• P/W: alleged MVA (MB vs car) – Was riding motor, wearing helmet, moderate speed – Was hit by car from the back – He was thrown away, fell on the side of road – Post trauma: unable to ambulate, multiple abrasion wound bilateral hand, forehead and foot • Went to ETD on 16/7/15 – O/E of right lower limb (On portable traction) • DPA/PTA palpable • CRT <2” • Able to move all toes • Tender over right knee, swollen • Multiple abrasion at dorsum right foot and leg • T&S done over dorsum right foot – O/E bilateral hands • Multiple abrasion wound • Able to move all fingers, full ROM • Xray right femur – supracondylar fracture of right femur • Was put on skin traction x 1/7 – Calcaneal pin inserted on PTD 1 skeletal traction 5kg • T&S done over bilateral hand • Plan for distal femoral locking plate • Noted ABG Type 1 respiratory failure referred to medical, suggested to refer anaesth for NIV support – Imp: Non infective AECOAD, unlikely lung contussion – Put on VM 40% 10L • CT brain: suspicious right tentorium cerebri subdural bleed – d/w neuroHKL – conservative mx, to start T. Dilantin • PTD 4, refered to anaesth for pre op assesment (27/7/15 – PTD 11) postponed for 1/52 in view of lung condition. • Re-refered back to anaesth on PTD8 for op as planned at HTAN • Done distal femoral locking plate of right femur – Intra op: supracondylar fracture of right distal femur with medial comminution • Reduced under i/I guidance • Distal femoral locking plate 7 holes inserted with screws – locking 5.0mm, 38x4, 60x1, 65x1, 70x1, 75x1 • Synthetic bone graft (granumas) 3cc inserted into bone gap • Progress in ward – On IV Zinacef 750mg TDS x 5 days – On epidural x 3 days, Iv tramal, t. pcm – Circulation chart in ward – Elevation of right lower limb – DT off on day 1 post op – WI D3 (30/7/15) • CRT <2”, Sensation intact, DPA/PTA palpable, No foot drop, Wound clean – STO D14 (10/8/15) – Discharge on 1/8/15 (POD5) • T Zinnat x 1/52 • TCA 3/52 XOA • Daily dressing at KK Trauma Day – 20/7/15
Case 2 PTD – D2
• 22 years old, Malay, Male, U/L bronchial
asthma • P/w: alleged MVA – Pt a MB rider, helmet, speed – ? MB skidded – Unsure mechanism • Post trauma sustained – + LOC – unsure duration (regained conciousness @ hosp – + retrograde amnesia – Pain over left upper limb and lower limb • Went to ETD HJEM – Left Upper limb • Laceration wound over dorsal aspect of right finger T&S done • Wound clean no discharge • Put on above elbow POP • Sensation intact • Able to move all fingers – Left lower limb • Laceration wound ant aspect of left knee T&S done ~ 4cm • Suture intact, serous discharge • Multiple abrasion wound • Laceration wound over dorsal lateral ascpect of left foot T&S done • Laceration wound 2nd toe ~4x0.5cm T&S done, mildly • Xray of left hand – Comminuted fracture of distal end of left radius ulna styloid • CMR done, check xray acceptable • Put on above elbow POP – Fracture midshaft of left 5th MCB • Xray of left foot – Fracture of base of proximal phalanx of 2nd toe • Xray left ankle – Bimaleolar fracture left ankle • PTD 1 – underwent: – open reduction + 1/3rd tubular plating of left lateral maleolus – Open reduction + screw fixation of left medial maleolus – WD, WE, T&S of laceration wound of left 2nd toe – Ext fixation & k-wire of left radius • Intraop – Left radius/ulna • Noted communited fracture over distal end of radius • Attempted buttress plating but failed to reduce in view of very communited fracture • Proceed with ext. fix of distal radius-ulna with 2 k-wire inserted • Fracture reduced under i/i • Intraop – Medial malleolus • Fracture of medial malleolus with min. comminution • 2 cancellous screws inserted size 45, 50 • Fracture reduced under i/I – Lateral malleolus • Noted fracture of distal end of lat. Malleolus • 1/3rd tubular plating (7holes) inserted • Cotton test negative • 6 screws inserted – 14x3, 16x2, 20x1 – Left foot • Noted fracture of proximal phalanx of 2nd toe • Progress in ward – On IV Zinacef completed 1/52 – WI D3 (31/7/15) • Xxx – PCA morphine off D3, C. celebrex, T. PCM – Ice compression and elevation left upper limb, lower limb – Check xray Left hand : left wrist slightly displaced dorsally – Plan for variable angle locking plate over left hand – Dermasyn + CMC EOD over suture site, flavin over pin site – STO D14 (12/8/15) Case 3 • Mr I, 29, Malay, Male • History of MVA in Oct 2014, sustained – Closed fracture midshaft of right humerus u-slab – Closed fracture midshaft left femur done ILN – Open fracture midshaft left tib/fib on ext fix, then full length POP – OP done at HTJ, under HTAN follow up • P/w – Alleged MVA (car vs car) – Pt was back passenger, not wearing seatbelt – The car hit the back of front car – Pt fell forward with left knee hit front sit • Post trauma – Unable to ambulate due to pain • Went to ETD HJEM – Left lower limb: tender over left knee and bilateral malleolar, swollen, reduced ROM due to pain – CRT<2”, sensation intact, able to move all toes • Xrays – CXR: old fracture neck of right scapular – Left femur: comminuted fracture supracondylar of left femur, implant insitu – Left tib/fib: old comminuted fracture left fibula, old fracture shaft of left tibia – Right humerus: old fracture midshaft of right humerus – Left ankle xray: old fracture left talus and calcaneum, degenerative changes of left ankle joint • Was put on skin traction 5kg over left leg • PTD 14 (31/7/15): done removal of ILN of left femur, distal femoral locking plate of left femur with synthetic plus iliac bone graft. • Intraop finding – Removal of ILN under i/I guidance, 4 locking screws and 1 nail – Noted fracture over supracondylar of left femur – Distal femoral locking plate (7 holes inserted) • Screws 5.0mm: 85x4, 42x3, 40x1 – Noted bone defect lateral cortex of old fracture of femoral shaft of femur – Synthetic plus iliac bone graft 5cc inserted • Progress in ward – EBL 3.8L, intraop transfused 4pints PC • Hb 12.8 12.8 10.3 12.2 – Antibiotic IV Zinacef x 5/7 – DT A & B was removed on POD1 – Analgesic: PCA morphine, C. Celebrex, T. PCM – WI D3 (3/8/15) – STO D14 (14/8/15) – Distal circulating chart – Elevate left lower limb, ice compression – SNWB Thank you