This the FRACTURE REVIEW (May) prepared and presented

Fracture review

1. FRACTURE REVIEW 08 /0 5 /2024 BY DR IBEANUSI A. REGISTRAR , ORTHOPAEDICS FMC ASABA

2. A 52yr old Trader who hails from Nkanu West, Enugu but lives in Ibusa , Asaba. She is a Christian of Catholic denomination and Married . Brought in with complaint of pain, bleeding and Inability to bear weight on Left leg x 30mins PTP Patient was an unhelmeted passenger on a motorcycle along Ibusa road late in the evening who got knocked down by a fast moving vehicle. There was no eye witness at the scene of the accident .

3. Following incidence, Patient sustained injuries to the left leg, with copious blood loss which couldn't be estimated. There was associated severe pain, deformity and was unable to bear weight. Patient was immediately brought to the A/E by a Good Samaritan. There was head injury with hx of LOC, bleeding from craniofacial orifice, and associated neck pain. However, no vomiting, no post traumatic seizures, no haemoptysis , no chest pain, no abdominal pain or swelling, no hematuria .

4. Nil prior hx of Hospital admission, blood transfusion nor surgery. Known Hypertensive on medication. Not a known Diabetic , Asthmatic nor PUDx patient. No known drug nor allergic reaction. She is married in a monogamous family with 5 offsprings (2M, 3F) She doesn't consume alcohol nor Tobacco in any form.

5. O/E: Middle-aged woman in severe painful distress, pale, afebrile, anicteric , acyanotic , not dehydrated. VS: PR 110b/m RR 20c/m BP 140/ 9 0mmHg SP02 9 7% CNS: Conscious and alert. GCS: 15/15 MSS: Left leg Extensive avulsion injury ., with bony fragments, ligament/tendons visible. Tenderness . Distal pulses not Palpable . No movement of distal Extremity. SpO2 of left limb ranges between 60 and 85% Chest: compression Tenderness – negative ABD: F,MWR. Nil area of tenderness Pelvis: CT/DT – negative

6. Assessment: Multiply Injured patient with Left Tibiofibular Fracture (GA type 3 C ) ?TBI

7. PLAN: Patient relatives counselled on diagnosis and possible management outcomes (which may involve amputation). Do FBC, EUCR, URINALYSIS GXM 5 units of blood, transfuse X-ray of the left leg showing ankle and knee joints AP/Lat. X-ray of the Left foot. Do Brain CT Scan.

8. I M TT 0.5mls stat IV PCM 600mg 8hrly IV Pentazocine 30mg 6hrly IV Ceftriaxone 2g dly IV Metronidazole 500mg 8hrly Review with investigation results .

9. Discussed with Consultant on call . Counsel patient relations on prognosis and management options . Booked for Emergency wound exploration and Ex -Fix application .

10. Patient was reviewed by the Neurosurgery team and an assessment of Mild head injury with bi-frontobasal skull fracture r/o mid frontal open depressed skull fracture was made. Craniocervical CT scan done shows bifrontal pneumoencephalus with subdural hematoma component on the left frontal aspect . Patient was booked for joint orthopedics and neurosurgery (Emergency burr hole) participation in theater .

11. Urgent PCV done = 19% Discussed with SROC ORTHO. To WITHOLD Emergency wound exploration and Exfix application until patient is fully optimized . Patient is currently in ICU after a successful burr hole procedure.

12. On re-examination yesterday, Mss: left foot dressing stained with blood in lateral tilt of left foot Spo2 of left foot: 98 % Assessment: Open distal tibiofibula fracture GA type 3b with extensive soft tissue loss on the medial aspect of distal leg and foot . Change wound dressing and for application of removable above knee back slab .

13. A 73 year old widow who resides at Ihala town, Anambra state, CHRISTIAN OF ROMAN CATHOLIC Denomination and Igbo. She presented to this facility o/a: Ulcer of the left leg X 2/52 She was brought into A & E by her relatives on account of a wound on the lower aspect of the left leg which was sustained while attempting to flee from unknown gunmen when her left leg stuck in a ditch and she fell into a gutter. She sustained a wound the size of her fist with her bone been exposed also. There was inability to bear weight following the incidence and she needed assistance to walk thereafter

14. She is a known diabetic and has been compliant with her medications, not a known hypertensive patient. Following the incident, she was initially taken to a traditional bone setter where attempts were made to set the bone but with no improvement presented in a private facility and referred to this facility for care. Prior to admission in this facility, she has recieved two units of blood. Nil hx of HEAS. She does not drink alcohol or smoke tobacco in any form. She has 4 children.

15. O/E: An Elderly lady, not pale, anicteric , acyanosed , not dehydrated. CVS: PR: 102bpm, BP: 110/ 60mmhg MSS: Presence of a 12 by 10cm ulcer on the distal medial aspect of the leg with presence of slough exposed tibia bone ( proximal aspect of fracture). Darkish discolouration around the skin. At the upper border of the ulcer, there is a large part of necrotic tissue. No neurovascular deficit Other system: NAD

16. Plan 1. Inform consultant on call consultant plastic and SR orthopedics 2. Do FBC, EUCR, urinalysis, x ray of the leg AP/ Lateral, wound swab mcs , GxM 2 units of blood, FBS, debride wound (Done). 3. Give IM TT 0.5mls stat 4. IV Tandak 1.5mg 12 hourly 5. Iv metronidazole 500mg 8 hourly 6. Caps Tramadol 50mg bd 7. Iv PCM 900mg 8 hourly 8. Subcut clexane 40mg daily 9. Daily dressing of wound with povidone iodine soaked gauze 10. Review with investigation results. 11. Invite MTOC

17. apply backslab – counsel relatives on prognosis