UNIVERSITI KUALA LUMPUR ROYAL COLLEGE OF MEDICINE PERAK

Orthopaedic case write up (Trauma)

Name: IC: Matrix No.

MUHAMMAD NAZMI BIN NOOH 890418-14-5723 57258208090

Patient Personal Data Name Age Ethnicity Gender: Reg No : Mr R : 38 years old : Indian : Male : HRPB 120250

Date of Admission: 5th May 2012

Chief complain Alleged motor vehicle accident, motorbike hit by a car

History of presenting illness Mr R rode a motorcycle and on the way to go home from his workplace. When he wants to cross a road, suddenly a car hit him in front. He wears his helmet but not properly tie it because it was thrown away when he was hit and he fell his back of his head on the road. He admitted he was on alcohol influence when he rode the motorcycle and he said he drank about 2 bottles of whiskey before he went home. His brother saw the incident, call the ambulance and he was sent to Hospital Raja Pemaisuri Bainun Ipoh. He has loss of consciousness and retrograde amnesia. He cannot recall exactly what happen and he did not know what happen at accident and emergency department. On post trauma, he complain of pain over right hip, right thigh and right leg. The pain was very severe and he grade the pain 9 out of 10. But no chest pain, no shortness of breath, no nausea, no vomiting, no abdominal pain, no weakness on right leg, and no numbness. There is small abrasion wound on his right and left finger, on his abdomen and on the back of his head and he also complains of headache. No open wound on the thigh and leg.

Past medical History Fracture of right leg 5 years ago and was inserted interlocking nail. The Interlocking nail is still inserted in the femur

Drug History No significant drug history and no allergy

Family History

Mother died at the age of 58 because of diabetes mellitus and heart disease Mr r is no 3 out of 8 in siblings. He is married and do not have any children.

Social History Works for money Lender Company. His job is to find debtors and collect money. Heavy alcohol drinker. Drinks about 3 bottles per day Not smoking No drug abuse

Physical examination General examination Rapport was established. Patient lying on bed comfortably with 1 pillow, alert and conscious, not in respiratory distress. His right leg is elevated and there is calcaneal pin traction attach to his right foot. Palm of the hand is pink and warm, no palmar erythema, no muscle wasting, no peripheral cyanosis. There is small abrasion wound over the finger on dorsum aspect of the hand. Capillary refilling time is less than 2 seconds. No leukonychia, no koilonychia, no clubbing of the finger. Pulse rate is 84 beat per minute, regular rhythm, normal volume. Blood pressure is 110/80, respiratory rate is 21 per minute. No pale of cunjunctiva, no jaundice of the sclera. Oral mucosa is well hydrated, no central cyanosis. No neck swelling and no lymph node enlargement.

Lower Limb Examination LOOK Patient is lying supine on the bed with skeletal calcaneal traction on the right foot. There is a deformity on the middle of the right shin bone indicate some fracture may taken place there. There is also a swelling on the right shin bone compare to the left side. FEEL On palapation of bony prominence, there is tenderness over greater trochanter, mid shaft of the femur and also tenderness over the swelling site. The skin over the swelling site is warm and tender. There is no skin change. The swelling is extending from the upper part of shin bone to the lower third of the shin bone. MOVE Patient cannot move the right lower limb because of skeletal calcaneal traction on the right foot. No restricted movement of Left limb.

SPECIAL TEST Measurement of apparent length shows right lower limb is 102cm, left lower limb is 112cm Measurement of true length shows right lower limb is 77cm, left lower limb is 84cm Neurovascular examination No loss of sensation on both lower limbs. Power on left lower limb graded 5. Femoral artery, popliteal artery and dorsalis paedis of both lower limbs are palpated

Examination of the Chest On inspection, there was no deformity of the chest. Both sides were moving symmetrically with respiration. On palpation, the trachea was central and no tenderness. Chest expansion was normal on both sides. Apex beat was in the fifth intercostals space in the mid axillary line. No heave or thrill could be felt. On auscultation, air entry was equal on both sides of the lung, both anteriorly and posteriorly. Breath sounds were vesicular over both sides of the lung. First and second heart sounds were normal. No murmur was detected.

Examination of the Abdomen On inspection, there is long abrasion wound, the abdomen was not distended and was moving normally with respiration. The umbilicus was central and inverted. There were no scars. No dilated veins were visible. On palpation and percussion, the abdomen was soft and non-tender. No organomegaly. The kidneys were not ballotable. No shifting dullness.On auscultation, normal bowel sounds were heard. There were no bruits.

Provisional Diagnosis with points support 1. Close fracture of right neck of femur The mechanism of injury is direct hit from the motor vehicle accident. There is tenderness over the greater trochanter of the right femur and right hip cannot move because of pain. There is shortening of right limb compare to left limb. No open wound 2. Close fracture of right mid shaft of femur The mechanism of injury is direct hit from the motor vehicle accident.There is tenderness over right mid shaft of femur and no open wound 3. Close fracture of right mid shaft of tibia and fibula The mechanism of injury is direct hit from the motor vehicle accident. The right mid shaft is swollen extending from proximal third of shin bone to the distal third of shin bone. There is also deformity on the distal third of the shin bone. On palpation, there is tenderness over the distal third of the shin bone.

Differential diagnosis 1. Close fracture of the right intertrochanter Point support - There is tenderness over the greater trochanter of the right femur and right hip cannot move because of pain. There is shortening of right limb compare to left limb. Point against there is no swelling. This fracture usually in osteoporotic patient 2. Dislocation of the right hip Point support Shortening of the right lower limb Point against there is no abnormalities in attitude of right lower limb

3. Close fracture of midshaft of right tibia with fibula intact Point support The right mid shaft is swollen extending from proximal third of shin bone to the distal third of shin bone. There is also deformity on the distal third of the shin bone. On palpation, there is tenderness over the distal third of the shin bone. Point against - There is deformity on the distal third of the shin bone.

4. Soft tissue injury

Investigation 1. X-ray of the right hip in AP and lateral view a. This x ray show there is fracture on the neck of femur. There is old interlocking nail inserted in the right midshaft of femur. Garden classification II 2. X ray of right mid thigh in AP and lateral view a. This x ray shows there is comminuted fracture of midshaft of femur. There is old interlocking nail inserted and there is callus formation on old fracture. The new fracture is not involve the old one 3. X-ray of right leg in AP and lateral view a. This x ray shows there is comminuted fracture of the midshaft of the right tibia and fibula

Final diagnosis 1. Close fracture of right neck of femur 2. Close fracture of right mid shaft of femur 3. Close fracture of right mid shaft of tibia and fibula Problem identification 1. Pain over the right hip, right thigh and right leg 2. Old interlocking nail in right midshaft of femur 3. A worry on compartment syndrome because of there is swelling over right shin bone. 4. A worry on fat embolism 5. A worry on non union of fracture bones

6. A worry on mal union fracture bones 7. A worry on avascular necrosis of neck of femur 8. A worry on blood loss because of fracture of midshaft of femur

Principle of management 1. Analgesia for the pain 2. Skeletal traction calcaneal pin traction 3. Open reduction and internal fixation with cannulated screw for fracture of neck of femur and plating for fracture of midshaft 4. Review after 8 weeks to assess clinically and radiologically that the fractures has unite

Discussion Mr R sustained multiple trauma at his right thigh and leg due to motor bike accident. He was diagnose with close fracture of right neck of femur, right mid shaft of femur and right mid shaft of tibia and fibula. Usually, a fracture in neck of femur is common in elderly associated with osteoporosis. But because of high energy blow to the hip, this young gentlemen fractured his neck of femur. Occasionally, stress fractures of the femoral neck occur in runners or military personnel. In fracture of neck of femur, we classified it according to Garden classification (Garden 1961). In Garden classification, it has 4 stages. Stage I is an incomplete impacted fracture in which the femoral head is tilted into valgus in relation to the neck. Stage II is a complete but undisplaced fracture. Stage III is a complete fracture with moderate displacement. And stage IV is a severely displaced fracture. From Xray of right hip, it shows Mr R sustained from Garden II classification of fracture of neck of femur which is the neck is completely fracture but undisplaced. Grade I and II has a better prognosis for union and viability of the femoral head compare to the Grade III and IV. The most feared complication of fracture of the femoral neck is avascular necrosis. Avascular necrosis is very common in fracture of neck of femur because of the blood supply of the femoral neck. The profunda femoris artery arising from the femoral artery gives off medical circumflex femoral artery. This gives off the lateral epiphyseal and superior and inferior metaphyseal arteries. The lateral epiphyseal arteries are important and supply the laterial 2/3 of the femoral head. The superior metaphyseal artery supplies the superior aspect of the femoral neck. The inferior metaphyseal artery supplies the inferior part of the neck and the adjacent part of the head derived from the metaphysis.

The medial epiphyseal artery supplies a circumfoveal sector of the head. It is a continuation of the artery of the ligamentum teres which arises from the acetabular branch of the obturator artery. Femoral neck fractures that are intracapsular and may threaten any or all of the three sources of blood to the femoral head; the cervical vessels in the retinaculum of the joint capsule usually

damaged if the fractures is displaced, intramedullary vessels always torn, and from the ligamentum teres usually contributs minimally in the elderly and not uncommonly, may be non-existent. The second fractures in Mr R case is close fractures of the midshaft of femur. The fractures is comminuted and not associated with the old fractures. Mr R has past history of fracture at the same site about 5 years ago and was inserted with interlocking nail. From the x-ray of right femur AP view, it shows there is old interlocking nail with old fractures have been united and there is callus formation. But the old fracture does not associated with the new fractures. In this case, combine fractures of the neck and shaft of femur can be fix together using multiple screws and the femoral shaft fracture can then be managed with retrograde lock intramedullary nail or by lateral plate inserted in a submuscular fashion. Tibia and fibula is the commonest long bone can be fractured especially in motor vehicle accident case. What we worry in this case is compartment syndrome, mal union and non union. Mr R develop pain and swelling of the site of fracture in right leg. This is the earliest sign of the compartment syndrome followed by parasthesia, pulslessnes, pallor and paralysis. To confirm it, we have to measure the intracompartmental pressure by the wick catheter/slit catheter method. Delayed union and non union is common because of lack of blood supply.

Summary Mr R is a 38 years old Indian gentlemen sustained close fracture of right neck of femur, close fracture of right mid shaft of femur and close fracture of right mid shaft of tibia due to motor vehicle accident. References Louis Solomon, David Warwick, Selvadurai Nayagam. Apleys System of Orthopaedics and Fractures. Ninth Edition.