CASE NO: 1 PATIENT DETAILS : Occupation : Housewife Date Of Admission :11/06/15 Residence : Nalgonda IP NO :

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2 CASE NO: 1 PATIENT DETAILS : Name : XXXX Age : 53yr Sex : Female Occupation : Housewife Date Of Admission :11/06/15 Residence : Nalgonda IP NO : CHIEF COMPLAINTS : - Pain in the right knee since 3 months - difficulty in walking since 3 months - stiffness of right knee since 3 months

3 HISTORY OF PRESENT ILLNESS Patient alleged to have sustained injury to her right knee joint 3 months back in her residence. Following which patient was unable to walk and stand due to pain and she underwent quack treatment from a local bone setter. After removal of bandages by quack, she was unable to bend her right knee joint and unable to walk. She came to our hospital for further treatment

4 PAST HISTORY : No significant medical illness. PERSONEL HISTORY : - Diet - mixed - Appetite - normal - Sleep - adequate - Bowel & bladder habits normal - Addictions nil - Menstrual history post menopausal

5 GENERAL EXAMINATION : Patient conscious & coherent Moderately built and nourished BP- 130/90 mmhg Pulse 72/min CVS s1s2 heard RS - bilateral air entry present P/A- soft Chest compression test negative Pelvic compression test negative Spine tenderness - negative

6 LOCAL EXAMINATION OF RIGHT KNEE ON INSPECTION : - Shortening of affected limb present. - Diffuse swelling present over the right knee joint. - No sinus and scars ON PALPATION : - Diffuse tenderness present over distal femur and knee joint. - Range of movements restricted - Ipsilateral hip and ankle joints are normal - No distal neurovascular deficit

7 INVESTIGATIONS Radiograph of right knee with thigh AP, lateral views shows Muller s type A1 supracondylar fracture of femur. Routine blood investigations Hb 14gms/dl TLC 7000/cumm Platelets 2lakhs/cumm Serum creatinine 0.6mg/dl RBS 110mgs/dl Blood group o positive

8 Pre operative x ray showing supra condylar fracture of femur

9 TREATMENT For stabilizing the fracture and to relieve the pain upper Tibial skeletal pin traction was applied temporarily with 5kgs of weight. Pre-anaesthetic check up done. pt was fit for surgery. Open reduction and internal fixation with (DYNAMIC CONDYLAR PLATE ) was planned.

10 PROCEDURE combined spinal epidural anaesthesia in supine position under tourniquet control, right lower limb scrubbed, painted and draped. Under C -arm guidance, fracture site identified. Incision was centered over the frature site and extended 5 cm above towards shaft of femur proximally and 5cm distally towards proximal tibia. Iliotibial band and vastus lateralis was split, fracture site exposed. Reduction done with bone clamps.

11 80 mm condylar screw was fixed above intercondylar notch in the distal femur. 8 holed femoral barrel plate was inserted into condylar screw, fracture site alligned plate fixed with cortical screws. Reduction checked under C arm, under negative suction drain wound closed in layers. Range of movements and neurovascular status checked.

12 INTRA OPERATIVE IMAGES

13 INTRA OPERATIVE IMAGES

14 INTRA OPERATIVE IMAGES

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17 IMMEDIATE POST OPERATIVE X RAY

18 POST OPERATIVE FOLLOW UP Limb elevation and active toe movements were advised Drain is removed on 2 nd post operative day Quadriceps strengthening and knee range of movement started on 6 th post operative day. Suture removal done on 10 th post op day Patient is discharged with advice not to bear weight for four weeks Active toe movements were advised and asked to review after two weeks in OPD.

19 POST OPERATIVE FOLLOW UP X RAY ( 6 WEEKS)

20 Movements during follow up Extension Flexion

21 CASE NO:2 PATIENT DETAILS : Name : xxxx Age : 42 yrs Sex : Male Residence : Nalgonda Occupation : Teacher IP.no : Date of Admission : CHIEF COMPLAINTS : Pain and swelling in right knee joint

22 HISTORY OF PRESENT ILLNESS: Patient alleged to have sustained injury due to road traffic accident (car vs bike) on Immediately after fall patient came to our hospital with pain and swelling of right knee joint. No h/o head injury

23 Past history : not significant medical illness Personal history : Mixed diet Bowel and bladder habits-normal Appetite - normal Sleep - normal No h/o addictions No h/o of any drug allergies

24 GENERAL EXAMINATION: Patient conscious and coherent Moderately built and well nourished BP: 140/90 mmhg Pulse : 80/min SYSTEMIC EXAMINATION: CVS : s1s2 heard RS : Bilateral air entry present P/A : Soft Chest compression test: negative Pelvic compression test : negative Spine tenderness : negative

25 LOCAL EXAMINATION OF RIGHT KNEE INSPECTION: Attitude :external rotation of foot. Diffuse swelling present over right knee. PALPATION: Tenderness present over distal femur. Crepitus present Range of movements restricted due to pain Ipsilateral hip and ankle joints are normal Distal pulses felt No neurological deficits

26 INVESTIGATIONS RADIOGRAPH of right knee AP and LATERAL views shows Type A1 supracondylar fracture of femur acc. to Muller classification ROUTINE BLOOD INVESTIGATIONS Hb gm/dl TLC /cu.mm Platelets 2lac/cu.mm HIV negative Hbsag negative Sr.creatinine - 0.7mg/dl RBS -100mg/dl

27 PRE OPERATIVE X-RAY

28 TREATMENT For stabilizing the fracture, upper tibial skeletal pin traction was applied. Pre-anesthetic check up done and was posted for surgery. Plan Open reduction and internal fixation with( LOCKING COMPRESSION PLATE).

29 PROCEDURE Patient under spinal anesthesia, in supine position, under tourniquet control, right lower limb was scrubbed, painted and draped. Lateral incision was given, fracture site exposed and reduced, repositioned anatomically. 5 holed locking compression plate was placed and fixed with 5 cancellous locking screws in distal femur in different angles. Proximally 5 cortical screws are applied into shaft of femur and checked under C arm.wound closed in layers under negative suction drain.

30 INTRA OPERATIVE IMAGES

31 IMMEDIATE POST OPERATIVE X-RAYS

32 POST OPERATIVE FOLLOW UP Advised limb elevation and active toe movements. Drain is removed on 2nd Post operative day. Static quadriceps exercises and range of movements started on 6 th post operative day. Suture removal is done on 10 th postoperative day. Pt was advised not to bear weight for 4 weeks. Weight bearing will be started when significant callus formation is seen on x-rays.

33 removal After suture

34 THANK YOU