INTERNATIONAL MEDICAL SCHOOL

CASE WRITE UP
ORTHOPAEDIC
YEAR 4 OCTOBER
ROTATION 3

NAME : PRIEYA RAMASAMY

Name : Gajethran
Age : 16 years old
Address : Meru, Klang
Gender : Male
Race : Indian
Religion : Hindu
Occupation : School Student
Marital status : Single
Informant : Patient
Place of admission : Ward 5B, Hospital Tengku Ampuan Rahimah
Date of admission : 19th February 2019
Date of clerking : 19th February 2019

CHIEF COMPLAINT
Pain, swelling and inability to move right lower limb due to Motor-Vehicle Accident
HISTORY OF PRESENTING ILLNESS

My patient, who has no any known medical illness, was apparently well till today
afternoon around 2 p.m. He met with a motor vehicle accident when he was on the way
back from school. He was riding a motorcycle and accidentally collided with a car in
front of him when the car had a sudden brake. He knocked on to the car’s rear bumper.

He fell off from his motorcycle since he was not able to apply the brake on his
motorcycle. He flew and fell on his right side. He was riding his bike about 40 km/h
when the incident happened. He was not wearing his helmet during the incident.

He sustained injury on his right upper limb and right lower limb. He had pain on his right
lower limb. The pain was pricking in nature. The pain was not radiating to anywhere
else. It was aggravated upon movement but has no any relieving factors. Pain score
during the incident was 8 out of 10. His right leg swell from the foot up to his shin. He
had bruises on his right upper limb and on the right knee.

He then called his brother and was brought to Klinik Kesihatan Meru by his brother.
Dressing was donek for the bruises and he was sent to Hospital Tengku Ampuan
Rahimah by an ambulance for further treatment. In the Emergency Department of
HTAR, blood tests and X-Ray was done. He was also given analgesics. He was then
admitted into ward 5B. An above knee backslab was done for his right lower limb.

Currently, he has been told that he has a lower limb fracture and his pain score upon
clerking was 3 out of 10.
PAST MEDICAL AND SURGICAL HISTORY
He has no any known medical illness.

He was admitted in Hospital Kuala Lumpur on December 2018 for 1 week due to
Dengue Fever.

He has not undergone any surgical interventions before.

DRUG AND ALLERGY HISTORY

He has allergy towards seafood where he develops swelling and rashes all over his face
if he consumes them.

He has no any drug allergy.

FAMILY HISTORY
His father is 45 years old and healthy.

His mother is 42 years old and healthy.

He is 3rd out 3 siblings. His sisters are 20 and 19 years old. Both of them are healthy.

No any malignancy or significant disease runs in the family.

His family lives in Sentul.

He currently lives with his aunty and cousins in Klang.

He is financially supported by his cousins.

SUMMARY
Gajethran, a 16 year old Indian boy, a school student with no any known medical illness
came with a chief complaint of pain, swelling and inability to move his right lower limb
due to motor vehicle accident.
PHYSICAL EXAMINATION

GENERAL EXAMINATION
Inspection:
He was lying comfortably on the bed, conscious and alert. He was not in mild pain but
was not on respiratory distress and clinically appeared pink. He was thin built with good
hydration and nutritional status. He had an ID tag on her right hand and IV branula on
the left dorsum of his hand attached to a bottle of Normal Saline. He was on a backslab
for her right lower limb.

Vital Signs:
 Temperature : 36.5ᵒC
 Pulse rate : 88 beats per minute (Regular rhythm, good volume)
 Respiratory rate : 18 breath per minute
 Blood pressure : 118/78 mmHg

Hand:
 The palm was warm and pink.
 No cyanosis
 Capillary refill time is less than 2 seconds.

Eyes:
 No pallor , no jaundice and no subconjuctival hemorrhage

Mouth:
 Oral hygiene is good
 Lips and tongue were moist
 No cyanosi

Neck:
 No lymphadenopathy.

Leg:
No pitting edema and no varicose vein
LOCAL EXAMINATION
Look

His right lower limb was elevated by 2 pillows and a backslab was placed from above
knee joint till his ankle bandaged with a crepe bandage. His right foot appeared to be
externally rotated with the backslab on. Swelling over the right ankle region and dorsum
of the foot noted. No skin discolorations. I was unable to assess the length and
alignment of the limb.

Feel:

Temperature was normal on his right lower limb as compared to the left lower limb.
Tenderness was elicited over the distal one third of his right lower limb. There was no
appearance of discontinuity of the bone.

Move:

He was able to move his toes in flexion and extension. However he was unable to
plantarflex and dorsiflex her ankle due to pain. Apart from that, other range of
movement for knee and hip joint cannot be elicited.

NEUROVASCULAR EXAMINATION:

Pulses are palpable at dorsalis pedis artery and posterior tibial artery. Capillary refill
time is less than 2 seconds. His sensation for tibial nerve, superficial and deep
peroneal nerve, sural nerve and greater sciatic nerve was intact. No foot drop noted.

Chest , shoulder and pelvic spring was done. No pain or any dislocations noted.

CARDIORESPIRATORY EXAMINATION

Cardiovascular system was examined. First and second heart sounds are present. No
murmur detected. Respiratory system was examined. Lungs were clear. Normal breath
sounds were present.
ABDOMINAL EXAMINATION

Abdominal examination was done. Abdomen was soft, no tenderness and no palpable
masses.

SUMMARY
My patient, Gajethran, a 16 year old Indian boy with no any known medical illness
presented with a chief complaint of pain, swelling an inability to move his right lower
limb due to a motor vehicle accident. He also had bruises on his right upper limb and on
his right knee.

Upon physical examination, he had tenderness over his distal one third of his right lower
limb and he also had swelling over the ankle and the dorsum of his right foot.
Otherwise, there were no any significant findings.

DIAGNOSIS
CLOSED FRACTURE OF RIGHT DISTAL TIBIA

POINTS SUPPORTING :-

 Pain and swelling of the right lower limb below knee

DIFFERENTIAL DIAGNOSIS
 Closed fracture of left medial malleolus
 Dislocation of left ankle joint
 Closed fracture of midshaft of tibia and fibula
INVESTIGATION
1. FULL BLOOD COUNT
 Hemoglobin - 14.8 g/dl
 WBC - 8.34 10^9/L
 Hematocrit - 43.2%
 Platelet - 276
 CRP - 12.73

2. X-RAY
DEFINITE DIAGNOSIS
SPIRAL FRACTURE OF DISTAL THIRD TIBIA AND FRACTURE OF
PROXIMAL THIRD FIBULA

MANAGEMENT
1. For cryocuff of right lower limb
2. Elevate right lower limb
3. Watch out for compartment syndrome
4. T. Voltaren 50mg TDS
5. Dressing over abrasion wounds
6. For right above knee POP later once swelling subsides
 DISCUSSION
Lower leg fractures include fractures of the tibia and fibula. Of these two bones,
the tibia is the only weight-bearing bone. Fractures of the tibia generally are associated
with fibula fracture, because the force is transmitted along the inter-osseous membrane
to the fibula. Fractures of the tibia can involve the tibial plateau, tibial tubercle, tibial
eminence, proximal tibia, tibial shaft, and tibial plafond. Fractures of the tibia are the
most common long bone fractures. The annual incidence of open fractures of long
bones is estimated to be 11.5 per 100,000 persons, with 40% occurring in the lower
limb. The most common fracture of the lower limb occurs at the tibial diaphysis.  Isolated
mid-shaft or proximal fibula fractures are uncommon.

Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories:

 Low-energy injuries such as ground levels falls and athletic injuries

The most common types of tibial shaft fractures include:

Transverse fracture: In this type of fracture, the break is a straight horizontal line
going across the tibial shaft.

Oblique fracture: This type of fracture has an angled line across the shaft.

Spiral fracture: The fracture line encircles the shaft like the stripes on a candy
cane. This type of fracture is caused by a twisting force.

Comminuted fracture: In this type of fracture, the bone breaks into three or more
pieces.

Open fracture: If a bone breaks in such a way that bone fragments stick out through
the skin or a wound penetrates down to the broken bone, the fracture is called an
open or compound fracture. Open fractures often involve much more damage to the
surrounding muscles, tendons, and ligaments. They have a higher risk for
complications—especially infections—and take a longer time to heal.

REFERENCES

1. APLEY AND SOLOMON’S CONCISE SYSTEM OF ORTHOPAEDICS AND

2. https://orthoinfo.aaos.org/en/diseases--conditions/tibia-shinbone-shaft-
fractures/