5. Lp Radius Ulna Fracture.docx

FRAKTUR RADIUS ULNA A. DEFINITION A radius fracture is a fracture that occurs in the bone radius due to a fall and the hand supports the elbow extension. (Brunner & Suddarth, Medical Surgical Textbook, 2002). An antebrachial fracture is a breakdown of the ulna radius of bone continuity, in children usually anterior angulation appears and both broken ends of the bone are still related to each other. The clinical picture of antebrachial fractures in adults is usually evident because ulna radius fractures are often in the form of fractures accompanied by dislocations of bone fragments (Mansjoer, 2000). Fractures or fractures are the breakdown of continuity of bone and / or cartilage tissue which is generally caused by forced ruda (Sjamsuhidajat & Dee Jong, 2004). Radius and ulna fractures can occur in 1/3 proximal, 1/3 middle, or 1/3 distal. The fracture can occur in one ulna bone or radius with or without joint dislocation. Ulna radius fracture usually occurs in children ( Muttaqin, 2008). Os fracture os radius and fracture of the os ulna is trauma that occurs in the front limb. Sometimes open fractures often occur, this often occurs because trauma occurs in thin and soft tissue layers. (Alex, 2008) Radial ulna fractures usually occur due to direct trauma when falling with a hyperextension hand position. This is due to a fall reflex mechanism where the arm will hold the body with the elbow slightly bent (Busiasmita, Heryati & Attamimi, 2009). The specificity of the ulna radius fracture can be affected by the muscles between the bones, namely the supinator muscle, the teron pronator, the quadratus pronator which contains the pronation-supination movement that inserts on the radius and ulna. B. ETIOLOGY The most common causes are trauma such as falls, injuries, abuse; there is a history of previous fractures or has a history of fractures that are inconclusive; or caused by some minor fractures due to bone weakness, osteoporosis, individuals who have bone tumors in antebrachial parts, infections or other diseases, this is called pathological fracture; or it can also be caused by stress fractures, which occur in

normal bones due to prolonged or repeated low levels of stress, for example in sports athletes, because muscle strength increases faster than bone strength, individuals are able to carry out activities beyond the previous level even though the bones cannot support increased pressure (Corwin, 2009). From the causative factors above, it affects when there is pressure from the outside to the bone. The bone is brittle only has little force and spring force to hold. A situation when there is an external pressure that comes greater than the ability of bone resistance and bone resistance to resist the pressure moves following the force of pressure (Muscari, 2005). At that time, trauma occurs which results in damage or discontinuation of bone continuity. After the fracture occurs, the peritoneum, blood vessels, nerves in the marrow cortex and soft tissue that wraps the bone are damaged. Then bleeding occurs around the fault and in the soft tissue that is inside it so that a hematoma is formed in the medullary cavity of the bone, edema, and necrocric so that interference occurs to the distal part of the body (Suratun, 2008). The etiology of fractures according to (Barbara C. Long, 2006) is 1. Fracture due to trauma events\ If the direct strength of the bone can be broken at the affected site, this also causes damage to the surrounding soft tissue. If the indirect strength of the bone can occur, a fracture can occur at a place far from the affected area and soft tissue damage in the place of fracture may not be present. Fractures can be caused by trauma, including: a. Direct trauma If the fracture occurs in a place where the part is forced, for example: collision or blow to the bone which results in a fracture. b. Indirect trauma For example, a patient falls with an arm in an extension, a fracture of the wrist, supracondiskuler, clavicle can occur. c. Mild trauma

It can cause a fracture if the bone itself is fragile. In addition, fractures are also caused by metastases from tumors, infections, osteoporosis, or due to the spontaneous pulling of strong muscles. 2. Fracture due to accident or pressure Bones if you can experience the muscles that are around the bone are not able to absorb the energy or the strength that perceives it. 3. Pathological fractures It is a fracture that primarily occurs because of the process of bone weakening due to a process of disease or cancer that metastasizes or ostepororsis. C. CLASSIFICATION Classification of antebrachial fractures: a. Antebrachial fracture, which is a fracture of both the radius and ulna bone

Gambar 5 Fraktur Radius-Ulna

b.

Ulna fracture (nightstick fracture), which is a fracture only in the ulna bone

Gambar 6 fraktur Ulna

c.

Montegia fracture, which is a proximal ulna fracture accompanied by a dislocation of the proximal radioulna

Gambar 7 Fraktur Montega

d.

Radius fracture, which is a fracture only in the bone radius

Gambar 8 Fraktur Radius

e. The Galeazzi fracture, which is a distal radius fracture accompanied by a distal radioulna joint dislocatio

D. CLINICAL MANIFESTATION Signs and symptoms of fractures include (Smeltzer & Bare, 2002): 1. Great pain in the place of fracture Pain will arise as long as the bone fragments have not been immobilized. This pain arises because when the bone is broken, the muscle will experience spasm. 2. There is bone shortening This is caused by muscle contractions that are attached above and below the fracture. 3. Swelling and Color Change This happens because of an inflammatory response. When a fracture occurs, a broken bone fragment will also injure the surrounding tissue resulting in an inflammatory response that begins with vascular vasodilation and the release of mediators. 4. Loss of radius-ulna function 5. Deformity 6. Crepitation In history, the deformity is found in the area around the radius of the client (Helmi, 2013). a. Look: In the initial phase of trauma, the client will grimace in pain. There is a deformity in the client's forearm. If pain and deformity are found in the forearm, it is necessary to examine the changes in pulse, poor perfusion (cold akral in the lesion), and CRT> 3 seconds where these are warning signs of the occurrence of the syndrome compartment. There are often cases of radius-ulna fractures with further complications. b. Feel:

a complaint of pain such as scale 6, tenderness and crepitation, the sensation is still felt in the distal area c. Move: limited elbow extension flexion motion, limited supination pronation

E. SUPPORTING EXAMINATION 1. Radiology Radiological examination using rongen rays (x-ray) is used to get a specific picture related to the condition and position of the bone, so the position of 2 projections is AP or PA and lateral. In certain circumstances additional projection is needed because of the pathology sought in the form of superposition. X-ray requests must be based on the existence of an investigation request. In this examination, there was a broken line on the humeral stem bone in a plain photograph. Things to read on an x-ray must include 6 A, namely:a. Anatomy b. Articular c. Alignment d. Angulation e. Apex f. Apposition In addition to plain x-ray photographs, there is a possibility that special techniques such as: Computed tomography-scanning (CT-scan): describes a transferal piece of bone where a damaged bone structure is obtained.

Hasil X-Ray Fraktur Antebranchii

Hasil CT-scan Radius Ulnaris

2. Laboratory a. Serum calcium and serum phosphorus increase during the bone healing stage. b. Alkaline phosphate increases in bone damage because it shows that osteoblast activity in forming bones. c. Muscle enzymes such as keratin kinase, lactate dehydrogenase (LDH-5) aspartate amino transferase (AST), aldolase which increases during the bone healing stage.

3. Other a. Examination of culture microorganisms and sensitivity tests that might indicate infection by microorganisms. b. Bone and muscle biopsy: essentially this examination is the same as the above examination but is more indicated by the suspected occurrence of infection c. Arthroscopy: Obtained damaged or sobel connective tissue trauma due to excessive trauma. d. Indium imaging: this infection will get an infection of the bone. e. MRI: describes damage to all tissues due to fractures, including soft tissue, and bone. (Ignatavicius, donna d, 1995)

F. MANAGEMENT Distal radius fracture is the most common type of fracture. Radius and ulna fractures are usually always in the form of changes in position and are unstable so they generally require operative therapy. Fractures that are not accompanied by changes in extra articular position from the distal radius and closed fracture of the ulcer can be effectively overcome primary care provider. Distal radius fractures generally occur in children and adolescents, and are easily cured in most cases. Fracture therapy requires the concept of "four R", namely: recognition, reduction / repositioning, sensitivity / fixation, and rehabilitation. 1. Technical or introduction is to do a variety of correct diagnoses so that it will help in handling fractures because the therapy plan can be prepared more perfectly.

2. Reduction or repositioning is the act of returning fracture fragments as closely as possible to the original state or position or normal location. 3. Retention or fixation or immobilization is the act of maintaining or holding a fragment of the fracture during healing. 4. Rehabilitation is an action with the intention that the part suffering from the fracture can return to normal.

In detail the fracture healing process can be divided into several stages as follows: 1. Hematoma phase Initially a hematoma occurs and is accompanied by swelling of soft tissue, then an organization occurs (proliferation of young connective tissue in the inflamed area) and the hematoma will deflate. Each fracture is usually accompanied by a rupture of a blood vessel so that there is accumulation of blood around the fracture. At the end of the broken bone ischemia occurs up to several millimeters from the fault line which results in the death of osteocyt in the fracture area. 2. Proliferative phase Proliferation of periosteal and endoosteal cells, which stands out is the proliferation of periosteal inner lining cells near the fracture area. Hematomas are pushed up by this proliferation and are absorbed by the body. Along with the activity of sub periosteal cells, the activity of cells from the medullary canal occurs from the layer of endosteum and from the bone marrow of each fragment. The process of the periosteum and medullary canal from each fragment converge in the same process, the process continues into and out of the bone so as to bridge the fracture surface with each other. At this time it may appear in some places of the cartilage islands, which may be many, although the presence of this cartilage is not absolute in bone healing. In this phase calcium deposits have occurred. 3. Phase callus formation In this phase fibrous callus is formed and here the bones become osteoporotic due to calcium resorption for healing. Osteoblast cells secrete an intra-cellular

matrix consisting of collagen and polysaccharides, which immediately unite with calcium salts, forming immature or young callus bones, because the intermingling process, then at the end of the stage there are two types of callus namely inside called internal callus and outside called external callus. 4. Consolidation phase In this phase the callus formed undergoes further maturation by osteoblast activity, callus being a more mature (mature) bone with lamellar formation). At this stage, the healing process is completely complete. In this phase fibrous callus changes to the primary callus. At this time it has begun to be placed so that the radioopaque tissue appears. This phase occurs after 4 (four) weeks, but at older ages it is easier faster. Primary bone callus is gradually resorbed and replaced with a second bone callus that is similar to normal bone tissue. 5. Remodeling phase In this phase the secondary bone callus has been filled with a lot of calcium and the bone has been formed well, and there is a re-formation of the bone medulla. If the union is complete, the new bone formed is generally excessive, surrounding the fracture area outside and inside the canal, so that can form the medullary canal. By following stress / pressure and mechanical pull, for example movement, muscle contraction and so on, the mature callus is slowly sucked back at a constant speed so that the bones that match the original form. Ilizarov, Bone lengthening, Bone distraction osteogenesis or Callotaxis is the same term in a bone lengthening program. Ilizarov was first developed by a Russian Siberian named Gabriel Abramovich Ilizarov. Ilizarov is an external fixation device that serves to keep the bone from shifting and to help in the process of bone lengthening.

Gambar 11 Callotaxis

Gambar 10 Proses Penyembuhan Fraktur

Indications for installation of Ilizarov: 1. arms

Equate the length of the

or legs that are not the same.

2. Equate and grow the area of bone lost due to a broken open bone. 3. Dispose of infected bones and filled with how to grow healthy bones. 4. Increase height. Counter indication of installation of Ilizarov: 1. Open the fracture with a soft tissue that needs further treatment better if a single planar fixator is installed. 2. Intra-articular fractures that need ORIF. 3. Simple fracture (can be done by installing plate and screw nail wire).

G. COMPLICATION Fracture ulna radius complications are classified as rapid complications (at injury), early (within a few hours or days), and slow (in a few weeks or months). 1. Rapid Complications of Radius Ulna Fractures, including: a. Bleeding, blood loss from fractured bones, including blood loss from damage to the tissue around the fractured bone. b. Damage to the brachial nerve artery located near the ulna radius 2. Early Complications of Radius Ulna, including:

a. Fat embolism that occurs especially in the part of the ulna radius fracture b. Problems with local immobilization (eg decubitus ulcers, deep vein thrombosis, chest infections). c. Compartment syndrome.

3. Slow Complications, including: a. Deformity. b. Secondary osteoarthritis (joints). c. Asepsis and / or avascular necrosis can occur mainly after a fracture in the bone such as the ulna radius. It occurs due to a disruption of blood supply to the bone after fracture (Brooker, 2008).

H. Nursing care 1. Assessment Assessment is the initial stage and foundation in the nursing process, for it requires precision and thoroughness on client problems so that it can provide direction to nursing actions. The success of the nursing process is very dependent on this stage. This stage is divided into: a) Data Collection Anamnesa 1) Demographic data 2) Main Complaints In general, the main complaint in cases of fractures is pain. The pain can be acute or chronic depending on the duration of the attack. To obtain a complete assessment of client pain, use:  Provoking Incident: is there an event that becomes a factor of precipitation pain.  Quality of Pain: what kind of pain a client feels or describes. Is it like burning, pulsing, or piercing.  Region: radiation, relief: whether the pain can subside, whether the pain spreads or spreads, and where pain occurs.  Severity (Scale) of Pain: how far the pain is felt by the client, can be based on the pain scale or the client explains how far the pain affects the ability of its function.  Time: how long the pain lasts, when, does it get worse at night or during the day. 3) Current Disease History Data collection is done to determine the cause of the fracture, which later helps in making a plan of action for the client. This can be a chronology of the occurrence of the disease so that later the strength can be determined and which body parts are affected. In addition, by knowing

the mechanism of the occurrence of accidents other injuries can be known 4) Past Disease History This study found possible causes of fracture and gave instructions on how long the bones would connect. Certain diseases such as bone cancer and paget's disease that cause pathological fractures are often difficult to connect. In addition, diabetes with foot sores is at risk of acute and chronic osteomyelitis and diabetes also inhibits bone healing. 5) Family Disease History Family disease associated with bone disease is one of the predisposing factors for fractures, such as diabetes, osteoporosis that often occurs in several offspring, and bone cancer which tends to be genetically inherited 6) Psychosocial History 7) Is the client's emotional response to the illness and the role of the client in the family and society and the response or influence in his daily life both in the family and in the community 8) Patterns of Health Functions a. Perception Patterns and Procedures for Healthy Living b. Pattern of Nutrition and Metabolism c. Elimination Pattern d. Sleep Patterns and Rest e. Activity Pattern f. Relationship Patterns and Roles g. Pattern of Perception and Self Concept h. Sensory and Cognitive Patterns

i. Pattern of Sexual Reproduction j. Stress Management Pattern k. Pattern of Values and Beliefs A. Physical Examination 1) Overview Need to mention: a) General circumstances: b) Systemically from head to sex 1) Integumen System 2) Chief 3) Neck 4) Face 5) Eyes 6) Ears 7) Nose. 8) Mouth and Pharynx 9) Thorax 10) Lungs. 11) Abdomen 12) Inguinal-Genetalia-Anus

2) Local Circumstances Proximal and distal conditions must be taken into account especially regarding neurovascular status (for neurovascular status à 5 P, Pain, Palor, Paresthesia, Pulse, Movement). Examination of the musculoskeletal system is: a. Look (inspection) Pay attention to what can be seen, among others: 1. Cicatriks (both natural and artificial scarring such as scars). 2. Color redness or blueness or hyperpigmentation. 3. Lumps, swelling, or basins with things that are unusual (abnormal). 4. Position and shape of the upper extremity (deformity) b. Feel (palpation) At the time of palpation, the position of the patient is repaired first starting from the neutral position (anatomical position). Basically this is an examination that provides two-way information, both examiners and clients. What needs to be noted is: i. Temperature changes around trauma (warm) and skin moisture. Capillary refill time à Normal> 3 seconds ii. If there is swelling, is there fluctuations or edema especially around the joints. iii. Tenderness (tenderness), crepitus, note the location of the abnormality (1/3 proximal, middle, or distal). Muscle: tone at the time of relaxation or contraction, a lump found on the surface or attached to the bone. In addition, neurovascular status was also examined. If there is a lump, then the nature of the lump needs to be described its surface, consistency, movement of the base or surface, pain or not, and its size.

c. Move (movement, especially the scope of motion) After checking the feel, then proceed with moving the extremities and note whether there are complaints of pain in the movement. Recording of the scope of this movement is necessary, in order to be able to evaluate the conditions before and after. Movement of the joints is recorded with the size of the degree, from each direction of movement starting from point 0 (neutral position) or in metric size. This check determines whether there is a movement disorder (mobility) or not. The movement seen is active and passive movements. Especially in the Radius Ulna, it is specific to a number of focus movements such as pronation of the forearm, wrist flexion and abduction, thumb flexion, etc.

2. Diagnosa Keperawatan 1. Acute pain b / d muscle spasm, movement of bone fragments, edema, soft tissue injury, traction installation, stress / anxiety, surgical wound. 2. Damage to network integrity b / d open fracture, installation of traction (pen, wire, screw) 3. Self-care deficit b / d neuromuscular weakness, decreased forearm strength. 4. Risk of infection b / d inability of primary defense (skin damage, soft tissue taruma, invasive procedures / bone traction) 5. Lack of knowledge about conditions, prognosis and treatment needs b / d less exposed or misinterpretation of information, cognitive limitations, lack of accurate / complete information available

3.1.3. Intervensi Keperawatan 1. Acute pain b / d muscle spasm, movement of bone fragments, edema, soft tissue injury, traction installation, stress / anxiety. Purpose: The client says the pain is reduced or lost by showing relaxed actions, being able to participate in activities, sleep, rest properly, show the use of relaxation skills and therapeutic activities according to indications for individual situations Result Criteria: 1. Subjectively, the client reports the scale of pain that feels diminished, lost, or can be overcome by the client. 2. Clients are able to identify activities that increase or reduce pain. 3. The client is not nervous, the scale of pain 0-1 or resolved. INTERVENSI KEPERAWATAN 1. Maintain immobilisation of the affected part with bed rest, casts, stabs and / or traction 2. Elevate the position of the affected limb. 3. Do and monitor passive / active motion exercises. 4. Take action to improve comfort (massage, change of position) 5. Teach the use of pain management techniques (deep breathing exercises, visual imagination, disional activities) 6. Do cold compresses during the acute phase (the first 24-48 hours) as needed. 7. Collaboration of giving analgesics as indicated. 8. Evaluation of pain complaints (scale, verbal and non-verbal instructions, changes in vital signs)

2. Damage to network integrity b / d open fracture, installation of traction (pen, wire, screw) Purpose: The client declares lost discomfort, shows technical behavior to prevent skin damage / facilitates healing as indicated, achieves wound healing according to the time / healing of the lesion occurs INTERVENSI KEPERAWATAN 1. Maintain a comfortable and safe bed (dry, clean, tight looms, bottom elbow pads, heels). 2. Massage the skin, especially the protrusion area of the bone and the distal area of stiffness / casts. 3. Protect the skin and casts on the perianal area 4. Observation of the state of the skin, press cast / weight against the skin, pen / traction insertion.

3. Self-care deficit b / d neuromuscular weakness, decreased forearm strength Objective: Clients can fulfill their personal care needs (toileting, dressing and feeding) Result Criteria: 1. The client's needs for self-care are fulfilled. 2. Complications can be avoided or minimized. 3. Clients express feelings of limitations. 4. Clients are able to carry out self-care activities to the maximum according to ability.

INTERVENSI KEPERAWATAN 1. Assess the client's functional level in carrying out activities. Document and report any changes (progress or deterioration of the client's ability to move). 2. Avoid activities that cannot be done by the client and help the client's activities if needed. 3. Plan actions to reduce movement on the affected side of the arm, such as placing food and equipment in one place opposite the affected side. 4. Assess client habit patterns defecation (BAB). Encourage clients to drink water ± 2500mL / day and increase physical activity / training according to their abilities.

5. Risk of infection b / d inability of primary defense (skin damage, soft tissue taruma, invasive / bone traction procedures Purpose: The client achieves timely wound healing, free of purulent drainage or erythema and fever INTERVENSI KEPERAWATAN

RASIONAL

1. Perform sterile pen treatments 1) Prevent secondary infections and wound care according to and accelerate wound healing. the protocol

2) Minimizing contamination. 3) Broad-spectrum or specific

2. Teach clients to maintain the sterility of pen insertion.

antibiotics

can

be

used

prophylactically, preventing or

3. Collaboration with tetanus overcoming infections. Tetanus antibiotics and toxoids as toxoid to prevent tetanus indicated.

infection.

4) Leukocytosis usually occurs in the process of

4. Analysis of laboratory results

infection,

anemia

and

(Complete blood count, LED,

increased LED can occur

culture and wound / serum /

in osteomyelitis. Culture

bone sensitivity)

to

identify

infectious

organisms. 5)

Evaluating

development

of

the client

problems. 5. Observation of vital signs and signs of local inflammation in the wound.

6. Lack of knowledge about conditions, prognosis and treatment needs b / d less exposed or misinterpretation of information, cognitive limitations, less accurate / complete information available. Objective: the client will show knowledge increases with the criteria the client understands and understands about the disease INTERVENSI KEPERAWATAN 1. Assess the readiness of the client

RASIONAL

1) The effectiveness of the

to take part in the learning

learning

process

is

program.

influenced by the physical and mental readiness of the client to take part in the learning program. 2)

2. Discuss the method of mobility

Increase

the

participation

and

and ambulation according to

independence of clients in

the physical therapy program.

planning implementing

and physical

therapy programs.

3. Teach clinical signs / symptoms

3)

Increasing

the

that require medical evaluation

alertness of clients to

(severe pain, fever, changes in

recognize early signs /

distal skin sensation of injury)

symptoms

that

initiate

further intervention. 4. Prepare clients to take surgical therapy if needed.

4) Surgical efforts may be needed to overcome the problem according to the client's condition.

DAFTAR PUSTAKA

Batticaca, Fransisca B. (2008). Asuhan Keperawatan Pada Klien dengan Gangguan Sistem Persyarafan. Jakarta: Salemba Medika. Carpenito, Lynda Juall. 2007. Buku Saku Diagnosa Keperawatan. Edisi 10. Jakarta: EGC. Corwin, Elizabeth J. (2009).Buku Saku Patofisiologi. Jakarta: EGC Dewanto, et al. (2009). Panduan Praktis Diagnosis & Tata Laksana Penyakit Saraf. Jakarta:EGC Doenges, Marilynn E. dkk. (2000). Penerapan Proses Keperawatan dan Diagnosa Keperawatan, EGC; Jakarta Muttaqin, Arif. (2008). BukuAjar Asuhan Keperawatan Klien dengan Gangguan Sistem Persarafan. Jakarta: Penerbit Salemba Medika. Nasissi, Denise. 2010. Hemorrhagic Stroke Emedicine. Medscape,. [diunduh dari: http://emedicine.medscape.com/article/793821-overview]