PATIENT’S BIODATA

Nur Azlan Firdaus, 20 year old single Malay male is a college student in Negeri Sembilan.
He lives in Kampung Pandan Dalam. He was admitted on 29 th November 2009 to Hospital
Ampang. The date of clerking was on 30 th November 2009. The source of information was
from the patient himself.

CHIEF COMPLAINT
Pain and swelling at the left elbow for 1 day

HISTORY OF PRESENTING ILLNESS

He was involved in motor vehicle accident between motorcycle and motorcycle at
Pandan Indah. It occurred in the evening, on the day of admission. He was on his way back to
his college and about to enter to the right junction when suddenly a motorcycle from behind
crossed in front of him to enter the opposite junction. He hit the brake immediately, causing
him to be thrown forward and skidded onto the road. He landed on his left arm and left leg.
During the accident, he was wearing helmet and claimed the speed was slow.
After that, he was able to stand up and walk. However, he complained of pain at the
left elbow. He was able to tolerate the pain, but there was restricted movement at the elbow
joint whereby he could not straighten and fully bend the elbow. He also noticed the area was
swollen and deformed, but no wound or bleeding present at that site.
In addition, he sustained multiple wounds at the forehead, nose, upper lip, both hands
and left knee. There was no loss of consciousness, headache, nausea and vomiting. He also
did not complain of any neck pain, chest pain, shortness of breath or abdominal pain after the
accident. He is a right hand dominant.
He was brought immediately to the hospital by his friend who lives nearby.

PAST MEDICAL / PAST SURGUCAL HISTORY / DRUGS HISTORY

He had history of motor vehicle accident in 2008. However, he claimed that there was minor
injury which does not warrant him for admission to hospital. There was no past surgical
history. He did not take any medication and no known drug allergy.

FAMILY HISTORY
Both parents are alive and well. He is the third of six siblings. All of them are alive and well.

SOCIAL HISTORY
He is a student in Jelebu Community College, Negeri Sembilan for Sijil Teknologi
Pembangunan. He lives with his family in a single-storey terrace house in Kampung Pandan
Dalam. He is non-smoker and non-drinker.

PHYSICAL EXAMINATION
The examination was done on the second day of admission.

GENERAL EXAMINATION
On inspection, he was lying supine on his bed. He was alert, conscious and orientated at time,
place and person. There was a backslab and bandage over the left forearm, extending to the
lower third arm with sling. There was intravenous cannulation on the dorsum of his right and
left hands. There were abrasion wounds at the left forehead, upper lip, nose, dorsum of his
right and left hands and at the medial aspect of his left knee. His vital signs were:
 Pulse rate : 84 beats/min with
 Blood pressure : 124/70 mmHg
 Respiratory rate : 20 breaths/min
 Temperature : Afebrile
There was no jaundice, pallor or cyanosis. Hydration status was fair. Capillary refill time was
good in both upper and lower limbs. No ankle oedema.

SYSTEMIC EXAMINATIONS
Cardiovascular System: The pulse was 84 beats per min with regular rhythm and good
volume. Both S1 and S2 heart sounds were heard and no murmur.
Respiratory System: Both lungs were clear, equal air entry and normal breath sound.
Abdominal Examination: Abdomen was soft, non-tender. Bowel sounds were heard and
normal.

REGIONAL EXAMINATION: UPPER LIMB

Look : The right upper limb was in supine position. The shoulder of the left upper limb was
internally rotated and flexed at the elbow joint. Both shoulders were of the same height.
There was swelling and deformity at the elbow joint. However, there was no wound at that
area. There were multiple abrasion wounds at the dorsum of both hands and left knuckle. No
muscle wasting, no skin changes.
Feel : The left elbow joint was warm and tender, especially at the area overlying the
olecranon process.
Move : Movement of wrist and metacarpal and interphalangeal joints of both limbs were
normal. However, there was restricted range of motion at the left elbow joint due to pain.
Flexion of the elbow joint was between 30° to 90° while maximal extension was until 30°. He
was able to achieved normal supination, but pronation was up until 45° only. Movement of
the right elbow joint was normal.
Neurovascular : Tone was normal on both sides. Power of the upper limb was 5/5, except for
the left flexors and extensors of the elbow joint i.e. 3/5 due to pain. No wrist drop, no clawing
of the fingers and patient was able to move wrist and all fingers. All the reflexes were intact
except for the triceps reflex on the left side because the posterior elbow was swollen and
tender. The sensation was intact on both upper limbs. Radial pulses were palpable on both
sides. Capillary refill time was less than 2 seconds on both upper limbs.

PROVISIONAL DIAGNOSIS
Closed fracture of the olecranon process of left ulna

DIFFERENTIAL DIAGNOSES
Fracture of left radial head

INVESTIGATIONS
1) Blood: All the blood investigations were done as baseline status of the patient and for
evaluation of the patient’s condition whether the patient is suitable for surgery or not.
Blood investigations Results
Full blood count (FBC) Haemoglobin – 12.6 g/dL (12-18)
 done on 30/11/2009 Haematocrit – 40.9 % (37.0-51.0)
Platelet – 198 K/uL (140-440)
White Cell Count – 13.1 K/uL (4-11)
Renal Profile (RP) Urea – 2.8 mmol/L (1.7-8.3)
done on 30/11/2009 Sodium – 140 mmol/L (135-145)
Potassium – 4.0 mmol/L (3.3-5.1)
Chloride – 98 mmol/L (98-106)
Creatinine – 83 umol/L (62-106)

2) Radiology – done on 29/11/2009

a. Anteroposterior and lateral X-rays of left elbow: Displaced transverse fracture
of the olecranon process of left ulna

MANAGEMENT
1) Primary survey
a. Patient was alert, conscious and orientated to place, person and time
b. Patient was breathing spontaneously. Negative chest and pelvic spring. Full
range of motion of the head and neck. No spine tenderness and no active
bleeding.
c. Peripheral pulses was felt
2) Resuscitation
a. IV infusion of normal saline
3) Secondary Survey
a. Significant history
i. Mechanism of injury – patient involved with MVA and thrown out
from motorcycle, landed on the left arm and leg.
ii. Other complaints – Pain and swelling at the left elbow. Multiple
abrasion wounds.
iii. Physical examination
4) Investigation
a. Blood – Full blood count (FBC) and renal profile (RP)
b. Radiological investigation – AP and lateral x-rays of left elbow
5) Management at Emergency Department
a. Intramuscular injection of anti-tetanus toxin 0.5 mg stat
b. Close manual reduction was done at the fracture site. Full upper limb backslab
was applied after CMR and second x-ray post CMR was done.
c. Referred to orthopaedic department was admitted to ward.
6) In ward
a. Patient was on strict circulation chart. Analgesia was given i.e. IM Voltaren
50mg tds and T.Paracetamol 1g qid. Planned for surgical intervention.
7) Definitive surgical treatment
a. Open reduction and internal fixation of left olecranon using tension band wires
was done on 1/12/2009 – fracture was stable after ORIF with full range of
motion of flexion and extension at the left elbow joint.
8) Post-operation
a. On circulation chart
b. Post-op x-ray was taken – the fracture was held together closely
c. Medication given: IM Diclofenac sodium 50mg tds, T.PCM 1g qid and IV
Zinacef 750mg tds
 d. Patient was encouraged to exercise on left elbow joint and fingers.
9) Discharge and follow-up
a. Patient was discharged on 2/11/2009 with next appointment at Klinik
Kesihatan after 2 weeks to open suture.
b. Wound dressing at abrasion wounds with normal saline and bactigrass every 3
weeks in Klinik Kesihatan.
c. Advised on upper limb and finger exercise at home to strengthen the muscle
d. Discharge with Tab.Voltaren 50mg tds when needed, Tab. Paracetamol 1g qid
and Tab. Zinnat 250mg bd for 3 days

DISCUSSIONS
The olecranon fracture is a fracture involving the olecranon process of the ulna bone. The
olecranon process forms part of the elbow joint that articulates with the trochlear of the
humerus. The olecranon fractures can occur in 2 types of injury:
1) A direct blow: This can happen due to fall (landing directly on the elbow) or direct
force being applied to the elbow, leading to a comminuted fracture.
2) An indirect injury: Resulted from a fall with outstretched hand. As the hand landed on
the ground with the elbow locked out straight, a forceful contraction of the triceps
muscle will produce traction towards the olecranon process, resulting in a clean
transverse fracture.
Symptoms may include history of trauma or fall, sudden intense pain at the elbow joint,
swelling around the area, inability to straighten the elbow and pain upon movement. Patient
also can present with numbness of one or more fingers. Since the ulnar nerve runs proximal
to the olecranon process, it may also get injured following fracture. Therefore, it is important
to pay attention on neurovascular examination. In this patient, he had no symptoms or signs
of ulnar nerve injury.
X-ray will be taken to confirm the diagnosis. A proper lateral view is essential to show
the details of the fracture and to check for any dislocation of the radial head. The treatment of
this fracture can be either non-surgical or surgical treatment. For the comminuted fracture and
undisplaced transverse fracture, treatment can be achieved via non-operative method using
sling and cast respectively with rehabilitation following that. In a displaced transverse
fracture, operative treatment is preferred rather than splinting the arm to avoid stiffness of the
joint. The fracture is reduced under vision and fixed using one of two methods; 1) fixation
using long cancellous screw 2) tension-band wiring. Early mobilization is encouraged soon
after that.
This patient had a displaced transverse fracture of the olecranon processs. Therefore
open reduction and internal fixation using tension-band wiring was done on him to stabilize
the fracture. Among the complications that he can develop is stiffening of the elbow joint.
However, with the use of internal fixation and early mobilization, the risk for him to get that
can be reduced. He should also be given appointment for follow up to check whether the
fracture has united or not besides for the dressing of the wounds.

REFERENCES
1. Apley’s Concise System of Orthopaedics and Fractures, Third Edition by L. Solomon,
D.J. Warwick and S. Nayagam
2. Netter’s Concise Atlas of Orthopaedic Anatomy, First Edition by Jon C. Thompson,
MD.
3. Basic Fracture Management For Students and Housemans by Muhammad Yusof
Aziz, UIA.
 ORTHOPAEDIC POSTING

CASE WRITE-UP 2

CLOSED FRACTURE OF THE OLECRANON PROCESS

OF LEFT ULNA

AHMAD HARIZ BIN AHMAD BADRUDDIN

1050021

GROUP B