INTERNATIONAL MEDICAL SCHOOL

MBBS YEAR 4 OCTOBER 2018/19

ORTHOPEDICS POSTING
CASE WRITE UP

NAME: DEVIGA SAMY VELU RAJA

ID NO: 012014100123
LECTURER: DR. SIAMAK
 I. Patient’s information
 Name: Leong Wai Lan
 Age: 50 years old
 R/N: 1884662
 Gender: female
 Race: Chinese
 Address: Sentosa Klang
 Occupation: Night market vendor
 Date of admission: 18th February 2019
 Date of clerking: 19th February 2019
 Informant: Patient and her sister

II. Chief complaint

Pain and swelling of the right leg after a motor vehicle accident.

III. History of presenting illness (HOPI)

My patient was apparently well until she met in a motor vehicle accident on the 10 th of
February 2019. The accident took place nearby to her place involving two motorcycles. She
was the pillion rider, her husband rode the motorcycle. The husband lose control of the
motorcycle when he tried avoiding from hitting a stray dog on the road and collided with
another motorcycle on the opposite side as it was a two way road. She was hit at her knee
on the right side and fell off the motorcycle on the left side.
The moment she fell off the motorcycle, she felt an intense and excruciating pain at her
knee. She was unable to move her right leg, the pain aggravated upon movement. She
scored her pain 8/10 according to the pain score scale. The pain was most prominent at her
knee region. She felt the pain from her mid –thigh up to her shin of her right leg. The pain
was associated with swelling. Her leg started swelling in a few hours after the fall. And she
was unable to stand. There was no bruises, bleeding or protruding bone out from the skin.
Otherwise, patient did not experience symptoms like headache, dizziness, loss of
consciousness, vomiting or bleeding from ears, nose and mouth to indicate head
trauma/injury. She did not experience symptoms like shortness of breath, chest pain or
hemoptysis indicating fat embolism or thorax injury. She did not have symptoms like
weakness or numbness on any of her other limbs indicating spine injuries. She did not
experience any abdominal symptoms too like abdominal pain or hematemesis.
Patient and her husband was brought home by their family after the MVA. She seek help
from the Chinese Chiropractor. However, her symptoms were not relieved and she
presented to the ED on the 8th day after the MVA. At the ED, patient’s vital signs and X-rays
were taken. And she was told that she had a bone fractured at her right leg. Then her lower
limb was immobilized with above knee back slab, no reduction was done.
 IV. Systemic review

Cardiovascular system No dyspnea, chest pain, palpitation

Respiratory system No shortness of breath, coughing
Gastrointestinal system No nausea, vomiting, abdominal pain
Genitourinary system No hematuria, dysuria, back or loin pain,
polyuria
Hematological system No bleeding tendency
Neurological system No dizziness, numbness or weakness on
the limbs, headache, seizure, blurring of
vision

V. Past medical history

No known medical illness

VI. Past surgical history

No surgical intervention was performed before

VII. Drug and allergy history

Patient is not on any medication. She does not take any over the counter mediation or
traditional medication
No drugs or food allergies

VIII. Family history

My patient is the second out of 4 siblings. Her father passed away at the age of 88 years old
due to old age. Her mother is 71 years old. She has Diabetes Mellitus Type 2 and
hypertension. She on medication. The age of her siblings ranging from 55 years to 35 years
old. They are all healthy.
IX. Social history
Patient is married and divorced about 15 years back. She has no children. She is living with
her younger sister and her family in single storey house with all the amenities. She helps her
sister at the night market. She does not smoke cigarettes but drinks alcohol occasionally. She
does not take recreational drugs. She leads a sedentary lifestyle.

X. Physical examination
 General inspection
My patient was lying comfortably in supine position. She was alert and cooperative.
She was well orientated to time, place and person. she had a above knee back slab
over her right lower limb and it was supported by 1 pillow. There was an intravenous
branula over her dorsum of right hand and an ID tag over her left wrist. She was
medium built and her hydrational and nutritional status was fair.

 Vital signs
 Blood pressure : 130/70 mmHg (Normal)
 Pulse rate : 72 beats/min (Normal)
 Respiratory rate : 20 breaths/min (Normal)
 Temperature : 37˚c (Normal)

 General examination

Eye No conjunctival pallor and yellowish sclera

Mouth Good oral hygiene, tongue was pink and moist. No angular stomatitis, no gum
bleeding.
Neck No thyroid or lymph node enlargement, jugular venous pressure was not raised
Hand Warm to touch. Radial pulse was palpable. No clubbing, no cyanosis, capillary
refilling time was less than 2 seconds, no koilonychias, no leuconychia.
Lower limb No pitting oedema , no varicose vein

 Systemic examination

Abdomen Examination The abdomen was soft and non-tender

Respiratory Examination
Cardiovascular Examination
No palpable mass
No abdominal distension
Normal vesicular breath sound was heard with no added
sound and equal air entry on both sides on auscultation
No displaced apex beat, raised JVP
First and second heart sound was heard
No murmur was heard
  Local examination
Inspection (Look)
She was lying comfortably on bed. She had an above knee back slab on her right
lower limb and the leg was supported by 1 pillow. The right leg was swollen when
was compared to the left leg. Otherwise, there was no visible muscle wasting,
dilated veins, loss of hair, discolouration of skin changes or foot drop noted.

Palpation (Feel)
Upon palpation of both lower limbs, there was an increase in temperature and
swelling with tenderness on the right lower limb. Capillary refill time was less than 2
seconds.

Movement
Active and passive movements were intact on right lower limb. Unlike, the left knee
joint were unable move to even slight flexion, extension, internal rotation, external
rotation, abduction and adduction due to pain. She was able to move all her toes,
she was able dorsiflex and plantarflex his ankle on both limbs.

 Neurovascular Examination
o Pulse :Dorsalis pedis and Posterior tibial pulses were felt equal in both lower
limbs
o Sensation: sensations over the deep peroneal area,superficial peroneal
nerve area, sural nerve area, tibial nerve area and saphenous nerve area
were intact.
XI. Summary
Madam Leong, 50 year old Chinese lady with no known medical illness presented to the ED
of HTAR with the complain of pain and swelling over her right lower limb after a MVA 9 days
ago. She initially went to a Chinese Chiropractor but however her symptoms were not
relieved. On physical examination, swelling and tenderness was noticed. Patient was not
able to move her right lower limb. Neurovascular examination findings were normal.
Otherwise, there was no abnormality noted on her left lower limbs.
XII. Investigations
Full blood count

Hb 12.4
TWBC 10.1
Platelet 476
PCV 40
PT/PTT 14.3/41.8
INR 1-10
*all parameters are within normal ranges.

Renal profile

Urea 5.6
Na 136
K 4.1
Cl 100
Serum creatinine 74
*all parameters are within normal ranges

Radiology (X rays)

This x ray belongs to Madam Leong. The x ray is taken in lateral and anteroposterior of the right leg.
An oblique fracture is seen at the medial condyle of the right tibial plateau.
XIII. Provisional diagnosis
Closed fracture of right proximal tibial plateau.

XIV. Differential diagnosis

1. Fractured right Patella
2. Dislocation of the right Knee
3. Dislocation of the right Patella
4. Fracture-separation of the right Proximal Tibial Epiphysis

XV. Management
 Admit patient
 Monitor her vital sign
 Physical examination and neurovascular examination
 IM Tramal 50mg given insert IV branula
 T. Paracetamol 1g QID
 Immobilize the left lower limb with a backslab
 Blood investigations and x ray was done
 Elevate right lower limb
 Start on cryocuff
 Look out for compartment syndrome
XVI. Discussion
Anatomy of the Tibia bone

The tibia is the main bone of the lower leg, forming the shin.It expands at its proximal and
distal ends. It articulates at the knee and ankle joints respectively. The tibia is the second
largest bone in the body and it is a key weight-bearing structure. The proximal tibia is
widened by the medial and lateral condyles, which aid in weight-bearing. The condyles form
a flat surface, known as the tibial plateau. This structure articulates with the femoral
condyles to form the key articulation of the knee joint.

My patient had a right proximal tibial plateau fracture due to a MVA accident about 10 days
ago, when her right leg was hit by another motorcycle on the opposite lane.
Tibial plateau fractures are usually caused by a varus or valgus force combined with axial
loading. The tibial condyle is crushed or split by the opposing femoral condyle which remains
intact.
My patient presented with swollen knee and very limited movement on the knee joint
however my patient did not feel doughy, indicating no haemarthrosis. The diagnosis is made
after the xrays are taken. Based on the x rays, Tibial plateau fractures can be classified into 6
types.
The fracture of my patient falls in type 4 (fracture of the medial tibial condyle), in this x ray,
due to the high energy collision, resulting in condylar split which runs obliquely from the
intercondylar eminence to the medial cortex. This might be severe enough to injure the
peroneal nerve but fortunately, there were no signs of damage to the nerve.
As this is a displaced fracture, open reduction and internal fixation need to be done. High
quality imaging is needed to define the fracture pattern accurately. The standard approach is
through a longitudinal parapatellar incision. The fixation made must be secure enough to
permit early joint movement
Post-operative measures such as limb is elevated and splinted until swelling subsides.
Movements are begun as soon as possible and active exercises are encouraged. The
complete healing takes at least 12-16 weeks.
 Compartment syndrome is an early complication for this patient but rarely in type 4. This
occurs more commonly in type 5 and 6 fractures with more bleeding and swelling of the leg.
Patient might develop some late complications like osteoarthritis that might develop after 5-
10 years from now. Patient might require reconstructive surgery. She also might suffer from
joint stiffness, but can be prevented by avoiding prolonged immobilization and encouraging
movement as soon as possible. Deformity of the leg like varus / valgus is quite common.

XVII. References
 Apley and Solomon’s Concise System of Orthopedics and Trauma, 4th edition by
Loius Solomon, David Warwick, Selvadurai Nayagam