A diabetic man with a history of tibia and fibula fracture treated with interlocking nail fixation 3 months ago presented with redness, swelling and foul-smelling discharge from his left leg. X-rays showed no healing of the fracture site. He was diagnosed with chronic osteomyelitis based on clinical findings and history. Management involved investigating with blood tests and imaging, surgically debriding dead tissue, administering IV antibiotics for 2-3 weeks followed by oral antibiotics for 6-8 weeks, optimizing blood sugar control, and considering implant removal or bone grafting.

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,Assignment on trauma complications
– Infection & Neurovascular injuries
1- Complete the table below:(70 marks)
No
Injury Common
neurovascular
injury(ies)
Clinical findings that support the Dx of injury(ies)
1 Shoulder
dislocation
Axillary nerve
palsy
- sensory:regimental badge sign
o over upper lateral of armor deltoid insertion
o sensory loss over outer lateral area of arm
- motor: weak deltoid, tested by abduction strength at
shoulder
Axillary vessel
injury (vein and
artery)
- impalpableaxillary artery
- impalpablebrachial artery
- compromise armcirculation (cold,pallor,delayed capillary
refill time)
palehand, decrease crt, cold peri
2 Humerus
fracture
Radial nerve - motor: depend on level of fracture
o loss elbowextension mean injury ataxilla)
o lesion in arm: weak/normal elbow extension,
wrist,thumb, finger drop (MCP JOINT)
o low (in radial groove) : wrist,thumb, finger drop
- sensory loss:firstwebspaceof dorsal/anatomical snuff
box, post surfaceof armand forarm
- absent supinator and triceps reflex
Profunda
brachii artery
- impalpablebrachial artery
- compromise armcirculation (cold,pallor,delayed capillary
refill time)
3 Supracondylar
fracture
Anterior
interosseous
nerve (median
nerve)
AND MEDIAN
NERVE
(RADIAL NERVE
RARE)
MEDIAN NERVE
- MOTOR: loss of opposition between on thumb and index
finger (OK sign)
- HAND OF BENEDICTION (CANT FLEX THE INDEX AND
MIDDLE FINGER ON MCP JOINT due to palsy of fdp radial 2
and lateral 2 head of lumbricel),voluntary flexion of ring
and litthe finger
- WEAK FOREARM PRONATION, WRIST FLEXION, WRIST
ABDUCTION, FINGER FLEXION, GRIP STRENGTH AND
OPPOSITION
- loss thumb juga,flexion,abduction,opposition
- SENSORY: NUMB AT THENAR AND MEDIAN DISTRIBUTION
OF NERVE (SKIN OF THERNAR, TIP OF FINNGER PALMAR
SIDE)
HIGH: above elbow: weak, wristflexion,finger flexion,thumb
flexion,opposition,abduction
LOW: after mid forearm, thumb je yg affected
AIN
- pure motor neuropathy
- isolated palsy of 3 muscle(fpl,index and long finger fdp,
pq)
- mostly pain in forearm
- characterisetic,weakness atthumb and index finger pincer

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movement
- no sensory
- froment sign
4 Monteggia Posterior
interosseous
nerve(radial
nerve)
- thumb and finger palsy ONLY
- INABLE TO EXTEND THUMB AND FINGER AT MCP JOINT
- pin only numbness, no motor!
- only post forarmpain,no weakness
- sever casemay have weakness of wristand finger extensor
- wristweak, no numbness, finger flexion weak mcpj
5 Hip
dislocation
Femoral artery - impalpablefemoral pulsation
Sciatic nerve - loss all kneeflexion,loss all motor activity atankleand
foot
- sensory loss as common peroneal and tibial nerve
distribution
- loss anklereflex
- loss hip extension
Femoral nerve - loss knee extensor and mild loss hip flexion
- sensory loss atanteromedial aspectof thigh and
anteromedial aspectof leg via sephaneous nerve
6 Knee
dislocation
Popliteal artery - impalpablepopliteal pulsation
Tibial nerve - weak plantar flexion
- sensory loss atplantar aspectof foot
7 Fracture of
head of fibula
Common
peroneal nerve
- sensory:loss dorsumof foot
- motor: weak dorsiflexion
- superficial peroneal nervesensory loss over firstwebspace
of dorsum and weak ankleeversion
2- Write a short note (bulletedparagraphstyle) onclinical diagnosis and
management of carpal tunnel syndrome. (up to 200 words - 15 marks)
answer:
- carpal tunnel syndrome clinical diagnosisby history and clinical examination
- history
o pain over ventral aspectof wrist and hand, noted to be more when wriston extended
position (typingon computer) or by doingcertain repetitive activities (athlete)
o numbness and tinglingover radial 2 and half digit palmar surface
o longterm patient can complain weakness on hand grip
o night pain severe enough to awake patient at nightand, relieve by elevated arm above head
o any past history fractureto hand: malunion of distal radiusfracture
o any swelling/bumb over wristarea (ganglion compressing)
- risk factor can be elicited through history (MEDIAN TRAP)
o Myxedema/hypothyroidism
o edema
o diabetes mellitus
o idiopathic
o acromegaly
o neoplasm
o trauma

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o rheumatoid arthritis
o amyloidosis
o pregnancy
o female patient
o obesity
o cushingsyndrome
o chronic renal failure
- examination
o look: not much abnormality, thenar muscleatrophy can be seen if long history and median
nerve is involved
o feel: pain,tenderness, riseof temperature
o move: restricted arm movement, pain
o special test:
 tinel test: tappingalongmedian nerve over carpal tunnel aka volar wristproduce
tinglingand numbness over radial 2 and ½ digit,
 durkan test: manual pressureapply to median nerve over carpal tunnel aka volar
wristproduce tinglingand numbness over radial 2 and ½ digit
 phalen test: flex both wristfor 1 – 2 minute, will producetingling and numbness
over radial 2 and ½ digit
- carpal tunnel management
o investigation:clinical diagnosis,several investigation can beconducted
 x ray hand and wristAP view to see if there is any fracture/malunion
 usg and mri wristcan be done: ganglion? carpal tunnel visualisation for any mass or
swelling
 nerve conduction study: confirmmedian nerve compression
 electromyography of muscle supply by median nerve-delay motor nerve conduction
(Lumbricleradially,Opponen pollicis,Abductor pollicisbrevis,Flexor pollicis brevis)
 ruleout systemic causes:fastingblood sugar (DM), thyroid function test (THYROID)
o treatment
 conservative:trial of night splintand activity modification for 6 month, intra-carpal
tunnel steroid injection
 surgical management: carpal tunnel release(open or arthroscopic)
3- Write a short note (bulletedparagraphstyle) onclinical diagnosis and
management of Ulnar claw hand. (up to200 words - 15 marks)
answer:
- ulnar clawhand clinical diagnosis can beelicited by history and examination
o history of trauma to arm, accident, deep laceration especially in medial aspectof elbow
o fracture of supracondylar of humerus,fall with arm out-strectch
o history of elbow dislocation,
o cubitus valgus dueto non-union fractureof lateral epicondyle fracture(tardy ulnar nerve
palsy)
- examination:
o look: clawingdeformity (hyperflexed interphalangeal joint,hyperextension of metacarpal
jointof ringand littlefinger-intrinsic minus hand), normal thumb and first2 finger, any scar
(help to diagnoselevel of injury),muscleatrophy (guttering of dorsal aspect-interossei,
hypothenar atrophy), swelling,redness,wounds, bruise,discharge
 ulnar paradox:
 ulnar nerve supply the flexor carpi ulnaris and hypothenar muscle (abductor pollicis,
flexor digiti minimi, opponen digitii minimi, ulnar lumbricle, all interossei and ulnar 2
flexor digitorum profundus.

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 In ulnar nerve lesion, the higher the lesion (near elbow) the less severe the clawing
defromity, the lower (near wrist) the lesion the severe the clawing deformity.
 In higher lesion the ulnar 2 flexor digitorum profundus is paralyse, there is no
hyperflexion at distal interphalageal joint and, while in the lower lesion, the
interosseoi and ulnar lumbricle paralyse casuing metacarpalphalageal joint to be
hyperextended and interphalageal joint hyperflexed due to unopposed ulnar 2 flexor
digitorum profundus and flexor digitorus superficialis action.
 complete claw hand: palsy of ulnar and median nerve
o feel: pain,tenderness, riseof temperature, sensory loss over tip of littlefinger (lowlesion) or
ulnar sideover dorsal surface(high lesion)
o move:
 high lesion:
 weakness in elbow flexion in radial deviation,
 weakness of medial 2 finger flexion over mcp and ip jpint
 weakness of hypothenar muscle- little finger pen test
 weakness in interossei- card test, egawa test
 low lesion
 weakness of medial 2 finger flexion over mcp and ip jpint
 weakness of hypothenar muscle- little finger pen test
 weakness in interossei- card test, egawa test
 adductor (adductor pollicis) compartment:
 froment sign- loss of thumb adduction and flexion at thumb ip joint
compensated by flexor pollicis longus (causing thumb to go into
hyperflexion when patient is asked to grip and pich a piece of flat object
such as paper)
 tinel sign : tapping alongnerve course from distal to proximal (only to
wrist-not high enough), recovery sign showpresence of numbness and
tinglingin area of nerve distribution (ulnar border and small finger)
o examine also oppositeleglateral side,to consider for sural nervetransfer in caseof nerve
graft needed. look for any scar or injury to lateral legsurface.
- management of ulnar clawhand
o investigation:
 clinical examination
 plain radiograph:visualisefracturelocation to help in predictinglevel of nerve injury
or to visualisedislocation of joint
 nerve conduction study: test the speed of conduction of electrical impulsethrough
nerve as itis beingstimulated through surfaceelectrode (maintained in neuropraxia
and lostin axonotmesis and neurotmesis)
 electromyography: graphic recordingof electrical activity in musclein responseto
electrical stimulation through needle inserted into muscle at rest and at voluntary
contraction (sign of recovery: fibrillatory potential presenceafter 2-3 weeks)
 MRI
o based on type of nerve injury (axonotmesis,neurotmesis,neuropraxia))
o mostly nerve injury managed conservatively
 limb care,preserve mobility as nerve recover in 3-6 weeks (neuropraxia)
 splint–knucklebender from ulnar claw
 range of motion exercise
 skin and nail care
 physiotherapy to avoid stiffness and retan jointmobility
o for severe nerve injury, operativemanagement
 tendon transfer can be done to preserve mobility atjoint
 neurotisation aka nerve transfer

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 neurolysis isnerveentrapted in neuroma or callus
 coaptation,end to end nerve repair
 nerve graft from sural nerve
4- A 35-year-old diabetic gentlemanwas admittedfor closed fracture of left
tibia& fibula and underwent interlocking nail fixation3 months ago.
Currently patient is afebrilehowever milderythemaand swelling as well as a
foul smelling sinus discharge was notedaroundthe left mid-leg.
His X-ray is attached. Write a short note (bulletedparagraphstyle) on
management of current complicationinthis patient. (50 marks – up to300
words).
answer
- elderly,man, diabetic unknown control and medication compliance,with pasthistory of closed
fracture tibia and fibula treated with interlockaingnail fixation (orif-3month ago)
- now present with mild redness and swelling (feature of incetion),but afebrile
- dischargefoul smelling,sinusopeningon left mid leg
- probably chronic osteomyelitis isthecurrent complication
- management
o investigation
 full blood count: rbc (anemia?) wbc (leucocytosis?) dlc (polymorphonuclear cell rise)
esr crp (sign of chronic inflammation)
 fastingblood sugar,hba1c- sugar control and compliance
 serum electrolyte/rft: serum potassium,sodium,serum urea, creatinine
 urineanalaysis:glucosuria,pus cell in urineuti?
 x ray affected limb:to see ofr fracture healing,implantand presence of
sequestrum?
 ct scan:to detect sequestrum
 mri: to visualiseabcessin tissueplaneand sinus tract
 sinugram:tractsinus pathway
 pus swab culture and sensitivity:specific antibody coveragebased on culture and
sensitivity
 culturefrom deep part/from insideof wound, not from sinus
o treatment
 ESSENTIALLY SURGICAL
 treat dead tissue:sinus tractexcision,sequestrectomy, saucerization based on the
bone condition and availability of enough involuvrum.curettage to remove all dead
and unhealthy tissue
 antibiotic laden cement bead might be inserted in the cavity
 treat dead tissue:bone graftcan be done/cancellous bonegraft or myocutaneous
flap transfer for soft tissuedifect

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 exchange to ilizarov method can be used: implantremoved as itmight be a sources
of infection
 iv antibiotic fot2-3 week, switched to oral antibioticfor next 6-8 weeks
 antibiotic choiceare:broad spectrum (eg: 3rd generation cephalosporin
ceftriaxone+ vancomycin + flucoxacilin)
 can be changed to specific antibiotic based on report of cultureand
sensitivity
 treat precipitatingcause
 optimiseblood glucosecontrol,insulin slidingscale,diabetologistreferrel
 treat underlyinganemia if present
-
- plain radiography of leftleg
- ap and lateral view
- interlockingnail in situ noted
- fracture sitenon healingas there is no callusformation and fracturelineis visibleseen even after 3
week

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