Case Write Up Mark Sheet

Students name Lim Chee Yao

ID 1001026509
Year and Batch Year 5 Batch 2012-2017
Rotation 1
Group 2
Date 1 October 2016

No Contents Words Full Marks

1,500 +/ marks awarded
_10%
1 A complete history 1
2 Full physical examination with detail of the local 1
problem 500
3 A list of problem faced by the patient and 1
provisional diagnosis
4 A summary of the history and physical examination 1
to support your provisional diagnosis
5 Differential diagnoses with discussion of points for 1
and against
6 Investigations you would ask for the patient with 1
500
reasons and expected results or findings and
possible complications
7 Principles of treatment and solution to patients 1
problem
8 Final discussion from literature search with 3
correlation to the patient problem and also 500
related basic sciences. The material should come
from reference books and medical journals
Total 1,500 10

Signature:

Assessor:
Date:
Patients Data

Name: Muhammad Sharizat

Age: 20 years old

Sex: Male

Race: Malay

Religion: Islam

Place of Residence: Dungun ( 77 kilometres South of Kuala Terengganu, about 1 hour drive to KT)

Occupation: College student at Polytechnic in Dungun

Date of admission: 19th September 2016 (Saturday)

Date and place of clerking: 25th September 2016 (Monday) at Ward 4E ( male orthopaedic ward)

Patients History

Chief complaints: Alleged motor vehicle accident, with pain at the right thigh as well as numbness

at right leg 3 hours prior to admission.

History of Presenting Illness:

Mr. Sharizat, who has no known medical illness, was riding motorcycle alone on his way to futsal

court on 18th September night, around 10.45p.m.. He was wearing helmet, going straight at about

50 kilometre per hour. A car from the opposite direction made a right turn suddenly, he was unable

to respond by braking and hit the car which turned into his way. His right lower limb hit the car

bumper while right upper limb hit the cars windscreen. He fell down and landed on the road on the

right side, made a few rolling turn.

Sharizat felt immediate sharp pain and bleeding on the right forearm, with pain score of 6/10, while

he tried to stand up but he felt sharp pain, bleeding with numbness of the whole right lower limb

and was unable to mobilise his right lower limb at all, with pain score of 6/10. However, he was still

able to move the right foot, toes without pain.

Sharizat denied of losing consciousness, having headache, nausea, vomiting, blurring of vision,

bleeding through ear, nose and eyes, chest, abdominal, pelvic, neck or back pain.
A friend of him who was coming from behind saw the incident and called ambulance to send him to

Dungun hospital, where he was stabilised and initial investigation taken, including X-ray of the right

upper limb, chest, pelvis and right lower limb. He was then being applied fixed traction and

transferred to HSNZ for admission into orthopaedic ward in 2.14a.m. on 19th September.

Sharizat developed fever one day after admission, but he denied of symptoms of shortness of

breath, chest pain, hemoptysis, as well as noticing conjunctival petechiae. There was also no prior

upper respiratory tract infection, nor symptoms of urinary tract infection. He was started with

antibiotics and the fever subsided accordingly.

Currently, he is fever free. Pain control is achieved by paracetamol 1000mg 4 times per day.

However, he is not able to ambulate, as balanced skeletal traction is applied to his right proximal

tibia. Defecation is controlled by medication prescribed by doctor, and urination is done using

container.

Systemic Review:

Not remarkable

Past Medical History:

No history of asthma and congenital heart disease, no previous hospital admission, no bleeding

disorder, no pre-existing anaemia

Past Surgical History:

Few episodes of motor vehicle accidents previously, none severe enough to seek medical attention

or hospitalisation. No surgical procedure done except circumcision.

Drug History:

Not on regular prescribed medication, over the counter drugs, traditional medicine or supplements,

no illicit drug use.

Allergy History:

No known food and drug allergy history

Family History:

Parents in their fifties, healthy. No known allergies and medical conditions. He is the 3rd out of 8

siblings. Other siblings are healthy.

Social History:

Currently living with the family in Dungun, economically supported by parents. Student in

polytechnic college. Smoker, since 12 years old, currently 1 pack per day. Has stopped smoking

since he was admitted. Non alcoholic. He is single, and has not been practicing promiscuous

lifestyle.

Physical Examination

Mr. Sharizat is alert, well orientated and cooperative, lying semi-recumbent in the bed, showing no

respiratory distress and not in pain. He was well nourished and hydrated. His right hand was

cannulated with a branula, but not connected to devices or fluids. Left lower limb was elevated by

Bohler Braun frame, with 7.5 kilogram of skeletal traction, pin applied at proximal tibia.

Vital Signs

Pulse rate: 69 beats per minute, normal rate,regular rhythm, good volume

Respiratory rate: 12 breaths per minute, normal

Blood pressure: 116/70 mmHg, normotensive

Body temperature: 36.8 C, normothermia

Pain score: 0/10

General Examination

Head and Face

No scalp tenderness, bleeding and scar, no bleeding through eyes, ears and nose. Pupillary light

reflexes are bilaterally normal. Palpebral conjunctiva was pink and sclera was white. Oral hygiene

was fair, without central cyanosis.

Neck

Active flexion, extension, lateral flexions were in full range. No cervical tenderness, no palpable

neck nodes.

Hand
Hands were warm, pink and dry. Capillary refill time was <2 seconds, Finger clubbing was absent.

Cardiovascular System

Dual rhythm, no murmur.

Respiratory System

No chest scar, deformity, skin changes. Bilateral equal air entry with vesicular breath sounds with

no adventitious sounds.

Musculoskeletal Examination

Back Examination

Patient was unable to ambulate, examination was done sitting.

Look: no swelling, bruises, deformity or skin changes.

Feel: No tenderness over spinous process and paravertebral soft tissues

Move: Limited range of motion, due to pain of left thigh on moving and limitation of the skeletal

traction.

Lower Limb Examination

Look: Right hip was slightly abducted, flexed and knee flexed because right lower limb was

elevated and right leg was rested on Bohler Braun frame. Right distal 1/3 of thigh has step

deformity, however overlying skin was intact, no wound or scar. Proximal tibia was inserted with a

Seinmann pin connected to traction weight through pulley. Site of insertion has no signs of infection

or bleeding, and dressed with acriflavine treated gauze. There is multiple abrasion scar at the

dorsum of right foot, 1st, 2nd, 3rd and 4th toes, measuring average 1cm by 1mm, healed by scab.

There is no swelling, bruises, bleeding and other deformities seen over the right hip, knee joint, leg

and ankle joint. The left lower limb was normal.

Feel: Temperature are equal bilaterally. There is tenderness on deep palpation above and around

the step at the distal 1/3 of right thigh, as well as the 3rd and 4th phalanges of the right foot on light

palpation. Dorsalis pedis and posterior tibial pulses have good volume bilaterally. Capillary refill

time is less than 2 second. Toes are sensitive to touch and pain sensation equally bilaterally. There

is no tenderness over the hip joint, knee joint, ankle joint, and over tibia.
Move: Right lower limb was immobilised, only ankle and foot were mobile. Range of motion was

not full in all movements of right ankle and phalanges while muscle power was reduced to 4/5 in

all movements of right ankle and phalanges. This could be due to the pain a the right 3rd and 4th

phalanges. Left lower limb was normal.

Measure: Apparent length and real length were both shorter at right lower limb compared to left

lower limb, with real length shortening above knee. However, Bryants triangle measurement was

equal bilaterally.

Special tests: Not able to assess.

Upper Limb Examination

Look: There is presence of multiple mixed laceration and abrasion wound at the dorsal aspect of

right arm, elbow, forearm and hand, measuring 4cm by 1cm in length for the largest of them,

located at the elbow, which are all healed and covered by both scab and new skin respectively.

There was no swelling and bruises, bleeding and deformities seen over the shoulder, arm, elbow,

forearm wrist, hand and fingers, however. left upper limb was normal.

Feel: Temperature was bilaterally equal. There was no bony tenderness of the shoulders and right

upper limb, however, there is slight tenderness over the scar on the dorsal aspect of elbow. Radial

and ulnar pulses were adequate, capillary refill time was less than 2 seconds. Touch sensation and

pain sensation were equal and adequate bilaterally.

Move: Full range of motion bilaterally. Muscle power are full bilaterally, Biceps, triceps and

supinator reflexes are normal.

Summary

Mohd Sharizat, 20 year old Malay male with no known medical illness, presented with pain and

numbness over right thigh and inability to mobilise right lower limb after allegedly hit a car on

collision in his bike. On examination, his vital signs were stable. Right lower limb was splinted with

Bohler Braun frame and applied skeletal traction at proximal tibia. There is a step deformity at the
distal 1/3 of the thigh, with tenderness on deep palpation. Movements of right ankle and foot were

restricted. Distal neuromuscular status are intact.

Diagnosis

Provisional Diagnosis

Closed fracture of the right distal 1/3 of femoral shaft.

Points for:

1) Right thigh hit car bumper in high energy collision

2) Pain at the distal 1/3 of right thigh, unable to stand up and mobilise right lower limb.

3) Tenderness and step deformity on the distal 1/3 of right thigh on examination, no overlying

fracture wound.

4) Application of skeletal traction at the level of right proximal tibia.

5) Shortening of real limb length above the knee without disruption of Bryants triangle length

Differential Diagnosis

1) Right Inter-articular fracture of the right femur (AO group Type B and C)

Points for:

1) High energy impact of right lower limb to cars bumper

2) Pain at the region of distal 1/3 of right femur

Points against

1) There is no associated knee joint pain and immobility due to the pain.

2) Absence of evidence of hemearthrosis, bleeding from shaft of femur, signifying inter-articular

type of supracondylar fracture.

2) Supracondylar fracture of the right femur (AO group Type A)

Points for:

1) High energy impact of right lower limb to cars bumper

2) Pain at the region of distal 1/3 of right femur

Points against

1) Absence of knee pain and swelling

3) Medical collateral ligament rupture of the right knee

Points for:

1) The force of impact of car on his right lower limb was causing a valgus force

Points against:

1) There is no pain, tenderness or swelling over the medial side of knee joint

3) Other internal derangement of the right knee joint including knee joint dislocation

Points for:

1) High energy impact of collision between car and his right lower limb

Points against:

1) There is no pain, tenderness, swelling or other skin changes observed.

4) Physeal plate injury of the right distal femur

Points for:

1) Patient is 20 years old, he is still young and physeal plate might not have fused

Points against:

1) There is absence of swelling, deformity, pain and tenderness of the knee.

Investigations

Imaging:

1) X-ray of the skull, cervical spine, right arm, right forearm, right hand, right thigh, right leg, right

knee, right ankle and foot, in anteroposterior, lateral view (ankle and foot with mortise view), to

look for any bone fracture, joint dislocation or soft tissue injury. Any reduced fracture and

dislocation will have to be x-rayed again to make sure the reduction is adequate.
2) X-ray of the chest and pelvis, both in AP view (patient bedbound, not likely to take PA chest), to

look for any rib fracture, any signs of lung contusion, pneumothorax, hemothorax, cardiac

tamponade, flail chest, aortic dissection in chest, and pelvic fracture or acetabular fracture in

pelvis, all of which indicate emergencies.

Lab Investigations

1) Full blood count: to detect anemia, either due to acute blood loss of shaft of femur, or

underlying anemia, which shall be treated accordingly. Baseline platelet level, as pre-op

assessment, white blood cell count and differential, to detect infections secondary to open

wounds.

2) Blood group and cross match: for transfusion in case of haemorrhage from the femoral fracture

or for surgical procedure.

3) Coagulation profile: To detect underlying coagulopathy leading to undetected incessant post-

traumatic internal haemorrhage and as preparation as pre-op assessment.

4) Blood urea and serum electrolytes and creatinine, liver function test, thyroid function test, as

pre-operative assessment

Investigation Results

X rays

Chest X-ray, AP Supine, taken on 19th September

Appears normal, no fracture of the clavicles, chest ribs, no pneumothorax, hemothorax and cardiac

tamponade.
Pelvis X-ray, AP position, taken on 19th September

Pelvic ring appears to be intact, no acetabular, head and neck of femur, intertrochanteric femur

fractures. No femur head dislocations. Artefact is most probably a Thomass splint.

Skull X-ray, AP and Lateral view, taken on 19th September

Skull bones appears to be intact, no fractures noticed.

Cervical Spine X-ray, AP and Lateral view, taken on 19th September

Cervical spine appears to be normal, no fractures or dislocation seen.

Right forearm AP and Lateral View, Right elbow AP view, taken at HSNZ on 19th September

All appears to be normal, no elbow joint dislocation, no fractures seen.

Right knee AP and Lateral view, taken on 19th September

Knee joint appears to be normal, no dislocations, patella no fracture, no supracondylar femur, no

proximal tibia fracture. The artefact is most probably a splint.

Right Femur X-ray AP view (left) and Lateral view (Right), taken on 19th September

On the anteroposterior view of the x-ray of femur, there is incomplete inclusion of hip joint and knee

joint into the film. There is presence of spiral comminuted fracture at the distal 1/3 of femur, with

medial displacement of middle fragment and lateral angulation of the distal fragment. Soft tissue

swelling is seen around the fracture site, however comparison with left femur x-ray AP view is

needed.

On the lateral view of the x-ray of femur, there is no inclusion of hip joint but knee joint was

included. Spiral comminuted fracture is present at the distal 1/3 of femur, with posterior

displacement of middle fragment. There is posterior shift and anterior angulation of the distal

fragment of the femur, as well as overlapping of distal fragments beneath proximal fragment.

Impression: Winquist Type 4 Fracture of the shaft of femur

Points for:

Segmental fracture of the femur, with no cortical contact between proximal and distal fragments.
Right Foot AP view, zoomed in by camera, taken on 19th September

Complete transverse fracture, with lateral shift of distal fragment seen at the neck of 3rd and 4th

proximal phalanges.

Laboratory tests

Full Blood Count

a. Total white cell 10.5x109/L (HIGH, range 4.0-10.0)

b. Total red cell 3.93x1012/L (LOW, range 4.5-5.5)

c. Hb 103.0g/dL (LOW, range 130-170)

d. HCT 43% (normal)

e. MCV 81.6fL (LOW, range 83-101)

f. MCH 26.3pg (LOW, range 27-32)

g. MCHC 322g/L (normal)

h. Platelet counts 200x109/L (normal)

i. Neutrophils 69.3% (normal)

j. Lymphocytes 22.3% (normal)

k. Eosinophils 2.9% (normal)

l. Monocytes 3.8% (normal)

Regarding the slight anaemia detected from the full blood count, it is highly recommended to do an
iron study to determine the cause of microcytic anaemia. Due to the fact that patient was not
bleeding during and after the accident, also with the exclusion of underlying chronic illness, it could
be due to pre-existing iron deficiency, or it could be due to underlying carrier of Beta-Thalassemia,
which is quite a common cause of microcytic anaemia in Malaysia.

Slightly elevated total white blood cell count is also a normal phenomenon considering the fact that
Sharizat underwent poly trauma and fracture as well as an episode of fever resolved with antibiotic
(highly suggesting of infective cause).

Blood Urea, Serum Electrolytes and Creatinine

a. BUN 3.2mmol/L (normal)

b. Sodium 134mmol/L (normal)

c. Potassium 3.6mmol/L (normal)

d. Chloride 106mmol/L (normal)

e. Creatinine 76mmol/L (normal)

Blood Coagulation Profile

a. PT - 16.8 second (HIGH, range 10-15)

b. INR - 1.33 (normal)

c. APTT - 42.0 (HIGH, range 29-40)

d. APTT ratio - 1.31 (normal)

Final Diagnosis

1) Closed comminuted fracture of distal 1/3 of right femur shaft.

2) Closed transverse fracture of 3rd and 4th neck of proximal phalanges of right foot.

Management

At the Emergency Department:

1) Triage into Yellow zone: patient is alert, conscious upon arrival of Accident and Emergency
department.

2) Airway: Jaw thrust, look for saliva, blood and clots, suck it out, secure a nasopharyngeal tube,
3) Breathing: Look out for tachypnea, dyspnea, paradoxical chest wall movement tracheal shift,
auscultate lung field for equal air entry, percuss lung, to look out for pneumothorax,
hemothorax, flail chest, and treat accordingly, adjunct include put on pulse oximetry, to look for
oxygen saturation status. Arterial blood gas, if needed, to look for possible metabolic acidosis
due to hypovolemic shock or respiratory distress due to lung trauma. Give face mask with
oxygen as supplementation, to reduce breathing effort and increase perfusion need.

4) Circulation: Assess pulse rate for tachycardia or bradycardia, assess peripheral pulses for
pulse volume, peripheral perfusion by capillary refill time, look for obvious bleeding wound, to
detect hypovolemic shock due to bleeding. Set up gauge 14 branula and start infusion of
Ringers lactate as replacement of fluids. Electrocardiogram, to detect any heart rhythm that is
erratic due to traumatic injury to the heart.

5) Disability: Assess patients Glasgow Coma Scale (GCS) score to detect underlying possible
underlying traumatic brain injury, and investigate accordingly, for CT scan of brain. Nasogastric
tube insertion for suction and decompression of stomach to prevent later on drop in GCS score
and cause aspiration of gastric content to tracheobronchial tree.

6) Exposure: to remove attire that is sticking with debris and contaminated with the road while
maintain body temperature by sufficient covering with clothing. Look for bleeding sites other
than the sites of massive bleeding, clean and irrigate wound, do compression with clothing to
stop bleeding.

7) Start history taking with AMPLE (food and drug allergies, medications taken currently, pre-
existing medical problems, last oral intake and events leading to the incident.

8) Do full physical examination, including neurological and musculoskeletal system examination

(head and scalp wound and tenderness, spinal tenderness and steps, limb movement and
power, sensation), and also anal sphincter tone as well as high rising prostate due to pelvis
fracture. Urethral meatus for blood due to urethral injury.

9) Reduce the fracture of femur and splint the right lower limb in fixed traction in a Thomass
splint while in transfer for X-ray chest and pelvis, to rule out undetected life threatening
fractures, and also the X-ray mentioned above in investigation section.

Supportive and Interim Management

1) Nil by mouth until patient is stable clinically, emergency surgery is completed or expected,
elective surgery is scheduled. Depending on severity, may start infusion of dextrose saline.
Start feeding once gag reflex is fully functional.

2) Start analgesic, preferably Non steroidal anti-inflammatory drug, such as diclofenac 50mg 3
 times per day with meal.

3) Thromboembolic prophylaxis started, with patient exercise of limbs and joints that are able to
move, use graduated compression stockings for the left lower limb, counselling to stop
smoking.

4) Insert continuous bladder catheter for monitoring of input and output of fluids. Strict fluid input
and output monitoring.

5) To look out for symptoms and signs of immediate complication of haemorrhage of femur shaft
fracture and fat embolism and subsequent acute respiratory distress syndrome.

6) To start prophylactic antibiotics with broad spectrum coverage/according to local guidelines of

Terengganu, due to multiple open injuries, and also prior to insertion of Steinmann pin for
skeletal traction.

7) Convert fixed traction to balanced traction for splinting of the distal fracture of right femur.

8) Give anticholinergic to prevent defecation due to inability to ambulate.

9) Removal of continuous bladder catheter once able to urinate into container.

10) Daily wound cleaning and wound dressing.

Definitive Management

1) After hepatoma, swelling and inflammation of the fracture site has subsided, open reduction
and internal fixation with intramedullary nail and interlocking screws, under general anesthesia.

2) Post-operatively, opioid (morphine) patient controlled analgesia for a few days, depending on
patients condition, then step down to celecoxib 200mg twice a day.

3) Prophylactic antibiotic cover according to local guideline (cefuroxime)

4) Allow early right lower limb joints exercise without weightbearing, to prevent joint stiffness.

5) Discharge when patient is well, feeling improvement in pain, lacking of post-op fever.

6) Follow-up 1 week, 2 weeks, 1 month for 3 months and 3 monthly afterwards for initial
assessment of wound healing, fracture healing and pain monitoring.

7) Allow partial weight bearing when callus forms around fracture site, about 6 weeks post
operation.

8) Look out for malunion, delayed/non-union, refractor and implant failure.

9) For the fracture of neck of 3rd and 4th proximal phalanges of right foot, splinting by strapping
of 3rd toe with 2nd toe and 4th toe with 5th toe for immobilisation and reduction of pain.
 Walking is encouraged, for faster healing. Strapping for 3 weeks is recommended.

Discussion

The fractured shaft of right femur is due to the high energy impact of himself during collision with
the bumper of car. Due to the large muscle bulk, reduced fracture will always be displaced when
contraction of muscles occur, so internal fixation is needed to splint the reduced fracture.

Talking on definitive treatment, in Sharizats case, in which he is relatively stable clinically, use of
intramedullary nail with interlocking screw seems to be a good choice, with an objective in mind:
intramedullary nail provides stronger axial loading support than other options, which is good for
early weight bearing exercise and ambulation with lower possibility of implant failure. Interlocking
screw serves the purpose of preventing angulation and rotational movements. Early weight bearing
and ambulation can promote healing by initiate micro movements at the callus site, while in the
meantime prevents hip and knee joint stiffness and chronic muscle disuse atrophy. Except for
minimally invasive plate osteosynthesis (MIPO), insertion of plate and screw will delay healing by
stripping off periosteum and ridding off blood supply to fracture site. Cast does not help due to the
fact that the fracture is easily displaced, leading to malunion.

Since he was delayed admission, being diagnosed with microcytic anemia and due to the fact that
elective surgery requires time arrangement, the fracture site has already developed into
hematoma, later on into into inflammatory then fibrocartilaginous tissue, injured tissue swelling
seems to be present and this increases injury to the patient systemically and locally if he is
subjected to immediate operation. Hence, a balanced skeletal traction is applied as a makeshift
measure and awaiting swelling to subside, optimising physiological condition for surgery.

While most complications are mentioned above, its worth noting that extra care for possible
infection of the surgical site. Any susceptive infection of the bone, patient should be managed as
osteomyelitis following the local guideline.

Fracture of toe is usually disregarded and patient will be encouraged to walk in a supportive boot
or shoe. However, Sharizat feel pain and tenderness over the toes, hence it is recommended to
splint the fractured toes to the neighbouring toes by strapping to reduce pain and improve healing
of the fractures.