Trauma case history

Orthopedic Case History

1. Traumatology case history Otuneye Oluwakemi Group 25 Kursk state medical university 5 th year 9 th semester

2. Patient profile Name: Ushakova Ludit sv Yuriev Age: 46 years old Sex: female Occupation: Date of admission: 13th February 2023 Address: deriglazova 115

3. Summary of case A 46 year old woman from Kursk Russia was admitted for a trauma case. The patient was okay according to her report until on Sunday the 12 th of February 2023, when she sustained an ankle injury. She said on the morning of the accident she got on the street, walked down the street, slipped and fell. Afterwards she called and ambulance.

4. She complain ed of pain at the site of injury, which is sudden onset. It was intermittent, throbbing in nature, aggravated on movements especially on movement of the right leg and foot . There is swelling at the site of fracture afterwards, start insidiously, increasing in size she was then sent to the hospital , on the same day she was told it was a broken ankle. The next day on Monday the 13 th of February an x-ray of her right foot was taken and she was told there is a fracture and she was admitted to the trauma hospital .

5. On general examination patient conscious and vitals are stable. On local examination ( right Ankle) Inspection Attitude - Planter flexion Swelling - Present in medial and lateral side Lesion - abrasion present over lateral malleolus

6. Palpation Local temp was raised, Tenderness was present Swelling was present Movement was painful and restricted • Dorsalis pedis artery and posterior tibial artery palpable bilaterally

7. Diagnosis  She had right Ankle Bimalleolar fracture -Medial Malleolus and Lateral Malleolus The site of the injury was dressed with Bandage to limit the movements around this area

8. Investigation Lab investigation - FBC, ESR, C reactive protein Total lymphocyte count  Imaging - X ray of the right leg AP and lateral view,

9. X-ray imaging -grams of the right ankle joint in 2 x pr-x foot subluxation outward, displacement of the fracture: of the medial malleolus outward by 0.4 cm, fragment of the lateral malleolus-posteriorly by 0.5 cm, fracture of the posterior edge of the distal epiphysis of the tibia, expansion of the gap of the distal tibi ofibular syndesmoses

10. On the 17 th of February she was scheduled for a close reduction and internal fixation surgery. She was given some pain killers while she awaited for the surgery

11. Operative procedure -Protocol for Spinal Anesthesia The patient is in the operating room. preoperative infusion was done in the ward. Patient ‘s vitals - breathing well , HR 17/min, pulse-76, blood pressure 130/80 mm Hg, oxygen saturation ( Sp02 ) -98%. Done under aseptic conditions puncture and catheterisation of left peripheral veins . Infusion therapy started - NaCl 0.9% 400 ml at 13 : 50. under aseptic conditions: sol. lidocaine 2%-3ml. at the level <3-<4, a spinal puncture was performed on the 1st attempt. Needle: 22 G CSF received. Input: Sol. Marcaine spinal 0.5% - 3 ml., aseptic dressing. the effect is satisfactory. Complications –n o - level of anesthesia : foot - navel at 14: 00

12. Surgical approach Medications given Atropin-0.1 % - 80mg Prednisolone - 30mg. Infusion during operation: Nacl 0.9%-800 ml Glucoses 5% - 800ml The operating Surgeon then manipu lated the fracture by placing the bone in the right position by pushing or pulling the bone. This procedure is known as traction. Once the fragments were aligned in correct position, metal plates, screws and pins are used to hold the fragments in place.

13. volume of the total infusion: / 600 ml. Diuresis: N ml. Blood loss: 20 ml. Hemodynamics during the operation is stable. Respiratory rate 17-16 per minute, pulse 76-82 per minute, BP (120-110/70 mm Hg. Operation duration -40mins At the end of the operation, the patient ’s l level of consciousness is normal(alert) . Dynamic observation in the operating room - 15 min under the supervision of a doctor on duty Pulse :76 per min. Blood pressure 124/84mm hg Recommended: -Nacl 0.9%-800 ml

14. Postoperative care A cast or splint was used to give rest to the operated part post surgically Soon after the procedure, she was shifted to the recovery room where she will be monitored until the effect of anaesthesia wears off. Once it wore off, she was given some painkillers short-term pai n and antibiotics after the surgery. Crutches were given to her for minimal movement On the 19 th she was taken for another x-ray imaging

15. Post operation day 1 Lateral malleolus Intramedullary cancellous screw Medial malleolus Plate Fixation with screw fixation

16. Rehabilitation The patient had no other injury or complications and was discharged on the 22 nd of February 2023 Medication to relieve pain and prevent infections.  proper rest and keep the affected area in an elevated position to avoid swelling. Exercise as recommended by a physiotherapist to gain strength and complete range of motion. Visit the hospitals on the scheduled