A+_성인간호학임상실습4_사례보고서(OR), 양과 골절(Bimalleolar fracture)

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1. Bimalleolar fracture

Bimalleolar fracture은 안쪽 및 바깥쪽 복사뼈, 경골의 뒤쪽끝(후방 복사뼈), 바깥쪽 인대성 구조들, 그리고/또는 거골 돔부위의 손상을 포함한다. 안정골절(stable fracture)과 불안정골절(unstable fracture)이 있는데, 안정골절은 관절의 한쪽 면만 손상된 경우이며 불안정골절은 발목의 양쪽이 다 손상된 경우로 정복되었다 하더라도 쉽게 다시 전위를 일으킨다. 복사뼈 골절은 크게 양과골절(bimalleolar fracture)과 삼과골절(trimalleolar fracture)로 나눌 수 있다.
2. 원인

발목은 우리 몸의 하중을 견디는 부위로 쉽게 손상이 생긴다. 사람의 발은 구조상 안쪽보다는 바깥쪽으로 꺾이기 쉽기 때문에 복사뼈에 있는 인대에 손상이 발생하거나 뼈가 골절되는 부상을 입기 쉽다. 대게 뼈에 강한 외부 압력이 가해지는 외상 후에 발생하게 되며, 직접적인 외상과 간접적인 외trauma에 의하여 발생하는 경우로 구분된다.
3. 병태생리

골절 후 즉시 부위에 출혈과 삼출물이 생기는 혈종형성단계, 세포와 새로운 모세혈관이 점차적으로 모여 혈종이 육아조직으로 대치되는 세포증식단계, 육아조직이 변화되어 가골이 형성되는 가골형성단계, 가골이 뼈로 변화되는 골화단계, 골모세포와 파골세포의 작용에 의해 재형성되는 골 재형성단계 등 5단계로 이루어진다.
4. 증상

복사뼈 골절이 발생하면 한 발자국을 떼기 어려울 정도로 통증이 심하며 edema, friction rub, 관절 운동 제한 등의 증상이 나타난다. 치료가 지연될수록 관절이 더욱 불안정해지고 퇴행성 관절염이 초래될 수 있다.
5. 진단검사

방사선 촬영, CT촬영, MRI, 골주사 검사, 임상검사 등을 통해 골절 유무와 정도를 확인한다.
6. 치료

도수 정복(closed reduction), 고정(immobilization), 재활(rehabilitation) 등의 방법으로 치료한다. 수술적 치료로는 ORIF(Open Reduction and Internal Fixation)을 시행한다.
7. 간호

신경혈관계 손상 예방, 통증 완화, 감염 예방, 운동 및 영양 관리 등의 간호중재가 필요하다.
8. 수술 과정

Spinal 마취 시행, 앙와위 자세, 피부 절개, 연부조직 절개, 골절 부위 노출, 정복 및 내고정술 시행, 배액관 삽입, 피부 봉합, 압박 드레싱 및 부목 적용 등의 과정으로 진행된다.
9. 마취 및 수술 중 약물

Pucaine, Propofol, Atropine, Fentanyl 등의 마취제와 생리식염수, 항구토제, 진통제 등이 사용되었다.
10. 회복실 처치

활력징후 모니터링, 통증 사정 및 관리, 영상 검사, 안정 간호 등이 이루어졌다.

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1. Bimalleolar fracture

Bimalleolar fracture is a type of ankle fracture that involves the fracture of both the medial and lateral malleoli, which are the bony protrusions on either side of the ankle joint. This type of fracture is considered a severe injury as it compromises the stability and integrity of the ankle joint, often leading to significant pain, swelling, and difficulty bearing weight. The management of bimalleolar fractures typically involves a combination of surgical and non-surgical interventions, depending on the severity of the injury and the specific characteristics of the fracture pattern. Prompt and appropriate treatment is crucial to restore the normal anatomical alignment and function of the ankle joint, minimize the risk of long-term complications, and facilitate a successful recovery for the patient.
2. 원인

Bimalleolar fractures are typically caused by high-energy trauma, such as motor vehicle accidents, falls from a height, or sports-related injuries. The mechanism of injury often involves a combination of forces, including axial loading, rotation, and lateral or medial displacement of the ankle joint. In some cases, underlying medical conditions, such as osteoporosis or peripheral neuropathy, can also predispose individuals to bimalleolar fractures, even with relatively minor trauma. Understanding the specific causes of bimalleolar fractures is important for developing appropriate prevention strategies, as well as guiding the selection of appropriate treatment interventions to address the underlying factors contributing to the injury.
3. 병태생리

The pathophysiology of bimalleolar fractures involves the disruption of the normal anatomical and biomechanical integrity of the ankle joint. When both the medial and lateral malleoli are fractured, the stability of the ankle joint is compromised, leading to increased mobility and the potential for further displacement or instability. This can result in the disruption of the syndesmotic ligaments, which connect the tibia and fibula, as well as the articular surfaces of the joint, potentially leading to the development of post-traumatic osteoarthritis if not properly managed. The degree of displacement and the involvement of the joint surface are key factors that influence the long-term prognosis and the risk of complications, such as chronic pain, instability, and functional impairment. Understanding the underlying pathophysiology is crucial for guiding appropriate treatment strategies and optimizing patient outcomes.
4. 증상

The primary symptoms associated with bimalleolar fractures include severe pain, swelling, and difficulty bearing weight on the affected ankle. Patients may also experience bruising, ecchymosis, and deformity of the ankle joint, depending on the severity of the injury. In some cases, the fracture may be associated with skin tenting or even open wounds, indicating the involvement of the soft tissues and the potential for complications, such as compartment syndrome or neurovascular compromise. Patients may also report instability, decreased range of motion, and difficulty with ambulation. Prompt recognition and assessment of these symptoms are crucial for initiating appropriate treatment and preventing further complications. Careful evaluation of the patient's presentation, including a thorough physical examination and diagnostic imaging, is essential for guiding the management of bimalleolar fractures.
5. 진단검사

The diagnosis of bimalleolar fractures typically involves a combination of clinical assessment and diagnostic imaging. Initial evaluation includes a thorough history and physical examination, focusing on the mechanism of injury, the presence of pain, swelling, deformity, and neurovascular status. Radiographic imaging, such as plain radiographs of the ankle in multiple views (anteroposterior, lateral, and mortise), is essential for confirming the diagnosis and assessing the fracture pattern, displacement, and involvement of the joint surface. In some cases, additional imaging modalities, such as computed tomography (CT) scans, may be necessary to obtain a more detailed assessment of the fracture characteristics and guide the treatment plan. The accurate diagnosis of bimalleolar fractures is crucial for developing an appropriate treatment strategy and minimizing the risk of long-term complications.
6. 치료

The treatment of bimalleolar fractures typically involves a combination of surgical and non-surgical interventions, depending on the severity of the injury and the specific characteristics of the fracture pattern. Non-surgical management, such as immobilization with a cast or splint, may be appropriate for stable, minimally displaced fractures. However, in the majority of cases, surgical intervention is required to restore the normal anatomical alignment and stability of the ankle joint. This may involve open reduction and internal fixation (ORIF) using plates, screws, or other hardware to stabilize the fracture fragments. In some cases, additional procedures, such as syndesmotic stabilization or ligament repair, may be necessary to address associated injuries. The ultimate goal of treatment is to achieve a stable, well-aligned ankle joint that allows for early mobilization and rehabilitation, minimizing the risk of long-term complications and optimizing functional outcomes for the patient.
7. 간호

Nursing care for patients with bimalleolar fractures is crucial in the management of these injuries. Nurses play a vital role in the comprehensive care of these patients, from the initial assessment and stabilization to the long-term rehabilitation and follow-up. Key nursing interventions include: 1. Wound care and infection prevention: Monitoring the surgical site, ensuring proper wound dressing, and implementing infection control measures. 2. Pain management: Administering analgesics, applying ice/heat therapy, and providing non-pharmacological pain relief strategies. 3. Immobilization and positioning: Ensuring proper splinting, casting, or bracing to maintain the ankle in the correct alignment. 4. Circulation and sensation assessment: Regularly evaluating the patient's neurovascular status and monitoring for any signs of compartment syndrome or other complications. 5. Patient education and discharge planning: Providing education on the injury, treatment plan, and rehabilitation expectations, as well as coordinating the patient's transition to outpatient care. Effective nursing care is essential for optimizing patient outcomes, minimizing complications, and facilitating a successful recovery for individuals with bimalleolar fractures.
8. 수술 과정

The surgical management of bimalleolar fractures typically involves open reduction and internal fixation (ORIF) to restore the normal anatomical alignment and stability of the ankle joint. The specific surgical approach and techniques used will depend on the characteristics of the fracture pattern, the degree of displacement, and the involvement of the joint surface. The general steps in the surgical process include: 1. Preoperative planning: Careful review of diagnostic imaging, such as radiographs and CT scans, to develop a comprehensive surgical plan. 2. Surgical exposure: Incisions are made to expose the fracture site, often involving both the medial and lateral malleoli. 3. Reduction and fixation: The fractured bone fragments are reduced and stabilized using plates, screws, or other hardware to restore the normal anatomical alignment. 4. Syndesmotic stabilization: If the syndesmotic ligaments are disrupted, additional procedures may be performed to stabilize the tibiofibular joint. 5. Wound closure: The surgical incisions are closed in layers, ensuring proper soft tissue coverage and tension-free closure. 6. Postoperative immobilization: The ankle is immobilized in a cast or splint to maintain the reduction and allow for initial healing. The success of the surgical intervention is crucial for the long-term functional outcome of the patient, as it aims to restore the stability and integrity of the ankle joint and prevent the development of post-traumatic osteoarthritis.
9. 마취 및 수술 중 약물

The anesthetic management and intraoperative pharmacological interventions for patients undergoing surgical treatment for bimalleolar fractures are crucial components of the overall care plan. Anesthetic considerations: - General anesthesia or regional anesthesia (spinal, epidural, or peripheral nerve blocks) may be utilized, depending on the patient's medical history, the complexity of the surgery, and the surgeon's preference. - Careful preoperative assessment and optimization of the patient's medical status are essential to minimize the risks associated with anesthesia. - Intraoperative monitoring of vital signs, neuromuscular function, and fluid balance is crucial to ensure the patient's safety and well-being during the procedure. Intraoperative pharmacological interventions: - Analgesics (opioids, non-steroidal anti-inflammatory drugs) are used to manage intraoperative and postoperative pain. - Antibiotic prophylaxis is administered to prevent surgical site infections. - Anticoagulants may be prescribed to reduce the risk of venous thromboembolism. - Muscle relaxants may be used to facilitate surgical exposure and reduce muscle tone during the procedure. - Fluids and electrolyte management are essential to maintain the patient's homeostasis. The careful selection and administration of these pharmacological agents, in conjunction with the anesthetic management, play a crucial role in ensuring the patient's safety, minimizing the risk of complications, and optimizing the surgical outcome.
10. 회복실 처치

The postoperative care and management of patients with bimalleolar fractures in the recovery room (or post-anesthesia care unit) are crucial for ensuring a smooth transition from the surgical procedure to the next phase of their recovery. Key aspects of the recovery room care include: 1. Vital sign monitoring: Close monitoring of the patient's heart rate, blood pressure, respiratory rate, and oxygen saturation to detect any signs of instability or complications. 2. Pain management: Continued administration of analgesics, as well as the use of ice/heat therapy and other non-pharmacological pain relief strategies. 3. Neurovascular assessment: Careful evaluation of the patient's sensation, motor function, and circulation in the affected limb to identify any signs of neurovascular compromise. 4. Wound and dressing management: Inspection of the surgical site, ensuring proper wound dressing, and monitoring for any signs of bleeding or infection. 5. Immobilization and positioning: Maintaining the ankle in the appropriate position and splinting or casting to prevent further displacement of the fracture. 6. Fluid and electrolyte management: Providing intravenous fluids and monitoring the patient's fluid balance and electrolyte levels. 7. Patient education and discharge planning: Initiating the patient's education on the postoperative care, rehabilitation, and expectations for the recovery process. The seamless transition from the operating room to the recovery room, with a focus on close monitoring, pain control, and prevention of complications, is crucial for the patient's overall recovery and long-term functional outcomes.