HPI - The patient had a closed fracture of the left femur following road traffic accident 3 month ago. The patient was treated by open intramedullary nailing which was complicated by iatrogenic fracture of the neck of the femur. Pinning of the fractured neck femur was done on the second day.
3 days later the patient had yellowish discharge from the wound used for reduction of the fracture. C & S: Klebsiella treated by imipenem and cilastatin for 15 days.
Labs on April 15th:
CRP: 2 ( N LESS THAN 0.5)
Labs on May 17th:
CRP: 1.7 (N LESS THAN 0.5)
In your opinion, what is the best treatment option?
HPI - H/O RTA 02 yr back
Sustained Galeazzi # R side with lacerated wound at rt forearm
Distal radius ulna # in the left forearm
Managed by close reduction and casting somewhere else
Multiple debridement and closure of soft tissue injury
After 02 month cast removed and physiotherapy started
Kept on conservative Rx & physiotherapy for 02 yr
what should be the treatment plan??
HPI - Optd in other center 04 yrs back for some calcaneal lesion - Curettage + Autologous iliac crest Bone grafting was done. (Documents, previuo radiographs and HPE report not available) .. wounds healed.
Sustained trauma to same side 01 yr back.. developed swelling laterally in hind foot. Had some discharge for a months which resolved on medications.(? antibiotics) and dressings.
Presently has swelling over the hind foot behind and below lateral malleolus (Picture for reference). Mild pain on weight bearing. No discharge.
Treatment options presently
HPI - Sustained fracture ulna shaft right Oct 2014.
Optd at another center using a posterior approach with ORIG with Plating of ulna.
How would you treat this patient?
HPI - RTA in 2012 - Open fracture distal femur with bone loss.
Initially managed with debridement, acute shortening (bone lost at the incident site) and K Wire fixation of fragments at different center ...
Later on put on Extenal fixator at another center ...
Patient consulted another center in 2013 ... Open reduction + Distal femoral locked plating was done .. bone grafting was not done.
continued to have pain and features of infection at the fracture site... Implant failure
Feb 2015 - Implant removal and debridement was done.. followed by antibiotics
Presently wound healed, no pain or discharge, ESR, CRP normal.
Ambulant with axillary crutch and brace support ... 12 cm of shortening.
How would you manage this patient at this time?
HPI - Fell from her height
What is the best treatment?
HPI - 4 days ago fell of the bike
HPI - Optd for closed fracture shaft femur in Jul 2014 - Open reduction + IL IM nailing femur done.
Dynamization of nail was done oin Oct 2014.
Was ambulant and no pain till Apr 2015.
Sustained slip in Apr 2015 and developed pain and swelling right thigh and painful weight bearing.
HPI - Delayed milestones
Most common association with this radiographic picture.
HPI - Pain thigh for 03 months spontaneous onset, gradually progressive.
No history of trauma, fever, tuberculosis in past.
Likely diagnosis on radiographs
HPI - Polytrauma patient, rib fx, pneumothorax, open left femur fx, closed right femur fx. Has chest tube currently, admitted to ICU (on 5/11/15)
Definitive treatment of left femur?
HPI - Fall on outstretched left hand
Is this a known pattern of injury ?
HPI - patient comes to the consult at 10 years of age mother refers surgical procedure at the age of 5 months, unspecified surgery at 2005 (elsewhere), also did not specify why follow up was lost until now.
At this age, what treatment would you offer to this patient and parents?
HPI - 17 yo male with 1 week of pain after walking at school. XR in ER are normal in first images. no constitutional symptoms. walking down steps and hears a pop in leg with pain with Xr showing displaced posterior cortex fracture and no anterior involvement. Has anyone seen a fracture pattern like this previously and any comment as to its etiology??
Is this fracture pattern suspicious for:
HPI - volume increased pain at metatarsal plantar.
What is your diagnosis?
HPI - Patient fell with the bike. No other complaints. Immediate closed reduction in ER.
How would you treat this injury?
HPI - History of injury right knee joint 15 yes back .Treated conservatively .Now presenting with pain on walking
Should TKR be done as a single stage or two staged procedure
HPI - 18 y/o male who presents with knee pain s/p football injury. MRI ordered by primary care doctor for evaluation of MRI - showed fracture and ACL tear. No prior injury.
How would you treat this fracture?
HPI - Vehicular Accident. Fell from a motorcycle.
How will you treat this multiply Injured patient?
HPI - Patient with bilateral knee osteotomy 10 years ago.
Now with knee OA.
HPI - 58 y/o postmenopausal long distance runner with 3 month history of left groin pain. MRI shows stress lesion subtrochanteric proximal 1/3 of MEDIAL femoral cortex
How would you treat this patient at the current time?
HPI - Patient was riding a motor bike in South East Asia when a car pulled out in front. Patient then swerved to miss the car and ended up going head first into a metal pole on the side of the road. He was wearing a helmet and traveling at 40 km/hr.
At hospital MRI showed no ligament damage but CT showed fracture of the right anterior arch and left posterior arch right behind the left lateral mass. CT also showed a clay shovelers fracture attributed to the patient holding on tightly to the handlebars. The patient was then airlifted to Singapore.
Time frame and Planning:
Week 1: Fitted with halo (discharged from hospital after 10 days)
Week 8: Halo removed Aspen Vista applied, no union
Week 12: New Scans, no improvement, gap widened.
Week 14: Soft Collar used during sleeping and on and off during day.
Week 16: Sleeping without brace, no brace for 50% of day. Return to work part time
Week 18: No brace.
Week 22: Return to work full time.
Currently the patient is a
Many patients have non-union. Is this a cause for concern?
HPI - Onset Oct 2014 - Mild pain left hip anteriorly after end of activities (evening pain after playing).
No history of trauma, fever, constitutional symptoms, obviuos limp, wt loss.
Has been treated suspecting infection at another center with antibiotics... Although no clinical history suggestive of any infection.
Clinical condition has remained static, no worsening of pain.
How would you treat this patient at this stage?
HPI - Active male.
Sustained fracture neck femur right hip in Nov 2014 for which optd at another center with Uncemented Bipolar HRA utilizing posterior approach.
Post op had persistent and increasing pain and stiffness right hip and painful weight bearing..
Jan 2015 - Evaluated for the above ...Healed surgical wound .. local temp increased painful movement .... Radiographs s/o progressive heterotopic ossification around hip ... Bone scan +ve for infected prosthesis, ESR and CRP positive. TLC WNL. Alkaline phosphatase - 100.
Underwent Hip aspiration under fluoroscopic guidance .. No pus/ fluid aspirated.
Feb 2015 - Underwent Removal of prosthesis and Debridement with excision of heterotopic mass which was obstructing implant removal. Intra op no pus or any abnormal fluid. Intra op cultures negative
Post op skeletal Traction applied.. indl was totally non compliant with skeletal traction .. surgical wound healed .. Post op given Tab ofloxacin and rifampicin for 06 weeks
Which approach to hip has the maximum risk for heterotopic ossification
HPI - Level fall 2 weeks ago, because of a operating room lack we could not fix it earlier.
HPI - Continuos secretion through a medial fistula on his tibia for the last 2 years
What is the best approach?
HPI - 25 yr female presented with rt lateral pelvic tilt,thigh adduction,internal rotation and tight rt hamtrings since childhood underwent adductor release plus hamstring release and derotation osteotomy 6 months ago,pelvic tilt improved(3cm on standing,5cm supine), patient now wear 1.8cm shoe lift and still have limping
What is the best treatment method to correct limp length inequality?
HPI - 6 yr female Rt handed, had closed Lt elbow supracondylar fracture type 3 reduced in ER, 4 days ago,treated second day by open reduction using campell approach due to 2 failed attempts of closed reduction,post reduction xray showed malreduction
Is this reduction accepted or she need revision surgery snd how?
HPI - 58 male with left knee. Diagnosed with back issues and was given multiple spinal injections. Eventually, the physician examined him and decided to xray his left knee
HPI - A 26 years old male involved in RTA , generally stable , with closed comminuted proximal RT femur fracture and ipsilateral tibial shaft closd non displaed fracture
whats the best option to treat the femure fracture?
HPI - struck by car
no soft tissues problem, no other injuries,
What is the best treatment option?
HPI - Conservative treatment for 7 months
HPI - Patient has a mechanic fall in Asia in April 2014. Treated with ORIF with proximal locking plate done there.
What is your preferred treatment for femoral subtrochanteric fractures?
HPI - Pain B/L knee joint.left more than right
What should be the treatment plan
HPI - Fall from bed and sustained fracture shaft femur left
Additional work up in this case
HPI - H/o of RTA on4/4/2014',pt admitted to hospital c/o inability to walk .x ray shows f/x upper tibia.f/x treated with T plate.
What would you do for this patient at the current time with the imaging available?
HPI - 69-y/o male status-post 10-foot fall from the roof. He has a history of CABG 3 years ago, and minimal intermittent pre-existing left hip discomfort but not inhibitive to daily activites and is currently not requiring any treatments for DJD of the hips.
Would you attempt to fix (cephalomedullary nail) or proceed with total hip arthroplasty with calcar replacing femoral stem?
HPI - RTA on 4/8/2015.Pt presented to ER complaining of difficulty to move his rt shoulder,
How you will manage this fructure.?
HPI - 75yo F w h/o L4-L5 L5-S1 laminectomy and discectomy several years ago without instrumented fusion presents complaining of severe axial lumbar pain of increasing intensity x 2 years despite physical therapy. She was seen by a Neurosurgeon who recommended no surgical intervention.
Non-operative vs operative?
HPI - not known
what is the best choice of fixation ?
HPI - 55Y F, normal weight, recreative sportswoman, last 3 months nonsmoker.
Ski injury in Jan.2015
Feeling of knee instability in some activities.
Plese give me an advice to reconstruct LCA or not!
She is smoker and 55Y old.
What to do...?
HPI - The pain in right hip started since 5 years. not relieved by analgesic .Pt tried local intraosseous injection of bone marrow one year ago without improvement of pain
what is the best treatment option?
HPI - Fall from standing height
HPI - Patient sustained injury right knee joint 2months back for which he was treated with above knee pop cast.Now patient has presented with stiffness of knee joint and pain
HPI - slip down injury
He was diagnosed distal clavicle fracture and treated CRIF c k-wire 6 weeks ago
At POD 6 weeks, X-ray reveals k-wire loosening & gap maintenance
According to the Neer classification of distal clavicle fractures, what Type is this?
HPI - Multiple gun shot of humerus and forearm on 2/ february.no vascular or neurological defect.wound 4x4cms on lt humerus.and 6x4cms on distal dorsum of lt forearm.POP SLAPfor lt humerus.2: POP SLAP FORLT FOREARM.
How will you treat the case.?
HPI - 90f frail, AAA, HTN with mechanical fall onto left hip. Isolated left hip pain.
What is your preferred treatment for reverse obliquity subtrochanteric proximal femur fractures?
HPI - History of injury right wrist joint 2years back.was treated by massage and crepe bandage.Now patient has presented with pain wrist joint.After investigation he was diagnosed as having scaphoid nonunion.
MRI shows the proximal fragment to be vascular
What is the treatment plan
HPI - 29 yo male wants hardware removed. Minimal to no symptoms, is afraid to participate in sports with plate in.
HPI - history of fall on outstretched hand 4 weeks back and took bandages from a bone setter. Now complains of stiffness of elbow
Best line of treatment for this patinet....