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ORTHO CASE STUDY final.pptx
- 2. Patient information • Name: Segole Makwe • Age: 59 years old • Sex: Male • Residence: Soshanguve • Occupation: Self Employed
- 3. Main complaint • Pain on the right foot
- 4. History of presenting complaint • Patient refers that he was mugged on his way home and was hit with a hard object on his right foot at around 10 in the evening . He rated the pain 10/10. it was not radiating and he says walking makes it worse and sitting down supporting the injured foot makes it better.
- 5. History • Systemic enquiry: Nothing of significance • PMH: No chronical illnesses, No known drug allergies, No previous surgical history • Family hx: he does not know • Social: Smoke 10 cigarrettes a day for 30 and has a pack year of 6years, an occasional drinker He is married and lives with his family
- 6. Examination • GA: middle aged man who looks clinically stable, conscious and alert and breathes well on room air, laying on his (L)side • Peripheral signs: JACCOLD- no positive findings • Vital signs: BP: 127/80mmHg(normal) Pulse: 87bpm(normal) RR: 18/min(normal) Temp: 35.4
- 7. Systemic examination • CVS: normal s1 and s2 no added heart sounds or murmurs • Resp: chest clear, equal bilateral entry • GIT: soft, non tender with no hepatosplenomegaly
- 8. Local examination of (R) leg Look • +/-5cm laceration • Tear of a deltoid ligament • Active bleeding • No swelling • Minimal contamination
- 9. Local examination Feel • The right ankle was cold, dry with active bleeding • Tendness to touch • Pulses are present, the dorsalis pedis and posterior tibial artery, comparable between both limps, no pulse delay.
- 10. Local examination Move • ROM on (R)leg: Active : Unable to do dorsiflexion, eversion and internal and external rotation Passive: We could not do any movement as the patient was complaining of severe pain. Neurovascular intact
- 11. Assessment
- 12. Differential diagnosis • Radial Fracture • Ulnar Fracture • Radial Subluxation • Ulnar Subluxation
- 13. Investigations Bloods • FBC + differential count: Hb, wcc • U&E: COVID swab Imaging • Leg X-rays: AP & Lateral view
- 14. X-rays
- 17. Diagnosis • Open fracture dislocation of the right ankle with a talus shift
- 18. Treatment In casualty • IV line 0.9% normal saline • Tetanus toxoid 0.5ml IM stat • Analgesic: Tramadol 100mg IM stat • Antibiotic: kefzol 2g IV stat • Debridement and close reduction
- 19. Plan • Cast Splintage • Antibiotics 1g tds • Below the knee half moon backslab. • Elevate for 24h and take to theater for deep debridement and externally fixation • Elevate above the heart level for 10days in the ward • Take to theater for ORIF • Discharge and follow up after 2 weeks