CASE WRITE UP : FRACTURE SHAFT OF FEMUR

CASE WRITE UP : FRACTURE SHAFT OF FEMUR

PATIENT PROFILE :

Name: Mr C

Age: 42 years old                                                          

Sex: Male

Race: Malay

Address: Melaka

Occupation: Factory worker

Date of Admission: 1^st June 2009

Date of Examination: 3^rd June 2009

CHIEF COMPLAINTS :

Pain at the right thigh for 1 day.

Swelling at the right thigh for 1 day.

HISTORY OF PRESENTING ILLNESS :

Patient was apparently well since 2 day ago when he was involved in a motor vehicle accident. He was riding his motorcycle with a helmet on, at a speed of 50 km/hour when suddenly a car in front of him applied the brakes. Patient then hit the car at the back and fell with his bike and his right lower limb got stuck under his motorcycle. Patient had bruises on the medial side of his right thigh and lacerations on the lateral aspect of his right thigh and he was bleeding profusely. Patient noticed a deformity of his right thigh of which he could see his bone protruding. Patient was then brought to the A&E department by car and suturing was done for the laceration on the lateral aspect of his right thigh. He was given analgesics for the pain and X-ray was taken.

Patient felt pain at his right thigh for 2 days which was maximally felt at the proximal 2/3^rd, sudden in onset, severe, continuous, and throbbing type, which progressively worsened. There was no radiation of pain. The pain increases upon movement of the limb. The pain is relieved upon rest.

Swelling was present throughout the whole right thigh. The swelling was seen immediately after the accident with no progression.

          

Patient was also unable to bear his own weight and was unable to walk following the accident.

There is no history of loss of consciousness, no vomiting, no headache, no blurring of vision or breathlessness, bleeding from ears, nose, and throat, and no injuries sustained to other parts of his body. There is no loss of sensation or any skin changes distal to the site of swelling. There is no associated breathing difficulty or abdominal pain following the accident.

PAST HISTORY :

Patient has no significant past history, no past history of allergy to any drugs.

No history of diabetes mellitus, hypertension, ischemic heart disease, asthma, malignancies or tuberculosis.

PERSONAL HISTORY :

Patient’s sleep has been disturbed due to the pain. He has also lost his appetite since admission to hospital. Patient is catheterized and has not passed stools since admission. Patient has been smoking for the past twenty years and he smokes 10 sticks per day. Patient does not consume alcohol and there is no history of drug abuse.

FAMILY HISTORY :

Patient’s father passed away due to old age of which patient is not aware of the cause. Patient has two siblings who are alive and well.

There is no family history of diabetes mellitus, hypertension, ischemic heart disease or tuberculosis.

SOCIAL HISTORY :

Patient stays in a terrace house which has 3 rooms with 2 toilet of both squatting and sitting type and lives with 5 of his friends and is about 30 minutes drive away from the hospital. Patient earns around RM 1200 per month.

Working Diagnosis :

1.      Post traumatic, displaced, open fracture of the middle 1/3^rd of shaft of right femur without any neurovascular deficit.

Reasons: Injury after direct impact on the right thigh, open wound, pain at proximal 2/3^rd and swelling at the right thigh and inability to bear weight indicates fracture. There is deformity at the right thigh. There is no loss of sensation or skin discolouration distal to the swelling.

2.      Post traumatic, displaced, open fracture of the upper 1/3^rd of shaft of right femur without any neurovascular deficit.

Reasons: Injury after direct impact on the right thigh, open wound, pain at proximal 2/3^rd and swelling at the right thigh and inability to bear weight indicates fracture. There is deformity at the right thigh. There is no loss of sensation or skin discolouration distal to the swelling.

EXAMINATION

GENERAL EXAMINATION :

Patient is conscious, co-operative, moderately built and moderately nourished, lying down in supine position. There is an iv cannula inserted on the dorsum of his left hand. There is an upper tibial skeletal traction with a 5kg weight attached to it.

There is no pallor, icterus, cyanosis, finger clubbing, and no lymphadenopathy. There is no spine tenderness. There is bruises on his medial side of right thigh and laceration on the lateral side of his right thigh.

Vital signs :

            Blood pressure: 126/86 mmHg

            Pulse: 78 beats/ min

            Respiratory Rate: 20/ min

            Temperature: 37 ºC

SYSTEMIC EXAMINATION :

Cardiovascular Examination:

S1, S2 heard, no murmurs heard.

Respiratory Examination:

Vesicular breathing heard with no added sounds.

Abdominal Examination:

No abdominal tenderness, no organomegaly.

Bowel sounds heard.

Central nervous system:

            Grossly intact.

LOCAL EXAMINATION :

Inspection :

Gait - Could not be assessed as patient was on traction.

Attitude - Patient was supine with right hip flexed 30 degrees and internally

    rotated, right knee flexed twenty degrees and right ankle plantar flexed

    twenty degrees.

Deformity - No deformity seen

Skin - There are abrasions on the upper part of medial aspect of his right thigh

           measuring about 10cm× 7cm which has been dressed. The right thigh

           appears swollen. There are signs of inflammation. There are no sinuses or

           ulcer or dilated veins.

Limb length discrepancy - There is no limb length discrepancy seen.

Palpation :

Temperature - There is a rise of temperature of his right thigh in comparison to

other parts of the body.

Tenderness - There is bony tenderness present on the upper 2/3^rd of his right

          thigh. 

There is no thickening and irregularity or any gap felt.

Swelling - There is diffuse swelling of the whole right thigh.

There is no abnormal mobility or crepitus.

Movements :

Patient could not move the right limb as he was on traction and due to tenderness.

Movements	Left		Right
	Active	Passive	Active	Passive
Hip joint
Flexion	0 - 130 º	0 - 130 º	Restricted	Restricted
Extension	0	0	Restricted	Restricted
Abduction	0 - 40 º	0 - 40 º	Restricted	Restricted
Adduction	0 - 20 º	0 - 20 º	Restricted	Restricted
External Rotation	0 - 45 º	0 - 45 º	Restricted	Restricted
Internal Rotation	0 - 30 º	0 - 30 º	Restricted	Restricted
Knee joint
Flexion	0 - 130 º	0 - 130 º	Restricted	Restricted
Extension	0	0	Restricted	Restricted
Ankle joint
Dorsiflexion	0 - 30 º	0 -30 º	0 - 20 º	0 -20 º
Plantar flexion	0 - 45 º	0 -45 º	0 - 20 º	0 -20 º
Subtallar joint
Inversion	0 - 40 º	0 - 40 º	Restricted	Restricted
Eversion	0 - 40 º	0 - 40 º	Restricted	Restricted
Movement of toes	Full range	Full range	Full range	Full range

Measurements :

Measurements	Right	Left
Apparent length (xiphisternum to medial malleolus	108 cms	110cms
True length (Anterior Superior iliac spine to medial malleolus)	84cm	86cm
Femur length (Anterior Superior iliac spine to medial joint line)	50cm	52cm
Tibial length (Medial joint line to medial malleolus)	34cm	34cm
Thigh circumference	48cm	46cm

Distal neurological status :

There is no distal neurological deficit. Active range of movements of toes and ankle present and there is no loss of sensation of the lower limbs. Muscle power grade V.

Distal vascular status :

There is no distal vascular deficit. Dorsalis pedis artery and posterior tibial artery could be felt  and there is no distal limb coldness and capillary feeling time is less than 3 seconds on both lower limbs.

Differential Diagnosis :

• Post traumatic, open fracture of the upper 1/3^rd of the shaft of the right femur without any neurovascular deficit.

Reasons: Injury after direct impact on the right thigh, open wound on upper part of medial aspect of thigh, pain at the upper 1/3^rd of thigh, and shortening. Swelling and bony tenderness at the upper 1/3^rd of the femur indicates fracture of the right femur. There is no loss of sensation or skin changes distal to the site of fracture.

• Post traumatic, open fracture of the middle 1/3^rd of the shaft of the right femur without any neurovascular deficit.

Reasons: Injury after direct impact on the right thigh, open wound on upper part of medial aspect of thigh, pain at the middle 1/3^rd of thigh, and shortening. Swelling and bony tenderness at the middle 1/3^rd of the femur indicates fracture of the right femur. There is no loss of sensation or skin changes distal to the site of fracture.

Investigations :

Full blood  count, WBC, RBC, Hb, HCT, MCV, MCH, MCHC, platlet, lymphocyte, blood sugar levels, blood urea and serum electrolytes.

Plain x-ray of skull, pelvis and right thigh with hip joint, both anterior-posterior and lateral view was done. Plain x-ray of right thigh with hip joint showed fracture at the upper 1/3^rd of the shaft of right femur. Plain x-ray of skull and pelvis were normal.

Patient on tibial skeletal traction

This is the anterposterior view of the right femur showing a comminuted fracture of the upper 1/3^rd of right shaft of femur.

FINAL DIAGNOSIS :

Post traumatic, displaced, comminuted, open fracture of the upper 1/3^rd of the shaft of the right femur without any neurovascular deficit.

SUPRAPUBIC BLADDER TAP

SUPRAPUBIC BLADDER TAP


Preparation :

• Dressing set
• Needle size 21, 23
• Syringe 5cc
• Urine culture bottle

Indication :

-Urine culture in young infant

Complications :

1. Microscopic hematuria
2. Infection
3. Viscus perforation

Procedure :

1. Make sure bladder is palpable. If needed, encourage patient to drink half to 1 hour before procedure.
2. Position the child in supine position.
3. Clean and drape the lower abdomen.
4. Insert the needle attached to a 5cc syringe perpendicular or slightly caudally to the skin, 0.5 cm above the suprapubic bone.
5. Aspirate while advancing the needle till urine is obtained.
6. Withdraw the needle and syringe.
7. Pressure dressing over the puncture site.
8. Send urine for culture.

CHEST TUBE INSERTION

CHEST TUBE INSERTION

Preparation :

• Suturing set
• Local anaesthetic +/- sedation
• Chest tube, appropriate size
• Underwater seal with sterile water
• Suction pump

Indications :

1. Pneumothorax with respiratory distress
2. Significant pleural effusion
3. Empyema

Complications :

1. Bleeding
2. Nerve injury
3. Injury to the nearby structures e.g. lung, heart, large vessels, liver
4. Subcutaneous emphysema
5. Infection

Procedure :

In open method, after making the skin incision, continue to dissect the tissues till the pleura is seen.

1. Sedate the child.
2. Position the child with ipsilateral arm fully abducted.
3. Clean and drape the skin.
4. Infiltrate LA into the skin at 4th ICS, AAL or mid axillary line.
5. Make a small incision just above the rib down to the subcutaneous tissue.
6. Place the tip of the chest tube at the incision, point the tip anteriorly for drainage of air and posteriorly for drainage of empyema. Slowly advance the chest tube with introducer by exerting a firm continuous pressure until a ‘give’ is felt.
7. Remove the introducer and advance the chest tube till the desired length.
8. Connect the chest tube to underwater seal. The water should bubble (for pneumothorax) and fluid move with respiration if the chest tube is in the pleural space.
9. Secure the chest tube with pulse string sutures.
10. Connect the underwater seal to suction pump if necessary.
11. Confirm the position with CXR

Size of chest tube mm :

8 for <2kg
10 for >2kg
Older children : 12-18 depending on size

INTRAOSSEOUS ACCESS

INTRAOSSEOUS ACCESS

Preparation :

• sterile dressing set
• intraosseous needle
• syringes for aspiration
• local anesthetic

Indications :

• Emergency access for IV fluids and medications when other methods of vascular access failed.

Complications :

1. Cellulitis
2. Osteomyelitis
3. Extravasation of fluids/compartment syndrome
4. Damage to growth plate

Procedure :

1. Immobilize the lower limb.
2. Support the limb with linen
3. Clean and draped the area
4. Administer local anesthetic at the site of insertion
5. Insert the intraosseous needle 1-3 cm below and medial to the tibial tuberosity caudally.
6. Advance the needle at an angle of 60-90 degrees away from the growth plate until a ‘give’ is felt.
7. Remove the needle trocar stylet while stabilizing the needle cannula.
8. Withdraw bone marrow with a 5cc syringe to confirm access.
9. Connect the cannula to tubing and IV fluids. Fluid should flow in freely
10. Check for any extravasation of fluids.

Notes :

1. Intraosseous infusion can be used for all age groups.
2. The most common site for IO cannulation is the anterior tibia (all age groups).

Alternate sites include :

a. Infant – distal femur
b. Child – anterior superior iliac spine, distal tibia.
c. Adolescent/adult - distal tibia, medial malleolus, anterior superior iliac spine, distal radius, distal ulna.
3. All the fluids and medications can be given intraosseously.
4. Intraosseous infusion is not recommended for use longer than a 24 hour period.

ARTERIAL BLOOD SAMPLING & PERIPHERAL ARTERIAL LINE CANNULATION

ARTERIAL BLOOD SAMPLING & PERIPHERAL ARTERIAL LINE CANNULATION


Preparation :

• Topical anaesthetic (TA)
• Alcohol swab
• Needle size 27
• Catheter size 25
• Heparinised saline in 5cc syringe, T-connector
• Heparinised saline (1 u/ml) for infusion

Indications :

1. Arterial blood gases
2. Invasive blood pressure monitoring
3. Frequent blood taking

Complications :

1. Arteriospasm which may lead to ischaemia and gangrene.
2. Neonates especially – digital and limb ischaemia which can lead to partial and complete limb loss.

Procedure :

1. Check the ulnar collateral circulation by modified Allen test.
2. The radial pulse is identified. Other sites that can be used are posterior tibial and dorsalis pedis artery.
3. A topical anaesthetic may be applied half an hour before procedure.
4. Clean the skin with alcohol swab.
5. Dorsiflex the wrist slightly. Puncture the skin and advance the catheter in the same direction as the radial artery at a 30-40 degrees angle.
6. The catheter is advanced a few millimetres further when blood appears at the hub, then withdraw the needle while advancing the catheter.
7. Aspirate to ensure good flow, then flush with heparinised saline.
8. Peripheral artery successfully cannulated.

• Ensure that the arterial line is functioning. The arterial pulsation is usually obvious in the tubing.
• Connect to T-connector and 3-way stop-cock to a syringe pump.
• Label the arterial line and the time of the setting.

9. Run the heparinised saline at an appropriate rate:

• 0.5 to 1.0 mL per hour for neonates.
• 1.0 mL (preferred) or even up till 3.0 mL per hour for invasive BP line (to avoid backflow in bigger paediatrics patients).

10. Immobilize the joint above and below the site of catheter insertion with restraining board and adhesive tape.


Precaution - Prevention of digital & limb ischaemia :

1. AVOID end arteries e.g. brachial (in cubital fossa) and temporal artery (side of head) in babies (BEWARE - both these arteries can be accidentally cannulated and mistaken as ‘veins’).

2. Test for collateral circulation

• If a radial artery is chosen, please perform Allen’s test (to confirm the ulnar artery collateral is intact) before cannulation.
• If either the posterior tibial or dorsalis pedis artery on one foot is chosen, ensure that these 2 arteries are palpable before cannulation.

3. Circulation chart
Perform observation and record circulation of distal limb every hour in the NICU
and PICU, and whenever necessary to detect for signs of ischaemia, namely:

• colour - pale, blue, mottled
• cold, clammy skin
• capillary refill > 2 seconds

4. Treatment of digital / limb ischaemia

• This is difficult as the artery involved is of small calibre.
• Refer vascular surgeon if available / orthopaedic surgeon.
• May consider warming the contralateral unaffected leg to induce reflex vasodilatation if part of one leg is affected (see section on UAC).
• Anticoagulant drugs and thrombolytic agents are unlikely to be beneficial.

5. Reminder

• Prevention of limb ischaemia is of utmost importance.
• Early detection of ischaemia is very important in order to avoid irreversible ischaemia.
• If the patient is in shock, the risk of limb ischaemia is greater.
• Small and preterm babies are at greater risk for ischaemia.
• The risk of limb ischemia is greater with fast infusion rate (e.g. > 1 ml per hour).
• No fluid or medication other than heparinized saline can be given through arterial line. This mistake can occur if the line is not properly labelled, or even wrongly labelled and presumed to be a venous line.

VENEPUNCTURE & PERIPHERAL VENOUS LINE

VENEPUNCTURE & PERIPHERAL VENOUS LINE

Preparation :

• Alcohol swab
• Topical anaesthetic (TA)
• Catheter or needle; sizes 25, 23, 21 G
• Tourniquet
• Heparinised saline, T-connector, rubber bung for setting an IV line

Indications :

1. Blood sampling
2. Intravenous fluid, medications and blood components

Complications :

1. Haematoma or bleeding
2. Thrombophlebitis
3. Extravasation of fluid or medications – this might lead to skin necrosis and gangrene. Neonates especially – digital ischaemia and even partial limb loss, nerve damage, contractures of skin and across joints

Procedure :

1. Identify the vein for venepuncture. Secure the identified limb and apply tourniquet or equivalent.
2. TA may be applied half an hour earlier.
3. Clean the skin with alcohol swab.
4. Puncture the skin and advance the needle or catheter in the same direction as the vein at 15-30 degrees angle.
5. In venepuncture, blood is collected once blood flows out from the needle. The needle is then removed and pressure applied once sufficient blood is obtained.
6. In setting an intravenous line, the catheter is advanced a few millimetres further. Once blood appears at the hub, then withdraw the needle while advancing the catheter.
7. Remove the tourniquet and flush the catheter with heparinised saline.
8. Secure the catheter and connect it to either rubber bung or IV drip.
9. Immobilise the joint above and below the site of catheter insertion with restraining board and tape.

Precaution - Extravasation

1. Signs include:

• pain, tenderness at insertion site especially during infusion or giving slow bolus drugs.
• redness
• swelling
• reduced movement of affected site.

(Note – the inflammatory response can be reduced in neonates especially preterm babies)

2. Observation

The insertion site should be observed for signs of extravasation:
• at least every 4 hours for ill patients.
• sick preterm in NICU – observation should be done more often, that is, every hour.
• each time before, during and after slow bolus or infusion.
(Consider re-siting the intravenous catheter every 48 to 72 hours)

3. If severe extravasation occurs, especially in the following situation:

• preterm babies
• delay in detection of extravasation
• hyperosmolal solutions or irritant drugs used (glucose concentration >10%, sodium bicarbonate, calcium solution, dopamine)

Refer to plastic surgeon / orthopaedics surgeon. Consider performing ‘subcutaneous saline irrigation’ especially for neonates. The drug hyaluronidase is not readily available. Therefore please use normal saline to flush out as much of the irritant drugs as possible

4. Reminder

• If the patient is in shock, the venous flow back and the arterial flow (in case of accidental cannulation of an artery) is sluggish.
• BEWARE! An artery can be accidentally cannulated, e.g. the brachial artery at the cubital fossa and the temporal artery at the side of the head of a neonate.
• Ensure the drug prescribed is given by the proper mode of administration. Some drugs can only be given by slow infusion (e.g. fusidic acid) instead of slow bolus in order to reduce tissue damage from extravasation.

ENDOTRACHEAL INTUBATION

AIRWAY ACCESS - ENDOTRACHEAL INTUBATION

(Please requests for assistance from the Anaesthetic Doctor if necessary)

Preparation :

• Bag and mask with high oxygen flow
• Laryngoscope
• Blades: straight for infant, curved for older child,
• size 0 for neonates, 1 for infants, 2 for children
• Endotracheal tube – appropriate size as shown
• Stylet (optional)
• Suction catheter and device
• Scissors and adhesive tape
• Pulse oximeter
• Sedation ( midazolam or morphine)
• Muscle relaxant (succinylcholine)

Note: The relative contra-indications for succinylcholine include increased intra-cranial pressure, neuromuscular disorders, malignant hyperthermia, hyperkalaemia and renal failure.

Size of ETT (mm):
2.5 for <1 kg
3.0 for 1-2 kg
3.5 for 2-3 kg
3.5-4.0 for >3 kg

Oral ETT length in cm for neonates : 6 + (weight in kg) cm

For children over 1 year: ETT size in mm = 4 plus (age in years / 4)

Oral ETT length in cm = 12 plus (age in years / 2)

Indications :

1. When bag and mask ventilation is insufficient
2. For prolonged positive pressure ventilation
3. Direct suctioning of the trachea
4. To maintain and protect airway
5. Diaphragmatic hernia (newborn)

Complications :

1. Esophageal intubation
2. Right lung intubation
3. Trauma to the upper airway
4. Pneumothorax
5. Subglottic stenosis

Procedure :

1. Position infant with head in midline and slightly extended.
2. Continue bag and mask ventilation with 100% oxygen till well saturated.
3. Sedate the child with IV midazolam (0.1-0.2 mg/kg) or morphine (0.1-0.2 mg/kg). Give muscle relaxant if still struggling (succinylcholine 1-2 mg/kg)
4. Monitor the child’s vital signs throughout the procedure.
5. Introduce the blade between the tongue and the palate with left hand and advance to the back of the tongue while assistant secure the head.
6. When epiglottis is seen, lift blade upward and outward to visualize the vocal cord.
7. Suction secretion if necessary.
8. Using the right hand, insert the ETT from the right side of the infant’s mouth, a stylet may be required.
9. Keep the glottis in view and insert the ETT when the vocal cords are opened till the desired ETT length while assistant applies cricoid pressure.
10. If intubation is not done within 20 seconds, the attempt should be aborted and reventilate with bag and mask.
11. Once successfully intubated, remove the laryngoscope and hold the ETT firmly with left hand. Connect to the self-inflating bag and positive pressure ventilation.
12. Confirm the ETT position by looking at the chest expansion, listen to lungs air entry and also the stomach.
13. Secure the ETT with adhesive tape.
14. Connect the ETT to the ventilator.
15. Insert orogastric tube to decompress the stomach.
16. Check chest radiograph.