Welcome to
Morning
Session
Dr Md. Sarifullah Mahmud
MS Resident(Phase-B)
Orthopaedic Surgery ,DMCH
Unit -II
Particulars Of The Patient
• Name :Md Mahbub
• Age :35years
• Sex :Male
• Address :Bandor, Barisal
• Date of Admission :24/5/2023
• Bed No :39(B)
• Reg No :41284/173
• Ward:North Cabin
• Mobole No:01309355433
Chief Complaints
• Pain in upper part of left leg for 15 days following
physical assault
• Inability to stand and walk over left lower limb for
same duration.
History of present illness
According to patient’s statement he was relatively
well 15 days back. Then he sustained trauma due to
physical assault and developed pain in upper part of
left leg. Pain was constant, localized, severe in
nature, associated with bleeding, aggravated by any
sorts of movement & partially relieved by taking rest
& analgesics.
History of present illness
He noticed swelling & deformity of upper part of left
leg . He also complained inability to walk & stand
over left lower limb .He is nondiabetic, normotensive
& non asthmatic. His bowel & bladder habits were
normal. With these complaints, he initially got
himself admitted to Sher-E-Bangla Medical College
Hospital & referred to DMCH for better
management .
• History of past illness: Nothing contributory
• Treatment History: Diagnosed as a case of Right
sided parietal extra dural hematoma(EDH) & treated
operatively by parietal craniotomy(Right) &
evacuation of EDH on 15/5/2023.
Long leg back slab was applied during admission
• Personal History: Nothing Contributory
• Socio-economic History: Belongs to middle class
family.
• Immunization History: Immunized according to EPI
schedule & vaccinated against COVID-19
• Allergic history : no known drug or food allergy
• Drug History: Nothing Contributory
• Occupational History: businessman
General Examination
• Appearance : Anxious
• Body build : average
• Decubitus : Supine
• Anaemia : absent
• Jaundice : absent
• Dehydration : absent
• Pulse : 78 beats/min
• BP : 120/70 mm of Hg
• Temperature : 98o F
• RR : 15 breaths/min
Respiratory system
Inspection:
• No visible apex beat or engorged vein.
• Respiration pattern: Abdomino-thoracic.
• Symmetrical movement of chest wall present.
• Respiratory rate & rhythm : 16 breaths/min & regular.
Palpation:
• Trachea - Centrally placed.
• Apex beat - Palpable on left 5th intercostal space just
medial to midclavicular line.
• Vocal fremitus - Equal on both sides.
• Chest expansion - 2.00cm (Normal 5-7cm)
• Tenderness on chest wall- Absent.
Percussion:
• Percussion note is resonant on both sides.
• Upper border of liver dullness : Right 5 th intercostal space
along the mid clavicular line.
Auscultation :
• Breath sound- vesicular.
• Vocal resonance - equal on both side.
• No added sound present.
Cardiovascular system
Inspection:
• No visible pulsation present.
• No venous engorgement.
Palpation:
• Apex beat - Palpable at left 5th intercostal space just
medial to midclavicular line.
• No thrill or left parasternal heave present.
Percussion:
• Area of superficial cardiac dullness - Normal.
Auscultation:
• Heart sound - Normal.
• No added sound present.
Alimentary system
Inspection:
• Abdomen is scaphoid in shape.
• Umbilicus is centrally placed & inverted.
• Movement with respiration - present.
• No visible peristalsis or engorged vein.
• Hair distribution is normal.
• Hernial orifices are intact.
Palpation:
• Temperature: Normal.
• Tenderness: Absent.
• No muscle guard or rigidity.
• No localized swelling or hyperaesthesia present.
• Fluid thrill - absent.
• Liver, spleen & kidney - not palpable.
Auscultation:
• Bowel sound - present.
Nervous system
• Higher psychic function test: Normal.
• Cranial nerve examination: Reveals no abnormality
detected
• Reflex: All superficial & deep reflexes are normal
• Sign of meningeal irritation: Absent .
Loco regional examination of lower limb
Look :
• Patient is supine on bed with long leg back slab on left
side .I examined the patient after removing the slab.
• Granulating wound ( size:2*2cm) present over antero-
medial aspect of upper part of left leg
• Mild swelling over upper part of left leg
• No apparent LLD & muscle wasting
Loco regional examination of lower limb
Feel :
• Temperature : Normal
• Tenderness : present over upper part of left leg
• Limb length discrepancy : there was 1cm shortening
of left lower limb in comparison to right lower limb
which is tibial component
• Distal neurovascular status : intact
Move :
• Both left hip & knee joint movement could not be
elicited due to pain.
• Movement of left ankle joint: full ROM .
Salient feature
• Md Mahbub 35 years old male hailing from Barisal
presented with the complaints of pain in upper part
of left leg for 15 days following physical assault.The
pain was constant, localized, severe in nature,
aggravated by any sorts of movement & partially
relieved by taking rest & analgesics, associated with
bleeding. He noticed swelling & deformity of lower
part of left leg .
Salient feature
He also complained inability to walk & stand over
left lower limb. He is nondiabetic, normotensive &
non asthmatic. His bowel & bladder habits were
normal. With these complaints, he initially got
himself admitted to Sher-E-Bangla Medical College
Hospital & referred to DMCH for better
management. Long leg back slab was applied during
admission .
Salient feature
All parameters of general and systemic examination
were within normal limit. On loco-regional
examination, Patient is supine on bed with long leg
back slab on left side. Granulating wound
( size:2*2cm) present over anterio-medial aspect of
upper part of left leg .Mild swelling present over left
upper leg & no apparent LLD & muscle wasting .
Salient feature
Temperature was normal.Tenderness present over
upper part of left leg .Thise was 1cm shortening of
left lower limb in comparison to left lower limb which
is tibial component. Distal neurovascular status was
normal. Both left hip & knee joint movement could
not be elicited due to pain.Movement of left ankle
joint was full ROM .
Provisional Diagnosis
A case of 15 days old open fracture (G-II) of proximal
shaft of tibia(left) with head injury in a 35 years old
male.
X-ray of left leg B/V view(14.05.2023)
X-ray of left leg B/V view (27.05.2023)
X-ray of left leg B/V view (27.03.2023)
Lab findings
• Hb% : 11.5gm/dl
• WBC count:7,400/mm3, ESR:24mm in 1st hour
• RBS :5.8mg/dl
• S.Creatinine:0.9mg/dl
• HbsAg :Negative, Anti HCV:Negative
• Blood group:A(+ve)
• S. Electrolyts:
• Na+:142 mmol/l, K+:3.25 mmol/l, Cl-:106 mmol/l
• CRP:2mg/L, 1.2mg/L
Clinical diagnosis
• A case of 15 days old open fracture (G-II) of
proximal shaft of tibia(left) with head injury in
a 35 years old male.
• AO type -42B3
Unit plan
• Close reduction & internal fixation by
proximal tibial locking plate & screw
(MIPO technique)
Implant list
1. Proximal tibial locking compression plate(medial
and lateral)-
2. Buttress plate – T shaped
3. Buttress plate- L shaped- Rt and left
4. 6.5 mm cannulated and non cannulated cancellous
screws( various size, distal 16/32 mm threaded, full
threaded) with wahis
5. 4.5 mm cortical screw, 5.0 mm cancellous screws
6. K- wires- various size
Thank you
