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CENCUS

15/7/15 – 21/7/15
Trauma Day – 16/7/15

Case 1 Post trauma D

• 74, Chinese, Male, NKMI


• 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

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