Break through Cases

Case 1

A 30-year-old class 2 obese (BMI: 35.4) male patient presented with an alleged history of road traffic accident sustaining injury to his right hip. The patient was unable to bear weight over his right lower limb since the injury. Warmth and tenderness were felt over the right hip with limb shortening on the right side. A swelling was also palpable over the right hip. Flexion, adduction, and internal rotation of the right lower limb were seen with a history of decreased range of movements. Range of movements could not be elicited in the patient as a result of pain. However, the range of motion at the ankle joint was full. Active toe movements were present. No distal neurovascular deficits were noticed. Plain radiograph of the right hip showed fracture of head of right femur with posterior dislocation of right hip.

Post-operative period was uneventful. Wound inspection was done on the second operative day. Sutures were removed on the 12th post-operative day. Physiotherapy was started on the 15th-day post-surgery. The patient was made to walk with walker assistance without weight bearing. At the time of discharge, a healed surgical scar of 20 cm was noticed over the lateral aspect of the right thigh. Range of flexion at right hip was 90° and right knee was 120°. Active ankle and toe movements were present. No distal neurovascular deficits were noticed. The patient was followed at regular intervals. Radiographs during the follow-up at six months are shown in Figures

Case 2

A 10-year-old female patient was brought to our tertiary care center at Kolar, Karnataka, with an alleged history of a fall when she sustained an injury over her left upper limb three weeks following the initial injury. The patient presented with swelling and pain over her left elbow with the inability to move her left little finger since the fall. She had no history of injuries elsewhere in her body. On examination, the left elbow joint was tender, grossly swollen, and in a slightly extended position. The three-point relation could not be assessed due to the swelling. The range of motion at the left elbow joint was painful and restricted. Sensation was lost in her left little finger, and extension of all other fingers was present. Brachial artery pulsation was palpable, and no vascular deficits were noticed. Anti-edema measures were taken through limb elevation over the pillow, above elbow plaster of Paris slab application in extension, and medications. Analgesics and prophylactic antibiotics were started, and the dosage was as per the weight of the child. The patient was sent for a plain radiograph of the left elbow joint. Radiographs showed left supracondylar fracture with gross rotational anterolateral displacement, as shown in Figure 1. As a trial, closed manipulation was attempted, and it failed as expected. After obtaining proper written, informed consent from her guardian, the patient underwent open reduction and internal fixation with two criss-cross Kirschner wire fixations, as shown in Figure 2, and above-the-elbow slab immobilization for four weeks.

Case 3

We present a 45-year-old male to our tertiary care facility in Kolar, India. Three years old infected non-union of distal femur with locking compression plate in place treated in various hospitals. With the support of the stick, the patient was partly weight-bearing. When examined, the distal left thigh portion - swelling, tenderness and abnormal mobility was present. The range of motion was 45-120 degrees of flexion at the left knee joint. The extensor lag was 45 degrees. There were no distal neurovascular deficits found. The patient was sent for a left thigh radiograph showing non-union distal femur with locking compression plate in in-situ as shown in Figure 1. The patient underwent locking compression plate removal with distal femoral nail fixation with allogenic bone grafting after written/informed consent. Patient was put on six weeks above knee slab immobilization. Hospital treatment: the patient received cephalosporin group intravenous antibiotics twice daily for seven days, followed by oral cephalosporin antibiotics twice daily for seven days, depending on the patient’s post-operative weight. In Figure 2, post-operative radiography of the left thigh was seen. There was an uneventful post-operative time. The site of surgery healed well. The range of motion at the knee joint was 0-120 degree flexion at discharge. After six weeks, partial weight-bearing was started. At the last follow-up, six months radiography, the fracture site is uniting as shown in Figure 3 and the patient is partially weight-bearing without any trouble.

Case 4

Two newborn babies were delivered by Caesarean section in our tertiary care centre, Kolar, Karnataka. The first was a 36-week preterm male infant small for gestation. Baby presented with swelling and deformity noted over left thigh after difficult labor. Baby was diagnosed with a closed proximal fracture on the left side of the femur. The second was a 38-week female infant small for gestation. Following difficult labor, baby presented with swelling and deformity over the right thigh. Baby was diagnosed with a closed proximal fracture on the right side of the femur. Radiographs of the babies are shown in Figure 1.

Case 5

A 52-year-old male patient presented at our tertiary care hospital, in Kolar, India, with pain and swelling over the heel, pain during rest, and more during ambulation. Mulholland deformity/Haglund's deformity was diagnosed clinically and radiologically on examination. The patient’s lateral ankle radiograph is shown in Figure 1. The patient was initially treated conservatively for six months using anti-inflammatory drugs, analgesic agents, physiotherapy, and soft sole heels. The conservative medication did not relieve the pain. Patient underwent surgical operation via the removal of the calcaneal spur following informed and written consent. A lateral technique was used. An incision of 5 cm was made. The insertion of Achilles tendon found was resected along the lateral border revealing the prominent calcar tuber. The spur was removed using the osteotome and the edges smoothed using rongeur and rasp. The post-surgical phase was uneventful.

In terms of hospital treatment, the patient required intravenous amoxicillin-clavulanate twice daily for seven days, followed by oral amoxicillin-clavulanate potassium twice daily for seven days, depending on the patient’s post operative weight. Figure 2 demonstrates the postoperative lateral view radiography of the ankle joint. A short leg splint was put on the patient. For two weeks, nonweight bearing ambulation was prescribed to the patient and accompanied by suture removal. The surgical wound was healthy. With the walker, partial weight-bearing was initiated. And later on, weight-bearing began to be tolerated. The patient recovered from pain due to bilateral calcaneal spur/exostosis at final follow up, six months after surgery. The visual analog scale was eight. The discomfort was greatly diminished in the final follow up. Without any pain or discomfort, the patient would be able to do his everyday activities.

Case 6

A 22-year-old left-handed male patient, a painter by occupation, presented to RL Jalappa Hospital and Research Centre affiliated with Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India. The patient gave the alleged history of the road traffic accident while traveling in a four-wheeler, which toppled and caused the patient sustained an injury to both his shoulders. On examination swelling, crepitus, and tenderness were present over the junction of the middle and lateral third junction of the right and left clavicle. The range of motion of both shoulder joints was painful and restricted. No distal neurovascular deficits were found. The patient was clinico-radiologically diagnosed as having closed bilateral clavicle fractures without neurovascular deficits, as shown in Figure 1. The patient and his relatives got an explanation about the severity of the injury, associated complications, and the need for surgery in their own understandable language. The patient was kept on the shoulder arm pouch on both sides with ice pack application and started on analgesics, anti-edema measures like bromelain, trypsin, and rutoside tablets. The patient and his relatives were asked about their demographic details, and surgical options were explained to them by a team of orthopedicians. The rehabilitation protocol, complications associated with both conservative versus non-conservative management were explained. After obtaining consent, the patient had surgery on the open reduction and internal fixation with a locking compression plate for the left side clavicle. The patient was not willing to get surgery for the right clavicle due to his financial constraints. The right clavicle fracture was treated conservatively by using a shoulder arm pouch application for three weeks. Range of right-shoulder activity limited to two weeks of pendulum exercise and active movements up in the horizontal plane during the first six weeks.

Post-operation of the left clavicle, the patient was able to raise the right arm above his shoulder. The patient was started on analgesics, anti-edema medications, and intravenous administration of augmentin 1.2 g twice daily for two days and started prophylactically oral amoxiclav 625 mg twice a day for seven days to prevent surgical site infection. Active ranges of motion were full with reduced pain. During one month follow-up, the radiograph over the left side showed better uniting of the fracture than the right side. The patient was allowed to return to work to his normal activity of painting three months post-operation. Figure 2 demonstrates the plain radiograph of the chest with bilateral shoulder anteroposterior view at six months follow up. Clinical picture comparing the range of motion over operative (left) versus non-operative (right) side shown in Figure 3. He was discharged from the follow up at six months.

Case 7

A 31-year-old male patient with no known comorbidities was brought to our tertiary care center at Tamaka, Kolar, Karnataka, South India. The patient revealed a history of road traffic accident, due to which he sustained injury to the right lower limb. The patient had been unable to walk since then. He underwent native treatment for about six weeks and was brought to our hospital for further management. On examination, his vitals were stable. Local examination of the right leg showed swelling and tenderness present over the proximal third of the right leg. Range of motion at the right knee joint was 10-30 degrees. Assessment of range of motion at the ankle joint revealed that dorsiflexion was absent. Capillary refill time was normal. All other long bones and joints were found to be clinically normal.
The patient was initially managed with intravenous administration of amoxicillin- potassium clavulanate 1.2 g prophylactically. The patient was then temporarily stabilized with an above-knee fiberglass splint. He was sent for preoperative imaging, as shown in Figure 1. Plain radiograph of the right knee showed split fracture involving the lateral tibial condyle extending into the articular surface, with lateral displacement of fracture fragments, and oblique fracture of fibular head with caudal displacement of fracture fragments. MRI of the right knee showed a high-grade tear in the proximal aspect of the lateral collateral ligament and a grade 2 medial collateral ligament tear. In addition, the patient was counselled regarding expectations and outcomes. After obtaining informed consent, the patient was operated under spinal anesthesia. Open reduction and internal fixation with proximal tibia locking compression plating with autologous bone grafting from the ipsilateral iliac crest (corticocancellous graft) along with lateral meniscectomy and arthrolysis of the knee joint was performed under spinal anesthesia, as shown in Figure 2. The post-operative period was uneventful.

Fig 2 - Intra-operative picture showing high-grade tear in the proximal aspect of the lateral collateral ligament and grade 2 medial collateral ligament tear, which was treated with open reduction and internal fixation with proximal tibia locking compression plating with autologous bone grafting from the ipsilateral iliac crest.
Post-operatively, the patient received intravenous amoxicillin-potassium clavulanate 1.2 g twice daily for seven days and amikacin sulfate 500 mg twice daily for five days followed by oral amoxicillin-potassium clavulanate 625 mg twice daily for seven days. Post-operative radiograph of the operated knee joint was taken on post-operative day 2, as shown in Figure 3. An above-knee slab support was applied, and the patient was advised strict non-weight bearing for six weeks. Culture and sensitivity from surgical site showed staphylococcus epidermidis, which was sensitive to tetracycline and doxycycline. The patient was started on tablet doxycycline 100 mg twice a day for 14 days. All staples were removed on post-operative day 14, and the surgical site was found to be healthy. The patient underwent physiotherapy in the form of muscle stimulation test 15 minutes daily till he recovered from the foot drop. The guarded continuous passive motion was also started for the patient. At discharge, range of motion at the knee joint was 0- to 120-degree flexion after one month of physiotherapy. Tinel sign was positive 1-cm along the common peroneal nerve distribution at the level of the middle third of the leg. The patient had recovered from the foot drop (possibly due to neuropraxia). Partial weight bearing was initiated after six weeks. The patient was allowed full weight bearing at three months. At the last follow-up, six months post-injury, he was walking without any difficulty.

Post-operatively, the patient received intravenous amoxicillin-potassium clavulanate 1.2 g twice daily for seven days and amikacin sulfate 500 mg twice daily for five days followed by oral amoxicillin-potassium clavulanate 625 mg twice daily for seven days. Post-operative radiograph of the operated knee joint was taken on post-operative day 2, as shown in Figure 3. An above-knee slab support was applied, and the patient was advised strict non-weight bearing for six weeks. Culture and sensitivity from surgical site showed staphylococcus epidermidis, which was sensitive to tetracycline and doxycycline. The patient was started on tablet doxycycline 100 mg twice a day for 14 days. All staples were removed on post-operative day 14, and the surgical site was found to be healthy. The patient underwent physiotherapy in the form of muscle stimulation test 15 minutes daily till he recovered from the foot drop. The guarded continuous passive motion was also started for the patient. At discharge, range of motion at the knee joint was 0- to 120-degree flexion after one month of physiotherapy. Tinel sign was positive 1-cm along the common peroneal nerve distribution at the level of the middle third of the leg. The patient had recovered from the foot drop (possibly due to neuropraxia). Partial weight bearing was initiated after six weeks. The patient was allowed full weight bearing at three months. At the last follow-up, six months post-injury, he was walking without any difficulty.

Case 8

A 40-year-old male patient was brought to R. L. Jalappa Hospital & Research Centre affiliated to Sri Devaraj Urs Medical College, Kolar, Karnataka, South India. The patient presented with an alleged history of road traffic accident, sustaining an open injury to his right foot. It involved the bipolar dislocation of the proximal phalanx of the third toe with extensor digitorum longus tendon injury and fracture of the neck of the fourth proximal phalanx of the right foot. Range of motion of the metatarsophalangeal joint of the third and fourth digits was painful and restricted. Active first, second, and fifth toe movements were present. No distal neurovascular deficits were noted. All other bones and joints were clinically normal. It was an isolated injury with no evidence of intracranial, thoracic, abdominal, or pelvic injury on clinical or radiographic examination. A focused assessment with sonography in trauma showed no signs of hemorrhage.
On arrival, tetanus prophylaxis was administered to the patient. Triple antibiotic prophylaxis consisting of amoxicillin-potassium clavulanate 1.2 g, amikacin sulfate 500 mg, and metronidazole 100 mL were administered in the emergency department. A brief bedside irrigation with 6 L of sterile saline was given, and the wound site was dressed with moist gauze. The patient was then provisionally stabilized with a short leg splint and sent for preoperative imaging. Clinical image and preoperative radiographs are provided in Figures 1, 2, respectively. After imaging was completed, a trial closed manipulation failed as expected, as shown in Figure 3. The patient was operated under spinal anesthesia. Three liters of sterile saline was then used to irrigate the wound. Gross wound contaminants were removed. The patient underwent wound debridement with extensor digitorum longus tendon repair of the fourth digit, and internal fixation with K-wire fixation for the third and fourth digit was performed. Post-operative image is shown in Figure 4. The post-operative period went uneventful. The superficial and deep wound infection never occurred at any point of time. This included physical signs (erythema, malodor, gross purulence, etc.) and hematological signs (rising of white blood cell count, erythrocyte sedimentation rate, C-reactive protein etc.). Post-operatively, the patient stayed in the hospital for seven days for wound monitoring. Daily physical and occupational therapy was routinely performed by the patient. The surgical site healed well. Active toe movements of the first to fifth digits were present.

Post-operatively, the patient received intravenous amoxicillin-potassium clavulanate 1.2 g twice daily for seven days, amikacin sulfate 500 mg twice daily for five days, and metronidazole 100 ml thrice daily for three days followed by oral amoxicillin-potassium clavulanate 625 mg twice daily for seven days. Analgesics and anti-edema measures were given. Protein-rich supplements along with personal hygiene measures were provided. A below-knee slab and strict non-weight bearing ambulation for six weeks were recommended. The K-wires were removed after six weeks, and partial weight-bearing was started with the help of a walker. Full weight-bearing was permitted after six months. The patient was being followed up at regular intervals. The patient returned to his work with no limitations on the activity or complications after his final follow-up.