First, we joined Mr.Shahidan's class on Polytrauma + Surgical site infection. Then we had teaching session with Mr.Shuk - two short cases. One was left leg cellulitis, another was external fixation.
If you get an obese, elderly patient came in with acute onset of unilateral leg swelling with redness, these are the differentials that you should consider:
1. Infection (cellulitis, erysipelas, necrotising fascitis)
2. Deep Vein Thrombosis
You have to organise your thoughts in short case examination. Remember to Inspect, Palpate, Move.
Let me tell you about the pakcik that we examined just now:
He was a 75-year-old Malay man, obese, with Venturi mask attached. He looked comfortable, not in pain. Hydration and nutritional status were fair.
On inspection of left lower limb, there was generalised swelling up to mid-thigh associated with redness. The redness was flat but not well-demarcated. Wrinkle sign was present. Ruptured blister was noted at posterior calf with clear discharge, not foul-smelling. There was no localised skin break or trauma.
On palpation, inguinal lymph nodes were palpable. There was warmness noted up to mid-thigh. No bony or calf tenderness, edema, collection of pus or crepitus felt. Pulses palpable. CRT less than 2 seconds.
On movement, active flexion and extension of distal toes and ankle joint noted - full range of motion.
So, based on the findings, the provisional diagnosis would be left leg cellulitis.
In erysipelas, the redness/rash are raised. It has a well-demarcated margin. It looks more red, angry-looking.
In necrotising fascitis (NF), although presence of blister is not pathognomonic, but it is a clinical feature in patient with NF. Crepitus can be felt in NF.
In DVT, calf tenderness was present.
So....what are the risk factors for cellulitis?
1. Old age
3. Diabetes Mellitus
4. Local infection
5. Skin break
How to remember major causes of a disease? TINCABED
T - Trauma
I - Infection
N - Neoplasm
C - Congenital
A - Autoimmune
B - Blood
E - Endocrine
D - Drug-induced
Next, the patient with external fixator on right leg.
Fadli, a 30-year-old man, medium-built, comfortable, not in pain or respiratory distress, hydration and nutritional status fair.
On examination of right lower limb, the leg was rested on a pillow. An external fixator was seen at right tibia. 4 Schantz pins, 2 parallel bars (2 proximal, 2 distal). The fracture site was probably at lower third of tibia, as evidenced by the location of the pins, as well as the healed scar located at the area. Pressure sore was noted at right heel. No evidence of pin track infection (redness, tenderness, discharge). No tenderness on palpation suggesting that the fractures were united. Movement normal.
Spot diagnosis? Open fracture of right tibia (Gustillo-Anderson Grade II or IIIA) because the size of wound was more than 5cm, most probably extensive soft tissue injury but it can be covered - no need for split skin graft or muscle flap. And no evidence of wound exploration scar.
What are the roles of external fixators?
1. Treatment of open fracture
2. Septic non-union
3. After vascular repair
4. Comminuted fracture involving joint
5. For bone lengthening (Illizarof)
6. Pelvic injury (open book)
7. Knee or ankle dislocation
How to make an external fixator more stable?
1. Increase number of pins
2. Angle of pin insertion
3. Bars located at least 2 cm from fracture site
4. Distance between pins
5. Multiplanar > uniplanar
That's all about it!
Oh wait wait. In paediatric ward, there was a patient who came in with Amniotic Band Syndrome! She is an eleven year old Malay girl on right leg prosthesis. Because she had an abnormal right foot (her right foot looked like a hockey stick and it was shorter than her left lower limb, her 15 year-old sister told me). It was like that since birth. So her parents got her a prosthetic leg, she used that since 5 years old.
But she complained of pain when she wanted to wear the prosthesis, so she came here for amputation. I cannot remember whether it was an AKA or a BKA.
And her fingers are abnormal too. Some of her fingers are shorter than the others. She has asthma too. But no other abnormalities noted at any parts of the body.
We have now come to the end of this post! No fun story to tell you today. Because I have to get ready for my oncall! Gotta take a shower!
You have a good day okay, and get some rest! You must be tired :)
Byebyeeee for now!!