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.