CASE WRITE UP

ORTOPEDIC POSTING
ROTATION 3 2018/2019

ATTIRAH NUR ASYURA BINTI AMRAN

012015100059
Patient’s biodata
• Name : Alvien a/l Karunakaran
• Age : 18 years old
• Gender : Male
• Race : indian
• Occupation : students
• Address : sungai jati, klang
• Informant : patient
• Date of admission : 16th February 2019
• Date of clerking: 17th February 2019

Chief complaint
 Pain over the right thigh following a fall from a stairs 1
hour prior to admission.
History of presenting illness
 Patient was going up a stairs to fix a lamp when he slipped
and fell landed on his right side. which then he heard a
“crack” sound and felt pain all over his right leg but more
on his thigh area.
 The pain was sudden in onset and progressively
worsening, he describe the pain as throbbing in nature and
radiate to his whole right leg. The pain aggravated by
movements and there is no relieving factor taken for it.
The pain was associated with swelling and he unable to
walk. He score the pain as 10.
 Otherwise , there is no bleeding, no deformity,no loss of
sensation, no numbness,no nausea no vomiting no
headache,no blurring of vision,no loss of consciousness.
 He then brought to HTAR emergency department by his
mother and brother. He was given with analgesic for the
pain XRAY was taken. A traction immobilizer was set on
his right leg.

Past medical and surgical history

No medical and any surgical intervention done before.
 Drug and allergy history
He has no known allergy to drug and food. And he was not any
over ther counter medication or any supplements.

Family history

53 years old

55 year old

24 years old 20 years old

27 years old 18 years old

 Patient is the youngest sibling out 4.

 All of his family member are healthy with no medical
illness and no malignancy in the family
Social history
 Patient is a student in a private university
 Still live and fully support by his parents.
 Patient is an occasional drinker
 Patient is an active smoker for 2 years , with 5 sticks per
day.

Summary
Mr alvien a 18 years old Indian gentleman who is a student
without any medical condition come with a chief complaint of
pain on the right thigh following alleged fall of stairs, cannot
walk and bear any weight and associated with swelling on the
right thigh. Otherwise, no loss of consciousness,nobleeding,no
seizure,no obvious deformity,no headache was nnoted.

General examination
Patient lying down in supine position. He is fully conscious and
alert to place,time and person. Patient is thin built not in pain
and not in respiratory distress with good hydration and
nutritional status
VITAL SIGNS

BP: 112/88 mmHg (normal)

Pulse: 65 bpm, regular rhythm and good volume

Respiratory rate: 20 breath/minute

Temperature: 37°C (afebrile)

Head –no conjunctival pallor,no sclera jaundice, no bruising or

bleeding noted,no thyroid enlargement.
Hands – warm and moist to touch. No pallor and peripheral
cyanosis. Capillary refill time was <2seconds

Systemic examination
Cardiovascular examination – no surgical scar seen, apex beat
felt at 5th intercostals space within the left midclavicular line. S1
and S2 was heard and no murmur heard.
Respiratory examination – normal vesicular braeath sound was
heard, symmetrical chest expansion bilaterally, no additional
breath sound noted.

Abdomen – abdomen was soft and non tender, it is not

distended,move symmetrically with respiration. There’s no
dilated vein and no surgical scar seen

Local examination
Inspection

Right limb was support and elevated by a skin traction with hip
externally rotated slightly and knee fully entended. Lower leg is
cover with bandage and it was intact and dry. There’s a swelling
around the right hip however the skin is intact and no bruises
seen. Both lower limb are seen to be in the same length and
there’s no significant finding on the opposite lower limb.

Palpation

Temperature is warm comparing to left lower limb (intact side),

tenderness over the swelling.
Movement

Range of motion on the hip and knee are very limited as he

going to feel pain even on the slightest movement. Active
dorsiflexion and plantarflexion is noted. And he’s able to move
all her toes.

Neurovascular examination

Colour of the skin oh his right thigh appear normal with normal
temperature. The capillary refill time is less than 2 seconds.
Pulse over the dorsalis pedis and posterior tibial artery are
palpable with regular rhythm and good volume. Saphenous
nerve is intact, deep and superficial peroneal nerve is
intact,tibial nerve is intact,sural nerve is intact. No foot drop
noted.
 Right Left

Tone Cant perform due Normal

to pain

Power Cant perform due 5

to pain

Reflex Cant perform due Normal

to pain

Sensory Intact Intact

Provisional diagnosis
Closed right femoral neck fracture
Point supporting –
Unable to move and bear weight on affected leg
Pain and swelling on the right hip
Limited range of motion and knee joint.
Differential diagnosis

 Closed right intertrochentric fracture

 Closed right fracture head of femur
 Closed right fracture of mid shaft of femur
 Closed right fracture of distal femur

Investigation
X ray

This x-ray of mr alvien

18years old,taken on the
16th February on an AP
view of femur show
fracture of the neck of
femur.
Full blood count
Haemoglobin – 13.6g/dl ( 13- 17) normal
White blood count – 6.21 10x9/L
Haematocrit – 42.9
Platelet – 360
CRP – 12.89
ESR – 23

Management

 Temporary immobilization of limb and Keep elevated

the affected right lower limb
 Maintain circulation of the limb
 Continue 2 hourly turning the patient.
 IM tramadol 50mg TDS
 Tablet paracetamol 1gOD
 s/c clexane 40mg OD
discussion

 incidence of fracture of neck of femur is highest in

older age > 65years old but also common in young
adult due to high impact.
 Risk factor for this fracture is, old age > 65 years old,
osteoporosis patient,lack in vitamin D in diet.
 Presentation : severe pain,bruising,swelling, unable
to bear weight on affected leg, may have shortened
leg when rotate externally.
 There are 2 type of fracture which is intracapsular
and extracapsular.
 As for my patient it is intracapsular as it involve the
neck of the fracture
 Based on garden classification my patient is garden
IV which is complete fracture with full displacement
 For garden I (incomplete fracture)
 Garden II (complete fracture without displacement)
 Garden III (complete fracture with partial
displacement)

 Management usually is open reduction and internal

fixation
 Treatment of choices includes : cannulated hip screw
, dynamic hip screw,cephalo-medullary device.