS

1. Blood clot. Clumps that occur when blood hardens from a liquid to a solid. Thrombus. A blood clot that forms inside one of your veins or arteries Embolus. A thrombus that breaks loose and travels from one location in the body to another Ischemia. A blockage in an artery may prevent oxygen from reaching the tissues in that area. 2. Comminuted. A fracture in which the bone fragments into several pieces.

3. Chest Tube Thoracostomy (CTT). A surgical opening in the chest wall and insertion of of a thoracostomy tube into the chest wall above the area of the second or third rib. A local anesthetic (xylocaine 1% or 2%) is administered and an incision is then made into the pleural space of the chest wall. The tube is inserted, positioned, and clamped, and silk sutures are use to secure the chest tube in place.

4. Debridement. The removal of unhealthy tissue from a wound to promote healing. It can be done by surgical, chemical, mechanical, or autolytic (using body's own processes) removal of the tissue. 5. Fracture. A complete or incomplete break in a bone resulting from the application of excessive force. 6. Hoarseness. Difficulty producing sound when trying to speak, or a change in the pitch or quality of the voice. The voice may sound weak, very breathy, scratchy, or husky. 7. Hematoma. Abnormal collection of blood in the body that is typically the result of a broken or ruptured blood vessel. 8. Hemothorax. A collection of blood in the space between the chest wall and the lung (the pleural cavity).

9. Hyperresonance. A sound increased above the normal, and often of lower pitch, on percussion of an area of the body; occurs in the chest as a result of overinflation of the lung as in emphysema or pneumothorax . 10. Laceration. A tear in the skin which results from an injury.

11. OREF. A method of immobilizing bones to allow a fracture to heal. External fixation is accomplished by placing pins or screws into the bone on both sides of the fracture. The pins are then secured together outside the skin with clamps and rods. The clamps and rods are known as the "external frame.
12. ORIF: is a method of surgically repairing a fractured bone. Generally, this involves either the use of plates and screws or an intramedullary (IM) rod to stabilize the bone.

13. Pneumohemothorax. Accumulation of blood and gas in the pleural cavity 14. Pneumothorax. Occurs when air leaks into the space between the lungs and chest wall. This air pushes on the outside of your lung and makes it collapsed. In most cases, only a portion of the lung collapses. 15. Radio Frequency Multiple Backscatter (RFMB). An X-ray-based technology that yields a highresolution image of a person's body beneath their clothing to reveal concealed objects. The process involved is sometimes referred to as "backscatting."

VITAL INFORMATION
Name: Dodoi Room #: 264 Age: 51 Birthdate: June 12,1961 Place Of Birth: Sultan Kudarat Cultural Group: Cebuano Reason For Health Contact: multiple gunshot wound Date Of Confinement: August 3, 2012 ; 5:20 PM Source Of History: Patient(40%) and SO(60%)

Primary Language: Cebuano Educational Attainment: high school level

Occupation: Farmer Civil Status: Married Usual Health Care Provider: quack doctor

Attending Physicians: Dr. Anastacio Gayao (Surgeon) Dr. Wilper Generato (Pulmonologist)
Final Diagnosis: Laceration of trachea and fracture of left 3rd post rib with pneumohemothorax left fracture, open III-A, comminuted p/3 tibia right with Radio Frequency Modulated Backscatter (RFMB) secondary to gun shot injury (GSI).

Description of Patient
DAY 1 lying in bed conscious and coherent, in high fowlers position, with patent IVF D5LR 1L regulated @ 30 gtts/min. hooked at left metacarpal vein, side drip of 0.9% NaCl 500mL. No presence of any mass, wounds, lesions and drainage in the head. chest has presence of dressings at right pectoralis major muscle, left trapezius muscle. Skin on the upper extremity is intact. In the lower extremities, specifically at right quadriceps femoris muscle, left gastrocnemius, left tibialis anterior and right gastrocnemius have dry and intact dressings. No complaints of any pain or discomfort. external fixator @ left tibia.

Description of Patient
DAY 2 lying in bed conscious and coherent, in high fowlers position, with patent IVF of D5LR 1L regulated @ 30gtts/min. hooked at left metacarpal vein, side drip of 0.9 % NaCl 500 mL. no presence of any mass, wounds, lesions and drainage in the head. chest still has presence of dressings at right pectoralis major muscle, and left trapezius muscle. Skin on upper extremity is intact. The lower extremities specifically at right quadriceps femoris muscle, left gastrocnemius, left tibialis anterior and right gastrocnemius muscle still have wounds with dry and intact dressings. Still with no complaints of pain or any discomfort. Still with external fixator @ left tibia.

NURSING HISTORY
HISTORY OF PRESENT ILLNESS
Dodois reason for visit was multiple gunshot wounds. He was shot by five bullets, 1 in the upper portion of the right pectoralis muscle, 1- left third posterior rib, 1- left posterior third tibia, 1- gastrocnemius muscle, and 1 in the right proximal thigh. The quality of pain was severe, with a pain scale of 7/10 as claimed. Onset of pain began when bullets penetrated in the five areas of the body as mentioned earlier. The rate of occurrence increased when he tries to moved, and relieved when immobilized. Signs and symptoms are the following: facial grimace, mild respiratory distress (RR: 32), increased pulse rate (PR: 97), pallor and dry lips. Significant others claimed that their initial management was immobilization of the affected area and call for help. Dodoi claimed, that his condition does not affect the way he feels about himself. He is very much anxious and fearful about/to the person who shot him.

NURSING HISTORY
HISTORY OF PAST ILLNESS Dodoi claimed he has no allergies in food and any food intolerance. He experienced measles, mumps and chicken pox, when he was a child. He did not have any previous surgery and past hospitalization. He claimed that he was immunized during his childhood days with, OPV, Hepa. B1, Hepa. B2, Hepa. B3, and BCG. Dodoi did not undergo any physical, vision and hearing examination.

GENOGRAM

GORDONS ASSESSMENT

The client was admitted due to multiple gunshot wounds. He claimed that he has never been hospitalized in the past. He thinks the treatment is working just fine and that he expects to recover swiftly and go back to work.

Nutritional/ Metabolic Pattern

PAST PRESENT

- good appetite - vegetables and fish - no food restrictions, food allergies, food intolerance - does not take any vitamins or supplements - does not dislike any food - havent tried eating in fast food chains - does not experience any discomfort in eating or swallowing - has dental problems - drinks about 8 to 10 glasses of water per day

- good appetite (consumes all of food served as client claimed) - restricted to a soft diet - still no food allergies and intolerance - still no vitamins and supplements - no swallowing discomfort - drinks about 1000 L of water per day

Elimination Pattern
Past Present

- moves bowels once - during 2 day a day assessment client - experienced diarrhea defecated only once. and constipation - complained of itching - experienced oliguria @ IV site. - excessive perspiration and odor problems

Exercise and Activity Pattern:

Past Present

- client does planting and cutting of weeds as form of exercise and leisure activity - does planting and cutting weeds everyday from morning to late in the afternoon - client experiences soreness of muscles after doing his ADLs.

-client only lying in bed due to external fixator on left leg although does passive ROM except for affected areas. - talking with SOs

GORDONS ASSESSMENT
Cognitive/Perceptual Pattern:
Past Present

- did not undergo eye examination, wears glasses and experiences pain in the eyes. - No hearing problem as claimed. - Able to distinguish bad and good odor. - Able to distinguish different tastes.

-still with no vision, hearing and sensation problems. -able to distinguish bad and good odor. -able to distinguish different tastes.

GORDONS ASSESSMENT
Self-Perception Pattern:

Past - feels satisfied with ones self and does not want to change a single bit of what and who he is. - He is anxious that he would not make the ends meet. - Most of the time when he is down or problematic he would devote himself to work to make himself feel better.

Present -still feels satisfied about oneself regardless of his condition. - the person who shot him makes him feel very anxious at present. -he talks with his wife and SOs to alleviate his feelings.

GORDONS ASSESSMENT
Role-Relationship Pattern
Past Present -client stays with his family -still stays with family which is a nuclear which is a nuclear type of family family. -while client is in the hospital, -family members depend family members try to help by watching on him for source of over the planting fields and saving money to buy food and money for the hospital bills. other necessities. -his health condition has not affected his relationship with his family. -family members and friends are worried about his condition, they want him to recover right away.

Sexuality and Reproductive Pattern:

Past -as what client verbalized he is satisfied with his sexual relationship with his wife and that they did not encounter any problems regarding their sexual relationship. -he does not use any contraceptives -he has 10 children -he did not undergo any testicular exam and as he claimed he does not have problems with his reproductive tract. Present

Coping Stress Management Pattern:

Past in the past years the major loss to the client was the death of his son Financial matters was the thing that caused stress to the client. As client claimed stressful situations dont get the best of him because for him it wont help solve the problem. When client is emotionally stressed out he said he would go and do his ADLs to relieve himself. During personal crisis client would turn to his family for help. As claimed by client they often handle problems successfully. Present -at present client claimed that he is really trying his best not to let his present condition get the best of him because for him its really not going to help.

Value and Belief Pattern:

Past
-the most important things for the client is having a good body so that he could still work and provide for the family, and to be able to eat regular meals three times a day. -client verbalized that he does not get everything he wants in life, his future plans aims at his children being able to finish school. -being sick has never affected his belief in God instead it strengthened his faith in God.

Present
- the most important thing to the client at present is to recover from his condition. - client finds prayers very powerful and that it really helps his condition.

PEROS

General Health Service

Subjective findings:
DAY 1

Wala man ko nitambok ug ni bug-at mao ra man ako timbang as claimed by the patient.
dili pako kalakaw, dayun wala pa kaayu na ayo ako samad as claimed by the patient.

Objective Findings:
DAY 1
Height: 54 No body odor noted No signs of respiratory distress noted Alert, responsive to questions, coherent Cooperative Lying in bed in a high fowlers position Dry and intact dressing on chest and lower extremities With external fixator on left lower leg, elevated by 1 pillow With an patent IVF of D5LR @ 20ggts/min. running and hooked @ left metacarpal vein No excessive perspiration V/S: T-36.8 , P-72bpm, RR-25cpm, BP-110/80 mmhg

DAY 2
Lying in bed, conscious, coherent, cooperative, not in respiratory distress, no body odor Dry and intact dressing on chest and lower extremities with external fixator on left lower leg, elevated by 1 pillow with an patent IVF of D5LR @ 20ggts/min. running and hooked @ left metacarpal vein

No excessive perspiration
V/S: T-36.5. P-68bpm., RR-23cpm, BP110/80mmhg

Problem Identified:
DAY1 Impaired verbal communication Fear Anxiety Imbalanced nutrition less than body image

Body image disturbance

Self-care deficit

Integumentary System
Subjective Findings:
Day 1

Nagkatol-katol akong kamut, tungod tingali ni sa tambal as claimed by the patient. Objective Findings:
Day 1 Day 2

Skin color- brown, presence of dressing @ chest and lower extremities -long nails on both hands and short nails on both feet with dirt -hair is evenly distributed on head, -no lesions noted -skin is warm to touch with good turgor and slightly dry

still with external fixator

-no lesions noted

-with fixator @ left lower leg

Problem Identified: Injury Impaired skin integrity Body image disturbance Risk for infection

Self care deficit

HEENT
Subjective Findings:
Oo, gasout ko ug antipara, pero kana rang magbasa ko. Wala pa ko kasulay magpa check-up sa mata as claimed by the patient. Objective Findings:
Day 1 Day 2

B.Eyebrows and eyelashes are evenly distributed. PERRLA -anicteric sclera, no scar over cornea, -no redness,swelling, and discharges noted

C. left and right ears are symmetrical in size , no discharges, even skin color, no odor noted
D. nares symmetrical, hair. No discharges noted

Neck:
Subjective Findings:
Mag sakit ra siya panalagsa, kana rang mag-alsa ko ug bug-at na akong ipatong sa ulo as claimed by the patient.

Objective Findings:
Day 1 No lumps bulges or masses noted Head can moved in all directions Trachea in midline No lesions noted No distended vein noted Day 2 Still no lumps, bulges and masses noted Head can moved in all directions Positive ROM Trachea is in midline No lesions noted No distended vein noted

Respiratory System
Subjective Findings: Dili man pud ko maglisod ginhawa. as claimed by the patient. Objective Findings:
Day 1 Day 2

No difficulty in breathing, RR-25

Still not in respiratory distress, RR- 23

no pain on chest as claimed Crackles heard over lung fields crackles heard over lung

fields upon auscultation

Problem Identified: Ineffective airway clearance

Cardiovascular System
Subjective Findings:
Wala man gasakit akong dughan. as claimed by the patient.

Objective Findings:
Day 1 Day 2

-no chest pain as claimed -P-72bpm, CRT <2seconds -with patent IVF of D5LR 1L @ 20gtts/minute

-still with no pain as claimed -P-68bpm -still with patent IVF of D5LR 1L @ 20gtts/minute

Breast And Axilla

Subjective Findings: Did not verbalized any cues.

Objective Findings:
Day 1 -with presence of dressing on left chest area, dry and intact -no lesions and lumps noted Problem Identified: Impaired skin integrity Day 2 -still with dressing on left breast, dry and intact -no lesions and lumps noted

Gastrointestinal System And The Abdomen

Subjective Findings: kausa ra ko kalibang sa isa ka adlaw. as claimed by the patient. Objective Findings:
Day 1 Day 2

-no pain, no difficulty in swallowing as claimed

-bowel sounds: 30/minute -no distention -no lesions and lumps noted

-still no pain nor difficulty in swallowing as claimed

Genitourinary/ Reproductive System

Subjective Findings:
Wala ko problema sa akong pag-ihi.as claimed by the patient.

Objective Findings:
Day 1 -not inspected -voids through straight catheter as claimed -no pain upon voiding as claimed Day 2 -not inspected -still with no pain upon voiding

Musculoskeletal System
Subjective Findings:
Dili ko kalakaw pa tungod sa akong tiil.as claimed by the patient.

Objective Findings:
Day 1 -lying in bed in High fowlers position Day 2 -lying in bed in High Fowlers position

-with external fixator on -still with external left leg elevated by a fixator on left leg pillow elevated by a pillow

Problem Identified:
Impaired physical mobility

Risk for injury

Risk for injury

Neurologic System
Subjective Findings: Did not verbalized any cues. Objective Findings:
Day 1 A. Balance -client can perform accurately touching examiners fingers and his nose, can alternately touch his own fingers rapidly. B. Strength -upper extremities have 5/5 muscle strength while the left leg had 2/5 muscle strength, right leg had 3/5 muscle strength results. Day 2 A. Balance -client can perform accurately touching examiners fingers and his nose, can alternately touch his own fingers rapidly. B. Strength -upper extremities have 5/5 muscle strength while the left leg had 2/5 muscle strength, right leg had 3/5 muscle strength results.

C.Sensory -client can feel soft brush from forehead towards the whole extremities. Can detect dull and sharp sensation. -client can detect number of hands holding him; can identify objects such as coin or pencil. D. Cranial Nerves Cranial Nerve I: Olfactory

C.Sensory -client can feel soft brush from forehead towards the whole extremities. Can detect dull and sharp sensation. -client can detect number of hands holding him; can identify objects such as coin or pencil. D. Cranial Nerves Cranial Nerve I: Olfactory

-can identify scents from alcohol and perfume.

Cranial Nerve II: Optic -peripheral vision intact

-can identify scents from alcohol and perfume.

Cranial Nerve II: Optic -peripheral vision intact

Cranial Nerve III: Occulomotor, IVTrochlear and VI- Abducens -can move eye up, down and both sides, PERRLA Cranial Nerve V: Trigemenal -can sense brush on face using sharp and dull objects. Cranial Nerve VII: Facial -smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VII: Acoustic -can hear examiner upon whisper test.

Cranial Nerve III: Occulomotor, IVTrochlear and VI- Abducens -can move eye up, down and both sides, PERRLA Cranial Nerve V: Trigemenal -can sense brush on face using sharp and dull objects. Cranial Nerve VII: Facial -smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VII: Acoustic -can hear examiner upon whisper test.

Cranial Nerve IX/X: Glossopharyngeal & Vagus -intact gag reflex, taste buds can taste sweet and bitter food. Cranial Nerve XI: Spinal Accessory Muscle -can move shoulder with resistance.

Cranial Nerve IX/X: Glossopharyngeal & Vagus -intact gag reflex, taste buds can taste sweet and bitter food. Cranial Nerve XI: Spinal Accessory Muscle -can move shoulder with resistance.

Cranial Nerve XII: Hypoglossal

-tongue is in midline and can move, up and down and in both sides.

Cranial Nerve XII: Hypoglossal

-tongue is in midline and can move, up and down and in both sides.

Lymphatic/Hematologic
Subjective Findings: Gikapoy na ko sige ug higda.as claimed by the patient.

Objective Findings:
Day 1 Day 2

-no enlargement of limbs

-still with no limb enlargements nor bleeding on different -no bleeding on fixator areas and dressing site Problem Identified:
Risk for infection Body image disturbance

DIAGNOSTIC TEST

NORMAL ANATOMY AND PHYSIOLOGY

THE HUMAN LUNGS

The primary organs of the respiratory system. The main function of the human respiratory system is to transport oxygen from the atmosphere into the blood, and to expel carbon dioxide from the body. Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic cavity, and covered by a protective membrane called the pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity.

The pulmonary arteries carry de-oxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body.

The lungs expand upon inhalation, or inspiration, and fill with air. They then return to their resting volume and push air out upon exhalation, or expiration. These two movements make up the process of breathing, or respiration. The respiratory system contains several structures. When you breathe, the lungs facilitate this process: Air comes in through the mouth and/or nose, and travels down through the trachea, or "windpipe." This air travels down the trachea into two bronchi, one leading to each lung. The bronchi then subdivide into smaller tubes called bronchioles. The air finally fills the alveoli, which are the small air sacs at the ends of the bronchioles.

In the alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and from the blood. Adult lungs have hundreds of alveoli, which increase the lungs' surface area and speed this process. Oxygen travels across the membranes of the alveoli and into the blood in the tiny capillaries surrounding them. Oxygen molecules bind to hemoglobin in the blood and are carried throughout the body. This oxygenated blood can then be pumped to the body by the heart. The blood also carries the waste product carbon dioxide back to the lungs, where it is transferred into the alveoli in the lungs to be expelled through exhalation.

LUNGS
The lungs consist of airways (trachea and bronchi) that divide into smaller and smaller branches until they reach the air sacs, called alveoli. The airways conduct air down to the alveoli where gas exchange takes place. The lung itself is covered with a membrane called the visceral (or pulmonary) pleura. The visceral pleura is adjacent to the lining of the thoracic cavity which is called the parietal pleura. Between the two membranes is a thin, serous fluid which acts as a lubricant reducing friction as the two membranes slide across one another when the lungs expand and contract with respiration. The surface tension of the pleural fluid also couples the visceral and parietal pleura to one another, thus preventing the lungs from collapsing. Since the potential exists for a space between the two membranes, this area is called the pleural cavity or pleural space.

Before we discuss the chest drainage unit in detail, it is important to briefly review normal anatomy and physiology of the thorax with emphasis on the physiology of respiration. This will help us understand what can go wrong in the structure and function of the chest and how these problems can be treated. CHEST WALL

The chest wall is made up of bones and muscles. The bones, primarily ribs, sternum and vertebrae, form a protective cage for the internal structures of the thorax. The main muscles of the chest wall, the external and internal intercostals, extend from one rib to the rib below (figure 3). The external intercostal enlarges the thoracic cavity by drawing the ribs together and elevating the rib cage, while the internal intercostal decreases the dimensions of the thoracic cavity.

MEDIASTINUM Within this musculoskeletal cage of the thorax are three subdivisions. The two lateral subdivisions hold the lungs. Between the lungs is the mediastinum, which contains the heart, the great vessels, parts of the trachea and esophagus, and other structures. RESPIRATION Respiration is a passive, involuntary activity. Air moves in and out of the thorax due to pressure changes. When the diaphragm, the major muscle of respiration, is stimulated, it contracts and moves downward. At the same time, the external intercostals move the rib cage up and out. The chest wall and parietal pleura move out, pulling the visceral pleura and the lung with it. As the volume within the thoracic cavity increases, the pressure within the lung decreases. Intrapulmonary pressure is now lower than atmospheric pressure; thus air flows into the lung inhalation.

When the diaphragm returns to its normal, relaxed state, the intercostal muscles also relax and the chest wall moves in. The lungs, with natural elastic recoil, pull inward as well and air flows out of the lungs exhalation. The lungs should never completely collapse for there is always a small amount of air, called residual volume, in them. Under normal conditions, there is always negative pressure in the pleural cavity. This negative pressure between the two pleurae maintains partial lung expansion by keeping the lung pulled up against the chest wall. The degree of negativity, however, changes during respiration. During inhalation, the pressure is approximately 8 cm H2O; during exhalation, approximately 4 cm H2O. If a patient takes a deeper breath, the intra pleural pressure will be more negative. Under normal conditions, the mechanical attachment of the pleurae, plus the residual volume, keep the lungs from collapsing.

Thoracic System Pathology When air or fluid enters the pleural space, it: Separates the visceral pleura from the parietal pleura, thus disrupting the negative pressure that prevents the lungs from collapsing at the end of exhalation Compresses the lung. If only a small amount of air or fluid is present, it may be reabsorbed without intervention. However, if large enough, the fluid or air compromises normal respiration and must be evacuated from the pleural space.

Tissue Repair
The inflammatory and repair processes are no longer simple events to describe in the light of the increased knowledge in this field. The review that follows is only a brief resume of the salient events associated with tissue repair, particularly concerning the soft tissues. For further information, the reader is referred to recent reviews listed at the end of the paper. Tissue healing (or tissue repair) refers to the body's replacement of destroyed tissue by living tissue (Walter and Israel 1987) and comprises two essential components Regeneration and Repair. The differentiation between the two is based on the resultant tissue. In Regeneration, specialized tissues is replaced by the proliferation of surrounding undamaged specialized cells. In Repair, lost tissue is replaced by granulation tissue which matures to form scar tissue.

In primary wound healing there is no tissue loss. A, Incised wound is held together by a blood clot and possibly by sutures or surgical clamps. An inflammatory process begins in adjacent tissue at the moment of injury. B, After several days, granulation tissue forms as a result of migration of fibroblasts to the area of injury and formation of new capillaries. Epithelial cells at wound margin migrate to clot and seal the wound. Regenerating epithelium covers the wound. C, Scarring occurs as granulation tissue matures and injured tissue is replaced with connective tissue.

Bleeding Phase
This is a relatively short lived phase, and will occur following injury, trauma or other similar insult. Clearly if there has been no overt injury, this will be of little or no importance, but following soft tissue injury, there will have been some bleeding. The normal time for bleeding to stop will vary with the nature of the injury and the nature of the tissue in question. The more vascular tissues (e.g. muscle) will bleed for longer and there will be a greater escape of blood into the tissues. Other tissues (e.g. ligament) will bleed less (both in terms of duration and volume). It is normally cited that the interval between injury and end of bleeding is a matter of a few hours (6-8 hours is often quoted) though this of course is the average duration after the average injury in the average patient. Some tissues will continue to bleed for a significantly longer period, albeit at a significantly reduced rate. A crush type injury to a more vascular tissue like muscle - could still be bleeding (minimally) 24 hours or more post trauma.

Inflammatory Phase
The inflammatory phase is an essential component of the tissue repair process and is best regarded in this way rather than as an 'inappropriate reaction' to injury. There are, of course, numerous other initiators of the inflammatory process (e.g. repetitive minor trauma, mechanical irritation), though for the purpose of this paper, the injury model will be adopted. The inflammatory phase has a rapid onset (few hours) and swiftly increases in magnitude to its maximal reaction (1-3 days) before gradually resolving (over the next couple of weeks). It can result in several outcomes (see below) but in terms of tissue repair, it is normal and essential.

Proliferation Phase
The proliferative phase essentially involves the generation of the repair material, which for the majority of musculoskeletal injuries, involves the production of scar (collagen) material. The proliferative phase has a rapid onset (24-48 hours) but takes considerably longer to reach its peak reactivity, which is usually between 2-3 weeks post injury (the more vascular the tissue, the shorter the time taken to reach peak proliferative production). This peak in activity does not represent the time at which scar production is complete, but the time phase during which the bulk of the scar material is formed. The production of a final product (a high quality and functional scar) is not achieved until later in the overall repair process. In general terms it is usually considered that proliferation runs from the first day or two post injury through to its peak at 2-3 weeks and decreases thereafter through to a matter of several months post trauma.

Remodelling Phase
The remodelling phase is an often overlooked phase of repair in terms of its importance. It is neither swift nor highly reactive, but does result in an organized, quality and functional scar which is capable of behaving in a similar way to the parent tissue (that which it is repairing). The remodelling phase has be widely quoted as starting at around the same time as the peak of the proliferative phase (2-3 weeks post injury), but more recent evidence would support the proposal that the remodelling phase actually starts rather earlier than this, and it would be reasonable to consider the start point at around 1-2 weeks.

General Phase Model Summary

The final outcome of these combines events is that the damaged tissue will be repaired with a scar which is not a like for like replacement of the original, but does provide a functional, long term mend which is capable of enabling quality recovery from injury. For most patients, this is a process that will occur without the need for drugs, therapy or other intervention. It is designed to happen, and for those patients in whom problems are realized, or in whom that magnitude of the damage is sufficient, some help may be required in order to facilitate the process. It would be difficult to argue that therapy is essential in some sense. The body has an intricately complex and balanced mechanism through which these events are controlled. It is possible however, that in cases of inhibited response, delayed reactions or repeated trauma, therapeutic intervention is of value.

It would also be difficult to argue that there was any need to change the process of tissue repair. If there is an efficient (usually) system through which tissue repair is initiated and controlled, why would there be any reason to change it? The more logical approach would be to facilitate or promote the normality of tissue repair, and thereby enhance the sequence of events that take the tissues from their injured to their normal state. This is the argument that will be followed in this paper the promotion of normality, rather than trying to achieve a better normality.

Bone is surrounded by a thin membranous layer of tissue called periosteum through a bone. Normally the bone is like a cylinder. When bone breaks, it bleeds from its torn ends due to disruption of its supplying vessels. Quite naturally the periosteum also is torn as shown in the figure. This periosteum may be completely torn or partially damaged depending upon the force of injury. The collected blood is called fracture hematoma.

Hematoma formation
Vessels are torn and a hematoma forms between and around the fractures between and around the fracture surfaces within the Periosteum. Bone at the fractured site surfaces are deprived of blood and phagocytosis occurs to remove 1-2 mm of bone.

Due to loss of vascularity or blood supply adjacent portion of broken ends die. Inflammation changes occur in the hematoma over next few hours ( A reaction by the body which occurs whenever there is an insult to a part or structure. The basic purpose of the inflammation is to contain the damage and facilitate the healing and regeneration. Inflammation is responsible for redness, pain, warmth and tenderness of the wounds and abscesses) .

Inflammation and proliferation

Time of injury to 24-72 hours, injured tissues and platelets release vasoactive mediators growth factors and other cytokines, these cytokines influence cell migration, proliferation, differentiation and matrix synthesis. This inflammation brings in many cells that would help in regeneration of the broken bone. Periosteum plays a vital role in fracture healing. The Periosteum is the primary source of precursor cells which develop into chondroblasts (cartilage cells) and osteoblasts ( bone cells) that are essential to the healing of bone. as the time progresses, the fibroblasts ( A kind of cells which produce fibrous tissue in the body) get interspersed with small vessels and form a loose mesh like structure uniting the broken ends of the bone and on which the future layers of bone tissue would be added. This structure is called granulation tissue.

Over the next few days, the cells of the Periosteum replicate and transform. The periosteal cells proximal to the fracture gap develop into chondroblasts and form hyaline cartilage. The periosteal cells distal to the fracture gap develop into osteoblasts and form woven bone a kind of bone which is structurally different from the lamellar bone found in the body. These two new tissues grow in size until they unite with their counterparts from other pieces of the fracture. This process forms the fracture callus. The callus is the first sign of union visible in x-ray and generally appears around two weeks after fracture. Eventually, the fracture gap is bridged by the cartilage and woven bone, restoring some of its original strength

Callus formation Occurs 2 weeks after bone fracture, the bone is uniting in correct position, thick cellular mass with islands of immature or woven bones and cartilage forms a callus, sufficient ossification to be visible in x-ray, bone can now take more stress From here on slowly and steadily bone is restructured by a process called remodeling.

Consolidation

Continuing osteoclastic and osteoblastic activity, woven bone is transformed into mature lamellar bone, on xray it looks whiter, and the bone is now strong enough to carry normal loads
Remodeling Middle repair phase up to 7 years, remodeling of the woven bone is dependent on the mechanical forces, fracture healing is complete when there is repopulation of the medullary canal.

CONCEPT MAP

DRUG STUDY

GENERIC NAME: Ranitidine BRAND NAME: Zantac CLASSIFICATIONS: gastrointestinal agent; antisecretory (h2receptor antagonist)

DOSAGE: 50 mg IVTT q 8 hours.

MECHANISM OF ACTION: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.

INDICATION: Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis, and postoperative hypersecretion); heartburn. CONTRAINDICATIONS: Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Renal impairment, Geriatric patients (more susceptible to adverse CNS reactions), Pregnancy or Lactation.

SIDE EFFECTS/ ADVERSE EFFECTS: Minor side effects include constipation, diarrhea, fatigue, headache, insomnia, muscle pain, nausea, and vomiting. Major side effects are rare; they include: agitation, anemia, confusion, depression, easy bruising or bleeding, hallucinations, hair loss, irregular heartbeat, rash, visual changes, and yellowing of the skin or eyes. DRUG INTERACTION: Ranitidine, like other drugs that reduce stomach acid, may interfere with the absorption of drugs that require acid for adequate absorption. Examples include iron salts (for example iron sulphate), itraconazole (Sporanox), and ketoconazole (Nizoral, Extina, Xolegel, Kuric).

NURSING IMPLICATIONS /RESPONSIBILITIES: Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.

Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid.
Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

GENERIC NAME: Tramadol BRAND NAME: Dolcet CLASSIFICATION: analgesics DOSAGE: 50 gm IVTT every 6 hours.

INDICATION: Management of moderate to severe pain.

CONTRAINDICATION: Hypersensitivity, Acute intoxication with alcohol, hypnotics, narcotics, centrally-acting analgesics, opioids or psychotropic drugs. Severe hepatic impairment; pregnancy, lactation.

MECHANISM OF ACTION: Centrally acting analgesic not chemically acting opiods but binds to mu opiod receptor and inhibit reuptake of norepinephrine and serotonin DRUG INTERACTION: Inhibitors, carbamazepine, quinidine, warfarin-like compounds, inhibitors of CYP2D6 such as fluoxetine, paroxetine, and amitriptyline. Cimetidine. SIDE EFFECTS : Dizzines, sedation, drowsiness, impaired visual acuity (avoid driving or performing task that require alertness); nausea, loss of appetite(lie quietly, eat frequent small meals).

NURSING CONSIDERATION: Assessment:

History:
Hypersensitivity to dolcet; pregnanacy, acute toxication with alcohol, opios, psychotropic drug or other centrally acting analgesic; lactation; seizure; concomitant use of CNS depressant or MAOIs renal or hepatic impairment; past or present history of opiod addiction. Physical: Skin color, texture,lesion, orientation, reflexes, bilateral grip strength, affect;P,auscultation,BP,bowel sounds,normal output;LEFTs, renal function test. Assess patient pain before therapy and regularly thereafter to monitor drug effectiveness

Intervention Control environment (temperature, lighting)if sweating or CNS affect occur. Ensure the patient does not cut, crush or chew ER tablet Patient teaching: Instruct patient to take drug only as prescribe and not to increase dosage or interval without medical advice. Report severe nausea, dizziness, severe constipation.

Brand name: Clindal Generic Name: Clindamycin hydrochloride INDICATION: Serious anaerobic infections especially those caused by Bacteroides fragilis. Alternative to penicillin in some severe staphylococcal and streptococcal infections, including staphylococcal osteomyelitis.

THERAPEUTIC ACTION: Inhibits protein synthesis in susceptible bacteria, causing death cells.
CONTRAINDICATION: Hypersensitivity. SIDE EFFECT: Diarrhea, nausea, vomiting, abdominal cramps, abnormal taste. Transient neutropenia, eosinophilia, agranulocytosis and thrombocytopenia. Pruritus, vaginitis. Hypersensitivity reactions.

NURSING CONSIDERATION Assessment: History: Allergy to clindamycin, history of asthma or other allergy, allergy to tartrazine (in 75 and 150 mg capsules); hepatic or renal impairment, lactation, history of regional enteritis or ulcerative colitis; history of antibiotic associated colitis.

Physical: Site of infection or acne; skin color; lesion; BR, R, adventitious sounds; bowel sounds, output, liver evaluation; complete blodd count, renal function test.
Intervention Assessment: Culture infection site before therapy Do not give IM injection of more than 600 mg,; inject seep into large muscle to avoid serious problem. Do not use for minor bacterial or viral infection

Brand name: Kenaxef Generic Name: Ceftriaxone Sodium INDICATION: Surgical infection prophylaxis. DOSAGE: 1gm IVTT every 8 hours CONTRAINDICATION: Changes in bowel flora, diarrhea; hyperbilirubinemia; neutropenia; hypoprothrombinemia. Pseudolithiasis, gallbladder disease.

ADVERSE DRUG INTERACTION: Changes in bowel flora, diarrhea; hyperbilirubinemia; neutropenia; hypoprothrombinemia. Pseudolithiasis, gallbladder disease

DRUG INTERACTION: Increased nephrotoxicity with aminoglycoside. Increased bleeding effects with oral anticoagulant. Risk of disulfiram like reaction with alcohol; avoid this combination during and for 3 days after completion of therapy. NURSING CONSIDERATION Assessment: History: Hepztic and renal impairment, lactation, pregnancy Physical: Skin status, renal function test, culture of affected area, sensitivity test

NURSING CARE PLANS

Health Education Plan

Name of patient: Dodoi Age: 51 Gender: Male Room #: 2648 Diagnosis/impression: Laceration of trachea and fracture of left 3rd posterior rib with pneumohemothorax left fracture, open III-A, comminuted P/3 tibia right with RFMB 2o GSI Attending physician: Dr. Anastacio Gayao(Surgeon) Objectives: Within 1 hour and 30 minutes of giving health teaching the SO (significant others) and the client will: 1. Able to verbalize understanding about the importance of the treatment. 2. Able to perform the said procedures such as bed bath, oral care, and care for fixator pin. 3. Able to initiate participation in treatment regimen.

Learners Code: To patient and significant others (spouse)

Methods of Education: Oral discussion and demonstration

Barriers to Learning: Communication impairment Physical impairment Materials: 1. Books 2. Pictures/ Visual aids 3. Fact sheets

General Health Teachings

Exercise

Specific Health Teachings

Instruct to do breathing and coughing exercise Procedure: Breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs. Encouraged for leg exercise. Procedure: Wash hands and don clean gloves. Place patient in supine or semi-Fowlers position. Instruct patient to bend knee, raise foot in air, and hold in this position for 23 seconds. Have patient extend leg and lower it to bed. Repeat procedure with other leg. Complete sequence 510 times each hour while awake.

Instruct patient to extend toes (plantar flexion) toward bottom of bed, then flex (dorsiflexion) toward head of bed. Repeat foot extension and flexion with the other side. Repeat sequence 5 times each hour while awake. Instruct patient to make circles with the ankle moving first to the left and then to the right. Repeat sequence 5 times each hour while awake. If you used gloves to assist patient with leg exercises, remove them and wash hands. Encouraged to turn side every 2 hours. Procedure: To place a patient in a side lying position, put a pillow between the leg before turning. If sensation is impaired, turning from side to side should be limited.

Safe exercise: get the approval first from the doctor before letting the patient lift weights.

HYGIENE

Instruct the SO to do bed bathing and oral care. Procedure: BED-BATH Discuss procedure with patient and ensure privacy. Place all supplies within reach. Wash hands. Position bed at comfortable height. Fill basin with warm water, and test temperature on wrist. Help patient to side of bed closest to you, and lower side rail. Remove patients clothes while providing warmth and privacy with a covering such as a bed blanket. Take washcloth and wrap the cloth around your hand tightly, forming a mitt.

Be careful of the patients eyes. Use clear water to clean them, starting from the inner canthus to the outer canthus. If patient is not sensitive to soap, lather washcloth and gently wash the patients face, starting from the forehead down. Bathe ears and front and back of neck. Bathe upper body and extremities, stroking arms from wrist to shoulder. Include axillary area. Soak hands in basin if indicated. Keep chest covered with towel and wash under breasts on female patients. Apply powder if patient desires. Bathe abdomen using side-to-side strokes on skin folds. Bathe legs and feet, being sure perineal area is draped.

Soak feet in basin if indicated, and if patient is able to hold leg in position. Change bath water if necessary. Assist patient to side-lying position and wash back. Give backrub. Put on clean gloves and bathe perineal area. Dry thoroughly. Remove gloves and assist patient to put on clean gown. Conduct other personal hygiene activities as needed. Lower bed, raise side rails, put call bell in reach, and dispose of used equipment and linen. Wash your hands. ORAL CARE Wash hands. Gather all equipment. Discuss procedure with patient

Put on clean gloves. Assess oral mucosa, teeth, and throat. Hold emesis basin beneath chin. Taking the soft toothbrush in hand, brush the teeth starting from the top front and moving to the back molars. Do not brush in a circular motion, but begin at the gum line and sweep toward teeth. Brush gently. Lightly brush the tongue. Allow patient to rinse his or her mouth and expectorate into emesis basin. Ask the patient if he or she uses dental floss. If acceptable to the patient, floss between each tooth, using approximately 1215 inches of easy-glide floss, taking care not to get floss lodged between teeth. Allow patient to rinse his or her mouth and expectorate into emesis basin. Remove equipment. Remove gloves and wash hands. Check to see if patient is comfortable.

Wound care:

Inform the patient of dressing change. Explain the procedure and have the patient lie in bed. Avoid changing dressings at mealtime. Ensure privacy by drawing the curtains or closing the door; expose the dressing site. Respect the patient's modesty and prevent the patient from being chilled. Wash your hands thoroughly. Place dressing supplies on a clean, flat surface (overbed table). If linen protection is needed, place a clean towel or plastic bag under part of the body where the wound is located. Cut (or tear) off pieces of tape to be used in dressing change.

Place a disposable bag nearby to collect soiled dressings. Determine how many and what types of dressings are necessary. Open each dressing by peeling apart the edges of the package (maintain the sterility of the dressing). Leave each dressing within the open package.

Removing old dressing: Put on disposable gloves. Loosen all tape and gently pull tape ends toward the wound. It helps to hold skin taut with one hand while carefully peeling up an edge of the tape with the other hand. Wiping the back of tape with alcohol will hasten removal of the tape.

Remove old dressings, one layer at a time, and place them in a disposable bag. Removal of adherent dressings may be facilitated by moistening dressing with sterile saline solution. Dressing the wound: Maintain sterile technique with the use of sterile gloves. After the wound is dry, apply the appropriate dressing, taking into consideration the nature of wound. Tape dressing, using only the amount of tape required for secure attachment of dressing. Wash hands.

Cleaning the fixator pin: Clean pin sites with a mixture of sterile saline and hydrogen peroxide and dip a sterile cotton tipped applicator into the mixture. Using sterile cotton tipped applicator; you will clean around and away from the skin of each pin. Always when cleaning your pins move away from the skin. Doing otherwise could cause a pin sire infection. Use a new cotton tip for each pin site; never use the same cotton tip for more than one pin site. Clean each pin site routinely 3 4 times per day. Wrap white gauze bandage around pin sites.

DIET

Instruct the patient to have soft diet. Encouraged fluid intake. Encourage to increase food rich in Calcium (milk, beans, bone meal ,dairy products green leafy vegetables, orange juice etc.) and Vitamin D (egg, liver meat, dairy products, fish and etc.) Sample menu: Breakfast: orange juice 1/2 cup oatmeal 1 cup whole wheat toast 2 slices margarine 2 tsp sugar 1 tsp whole milk 1 cup banana 1 med

Lunch: Plain white rice 11/2 cups steamed fishmalunggay soup- 1 cup Orange juice-1 cup Dinner: marinated chicken breast 3oz plain white rice-1 cup whole milk 1/2 cup

REST

Encouraged clients SO to provide calming diversional activities for relaxation. Instructed SO to have quiet and pleasant environment.

Evaluation:
After 1 hour of providing health teaching to the patient and the significant others, they were able to met all the objectives mentioned above.

Discharge Plan

Name of patient: Dodoi Room #: 2648 Date: August 16, 2012

Age: 51

Gender: M

Diagnosis/impression: Laceration of trachea and fracture of left 3rd posterior rib with pneumohemothorax left fracture, open III-A, comminuted P/3 tibia right with RFMB 2o GSI Attending physician: Dr. Anastacio Gayao(Surgeon)

Medications Drugs: Calcium citrate Route/Frequency: 250 mg tab. PRN Nursing responsibilities: -Use exactly as directed on the label, or as prescribed by your doctor.
-Do not use in larger or smaller amounts or for longer than recommended. -Calcium citrate works best if you take it with food. -Take calcium citrate with a full glass of water. -Allow the effervescent tablets to dissolve completely in the amount of water directed on the package. Drink the full amount of the mixture once it has dissolved. -Store at room temperature away from moisture and heat. -Review signs and symptoms of overdose.

Drugs: Tramadol/Dolcet Route/Frequency: 250 mg. tab. PRN Nursing responsibilities:

Instruct patient to take to take the drug with a full glass of water and to remain in an upright position for 1530 min after administration. Adults should not take analgesia longer than 10 days unless directed by HCP.

NSAIDs should not exceed the recommended daily dose of either drug alone.
Review signs and symptoms of overdose.

Drugs: Vitamin D Route/Frequency: 1 tab. per day Nursing responsibilities

Be sure to teach the client the following about this medication to take it only with prescription.
Review the diet modification with patient. Do not exceed to the recommended daily intake (RDA) Review signs and symptoms of overdose.

Exercise: Encourage to do deep breathing and coughing exercise and leg exercise. Instruct to turn position every 2 hours. Therapy: Encourage to increase fluid intake. Encourage to have a good rest and good sleeping pattern. Health teachings: Encourage for proper oral care, bed bath, wound care, and care for fixator pin. Instruct to avoid strenuous activities. Encourage to avoid heavy lifting.

OPD visit/ Referrals: Instruct patient to return for a follow-up checkup. Notify physician for any signs of infection and side effects of treatment. Diet: Encourage to increase for fluid intake. Encourage to increase in taking nutritious foods such as food with rich in Calcium and Vitamin D. Instruct to have a soft diet plan.

Spiritual care: Encouraged SO to pray with and attend churches activities with the patient to enhance good relationship to God. Discuss to your client and family member the importance of having God at the center of their lives.

SURGICAL MANAGEMENT

Debridement and Removal of RFMB of Right Leg Debridement is the process of removing dead (necrotic) tissue or foreign material from and around a wound to expose healthy tissue. Application of Multipurpose Delta Frame Fixator An external fixator is a device that either encircles or lies adjacent to the limb, which is attached to the skeleton by fine tensioned wires or screws. It is used to treat fractures or reconstruct bones and joints that are deformed or damaged.

Chest Tube Thoracostomy (CTT) Insertion

A local anesthesia is utilized in the skin, musculature and pleura. A small incision(2-3 cm) is made over the fifth or sixth rib along the anterior or midaxillary line. Tissues are spread with a clamp until entry into the thoracic cavity. A finger may be introduced to confirm entry into the chest. The chest tube is placed and directed over the apex of the hemithorax, secured to the skin, and connected to a water-seal or a one way valve.

PROGNOSIS
PNEUMOTHORAX
The outcome of pneumothorax depends upon the extent and type of pneumothorax. A small spontaneous pneumothorax will generally resolve on its own without treatment. A secondary pneumothorax associated with underlying disease, even when small, is much more serious and carries a 15% mortality (death) rate. A secondary pneumothorax requires urgent and immediate treatment. Having one pneumothorax increases the risk of developing the condition again. The recurrence rate for both primary and secondary pneumothorax is about 40%; most recurrences occur within 1.5 to two years(The American Lung Association).

HEMOTHORAX
At present, the general outcome for patients with traumatic hemothorax is good. Mortality associated with cases of traumatic hemothorax is directly related to the nature and severity of the injury. Morbidity is also related to these factors and to the risks associated with retained hemothorax, namely empyema and fibrothorax/trapped lung. Empyema occurs in approximately 5% of cases. Fibrothorax occurs in about 1% of cases. Retained hemothorax with or without one of the aforementioned complications occurs in 10-20% of patients who sustain a traumatic hemothorax, and most of these patients require evacuation of this collection. Prognosis after the treatment of one of these complications is excellent.

BONE FRACTURE
The outcome of tibial fractures can be less than ideal under many circumstances. These fractures almost always heal with some angulation, rotation, or shortening, which alters load transmission across the extremity. Patients with tibial fractures have been evaluated with respect to joint pain,disability, osteoarthritis, and joint stiffness. Studies have shown that long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed. The cause of increased osteoarthritis appears to be multifactorial. Reamed intramedullary nails with interlocking screws provide an excellent means to control rotation and limb shortening.