ORTHO CASE STUDY final.pptx

ortho case presentation

1. Orthopedics Case Presentation MPJ MOrokane 202016997

2. Patient information Name: Segole Makwe Age: 59 years old Sex: Male Residence: S oshanguve Occupation: Self Employed

3. Main complaint Pain on the right foot

4. History of presenting complaint Patient refers that he was mugged on his way home and was hit with a hard object on his right foot at around 10 in the evening . He rated the pain 10/10. it was not radiating and he says walking makes it worse and sitting down supporting the injured foot makes it better.

5. History Systemic enquiry: Nothing of significance PMH: No chronical illnesses, No known drug allergies, No previous surgical history Family hx : he does not know Social: S moke 10 cigarrettes a day for 30 and has a pack year of 6years, an occasional drinker He is married and lives with his family

6. Examination GA: middle aged man who looks clinically stable, conscious and alert and breathes well on room air, laying on his (L)side Peripheral signs: JACCOLD- no positive findings Vital signs: BP: 127/80mmHg(normal ) Pulse: 87bpm(normal ) RR: 18/min(normal ) Temp: 35.4

7. Systemic examination CVS: normal s1 and s2 no added heart sounds or murmurs Resp : chest clear, equal bilateral entry GIT: soft, non tender with no hepatosplenomegaly

8. Local examination of (R) leg Look +/-5cm laceration Tear of a deltoid ligament Active bleeding No swelling Minimal contamination

9. Local examination Feel The right ankle was cold, dry with active bleeding Tendness to touch Pulses are present, the dorsalis pedis and posterior tibial artery, comparable between both limps, no pulse delay.

10. Local examination Move ROM on (R)leg: Active : Unable to do dorsiflexion, eversion and internal and external rotation Passive: We could not do any movement as the patient was complaining of severe pain. Neurovascular intact

11. Assessment

12. Differential diagnosis Radial Fracture Ulnar Fracture Radial Subluxation Ulnar Subluxation

13. Investigations Bloods FBC + differential count: Hb , wcc U&E: COVID swab Imaging Leg X-rays: AP & Lateral view

14. X-rays

15. Diagnosis Open fracture dislocation of the right ankle with a talus shift

16. Treatment In casualty IV line 0.9% normal saline Tetanus toxoid 0.5ml IM stat A nalgesic: Tramadol 100mg IM stat Antibiotic: kefzol 2g IV stat Debridement and close reduction

17. Plan Cast Splintage Antibiotics 1g tds Below the knee half moon backslab . Elevate for 24h and take to theater for deep debridement and externally fixation Elevate above the heart level for 10days in the ward Take to theater for ORIF Discharge and follow up after 2 weeks