Orthopedic Case History

1. TRAUMATOLOGY CASE
HISTORY
OTUNEYE OLUWAKEMI
GROUP 25
KURSK STATE MEDICAL UNIVERSITY
5TH YEAR 9TH SEMESTER

2. PATIENT PROFILE
• Name:Ushakova Luditsv Yuriev
• Age: 46 years old
• Sex: female
• Occupation:
• Date of admission: 13th February 2023
• Address: deriglazova 115

3. SUMMARY OF CASE
• A 46 year old woman from Kursk Russia
was admitted for a trauma case. The
patient was okay according to her report
until on Sunday the 12th of February 2023,
when she sustained an ankle injury. She
said on the morning of the accident she
got on the street, walked down the street,
slipped and fell.
• Afterwards she called and ambulance.

4. • She complained of pain at the site of injury, which is sudden onset. It
was intermittent, throbbing in nature, aggravated on movements
especially on movement of the right leg and foot.
• There is swelling at the site of fracture afterwards, start insidiously,
increasing in size
• she was then sent to the hospital , on the same day she was told it
was a broken ankle.
• The next day on Monday the 13th of February an x-ray of her right
foot was taken and she was told there is a fracture and she was
admitted to the trauma hospital .

5. • On general examination patient conscious and vitals are stable.
• On local examination (rightAnkle)
• Inspection
Attitude - Planter flexion
Swelling - Present in medial and lateral side
Lesion - abrasion present over lateral malleolus

6. • Palpation
Local temp was raised,
Tenderness was present
Swelling was present
• Movement was painful and restricted
• • Dorsalis pedis artery and posterior tibial artery palpable bilaterally

7. DIAGNOSIS
• She had right Ankle Bimalleolar fracture -Medial Malleolus and
Lateral Malleolus
• The site of the injury was dressed with Bandage to limit the
movements around this area

8. INVESTIGATION
• Lab investigation -FBC, ESR, C reactive protein
• Total lymphocyte count
• Imaging -X ray of the right leg AP and lateral view,

9. X-RAY IMAGING
-GRAMS OF THE RIGHT ANKLE JOINT IN 2 X PR-X FOOT
SUBLUXATION OUTWARD, DISPLACEMENT OF THE FRACTURE:
OF THE MEDIAL MALLEOLUS OUTWARD BY 0.4 CM, FRAGMENT
OF THE LATERAL MALLEOLUS-POSTERIORLY BY 0.5 CM,
FRACTURE OF THE POSTERIOR EDGE OF THE DISTAL EPIPHYSIS
OF THE TIBIA, EXPANSION OF THE GAP OF THE DISTAL
TIBIOFIBULAR SYNDESMOSES

10. • On the 17th of February she was scheduled for a close reduction and
internal fixation surgery. She was given some pain killers while she
awaited for the surgery

11. OPERATIVE PROCEDURE
-PROTOCOL FOR SPINAL ANESTHESIA
• The patient is in the operating room. preoperative infusion was done in the ward.
• Patient ‘s vitals -breathing well, HR 17/min, pulse-76, blood pressure 130/80 mm Hg, oxygen saturation
(Sp02)-98%.
• Done under aseptic conditions puncture and catheterisation of left peripheral veins.
• Infusion therapy started - NaCl 0.9% 400 ml at 13:50.
• under aseptic conditions: sol. lidocaine 2%-3ml. at the level <3-<4, a spinal puncture was performed on
the 1st attempt. Needle: 22 G CSF received.
• Input: Sol. Marcaine spinal 0.5% - 3 ml., aseptic dressing. the effect is satisfactory. Complications –no
- level of anesthesia : foot - navel at 14:00

12. SURGICAL APPROACH
Medications given
• Atropin-0.1% -80mg
• Prednisolone- 30mg.
• Infusion during operation: Nacl 0.9%-800 ml
• Glucoses 5%- 800ml
• The operating Surgeon then manipulated the fracture by placing the bone in the right
position by pushing or pulling the bone. This procedure is known as traction.
• Once the fragments were aligned in correct position, metal plates, screws and pins are
used to hold the fragments in place.

13. • volume of the total infusion: / 600 ml.
• Diuresis: N ml. Blood loss: 20 ml.
• Hemodynamics during the operation is stable.
• Respiratory rate 17-16 per minute, pulse 76-82 per minute, BP (120-110/70 mm Hg.
• Operation duration-40mins
At the end of the operation, the patient’s llevel of consciousness is normal(alert).
Dynamic observation in the operating room - 15 min under the supervision of a doctor on duty
• Pulse :76 per min. Blood pressure 124/84mmhg
• Recommended: -Nacl 0.9%-800 ml

14. POSTOPERATIVE CARE
• A cast or splint was used to give rest to the operated part post
surgically
• Soon after the procedure, she was shifted to the recovery room where
she will be monitored until the effect of anaesthesia wears off. Once it
wore off, she was given some painkillers short-term pain and
antibiotics after the surgery.
• Crutches were given to her for minimal movement
• On the 19th she was taken for another x-ray imaging

15. POST OPERATION DAY 1
• Lateral malleolus Intramedullary
cancellous screw
• Medial malleolus Plate Fixation
with screw fixation

16. REHABILITATION
• The patient had no other injury or complications and was discharged
on the 22nd of February 2023
• Medication to relieve pain and prevent infections.
• proper rest and keep the affected area in an elevated position to avoid
swelling.
• Exercise as recommended by a physiotherapist to gain strength and
complete range of motion.
• Visit the hospitals on the scheduled