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DFU CASE

Right Foot examination

On inspection, there is no loss of hair, shiny and pale skin and no
brittle nail. There is dryness of skin but no callous formation. There
is no deformity noticed such as hammer toe, mallet toe, claw toe,
hallux valgus, pes planus, pes cavus or charcot deformity. Otherwise,
there is no fungal infection noticed between the toes and other ulcer
at other parts of foot.

Additionally, there is surgical wound at the lateral aspect of plantar

and extending to the dorsum, measuring 6cm x 5cm. the wound
appears clean with well-defined margin. There is tendon exposed but
no bone exposed. There central slough with granulation tissue
surrounding it. No pus, blood or seropurulent discharge seen. The
surrounding skin is hyperpigmented but not erythematous and not
swelling.

On palpation, the skin is warm, with no tenderness. The capillary

refill time of all toes are less than 2 seconds. The pulse of dorsalis
pedis artery and posterior tibia artery was palpable. No crepitus over
right foot.The patient is able to dorsiflex and plantarflex the foot.
There is reduce sensation stocking distribution up to ankle.
Proprioception was intact. Silfverskiold test was negative.

Other systemic examination was unremarkable

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DFU CASE

Right Foot examination

On inspection, there is no loss of hair, shiny and pale skin and no
brittle nail. There is dryness of skin but no callous formation. There
is no deformity noticed such as hammer toe, mallet toe, claw toe,
hallux valgus, pes planus, pes cavus or charcot deformity. Otherwise,
there is no fungal infection noticed between the toes and other ulcer
at other parts of foot.

Additionally, there is surgical wound at the lateral aspect of plantar

and extending to the dorsum, measuring 6cm x 5cm. the wound
appears clean with well-defined margin. There is tendon exposed but
no bone exposed. There central slough with granulation tissue
surrounding it. No pus, blood or seropurulent discharge seen. The
surrounding skin is hyperpigmented but not erythematous and not
swelling.

On palpation, the skin is warm, with no tenderness. The capillary

refill time of all toes are less than 2 seconds. The pulse of dorsalis
pedis artery and posterior tibia artery was palpable. No crepitus over
right foot.The patient is able to dorsiflex and plantarflex the foot.
There is reduce sensation stocking distribution up to ankle.
Proprioception was intact. Silfverskiold test was negative.

Other systemic examination was unremarkable

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KNEE CASE (ACL)

My patient was medium built man lying comfortably in supine position. He was conscious and alert. His hydration
status was good with capillary refill time less than 2 seconds. He was pink with no signs of pallor, jaundice or cyanosis.

Upon gait assessment, patient was able to ambulate without aid and there were no abnormal gait or instability
noted.
On inspection, no knee deformity, scars, skin changes, swelling, misalignment of the legs or wasting muscles.
On palpation, there was no tenderness noted over the joint line. In addition, the skin temperature was normal
and equal bilaterally and no knee joint effusion noted.
He was able to move the knee with full range of motion (0-130o). No crepitus noted over the right knee.
Special test: Anterior drawer test and Lachmann test was positive. Otherwise, posterior sagging, posterior
drawer test, McMurray test and varus and valgus test were negative. Examination of the left knee was
unremarkable. Other examination

SPINE CASE

My patient, a medium-build woman. She is alert and conscious lying in supine position. She is not in pain or respiratory
distress. Her hydration status was good and there was no pallor or jaundice There were no neck swelling and oral
thrush noted. There was a branula attached on her left dorsum hand with passive infusion. The capillary refill time was
less than 2 seconds.

Spine examination
Patient was unable to stand upright due to pain, hence the examination was done in lateral supine position.
On inspection of the back, there was no scar, swelling, skin changes, tuft of hair or obvious deformity seen.
There was no loss of normal curvature of spine, no shoulder asymmetry. However, the correct posture of the
patient and gait assessment could not be assessed as patient was unable to stand due to pain.
On palpation, there was spinal tenderness L4 and below. No paravertebral muscle spasm down to lumbar area
noted.
Range of motion (ROM) was limited due to pain. Straight leg raising test (SLR) was positive on the right side.
Schober test and Femoral nerve stretch test unable to do due to pain.

Lower leg examination

On inspection, no deformity and muscle weakness seen at both lower limb. There was no fasciculation,
involuntary contraction scar or abnormal skin changes seen.
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On palpation, the temperature of both lower limbs was equal and normal. There was no tenderness over all
bony prominences of lower limb. Both posterior tibialis artery and dorsalis pedis artery pulses were palpable
and equal bilaterally. Capillary refill time was less than 2 seconds.
On neurological examination, the tone was normal bilaterally. The power on the right lower limb was reduced
with MRC grade 4 while the left lower limb has normal power. Sensation was reduced at L2, L3, L4, L5, S1
and S2 dermatome of right lower limb. Reflex were normal. Clonus and barbinski sign were

HAND CASE (CARPAL TUNNEL SYNDROME)

On hand examination, on inspection, both hands are in normal resting position with forearm supinated and
wrist extended. There are no scars noted. No deformity of the hand, no swelling noted. There is wasting
of thenar eminence muscle bilaterally more prominent on the right side.
On palpation, there is no increase in temperature, both wrist joints are non-tender. Capillary refill time is
less than 2 seconds and radial pulse was palpable. There is no palpable swelling in DIPJ, PIPJ.
On movement, abduction of thumb was slightly reduced 4/5 on right side while full 5/5 on the left hand.
He is able to make an OK sign. (Flexor digitorum profundus and flexor pollicis longus). He is able to fully
flexed and extend his fingers. Range of movement of wrist joint, DIP, PIP and MCPJ joints are not limited.
Grip strength is 5/5 bilaterally.
Sensation was reduced over radial 3 ½ digits of right hand but intact in other digits and in left hand.
Special test for median nerve: Phalanx test, durkhan and tineal test positive bilaterally.

FRACTURE CASE

On inspection, there was adhesive skin traction over his lower limb attach with a hanging 3kg load. There was
no swelling, no bruises, wound or active bleeding.
On palpation, the left thigh was warm and tender. The dorsalis pedis and posterior artery were palpable with
good volume. The capillary refill time was less than 2 second.
The sensation was intact. He was able to move all of his toes and dorsiflex and plantarflex the ankle.
However, the range of motion of right hip cannot be assessed due to pain.
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Oncall teaching Mr Raffael 2.0: SKIN TRACTION (in this case, midshaft of left femur fracture)

‼Jangan lupa button your whitecoat before examine patient! Pantang kalau examiner nampak your matric card
dangling terkena patient!

🌟Usually examiner will ask, “examine the lower limb.”

🌟The flow will be: General > Look > Feel > Move > Sensory + Pulse

✅Start with general first:

"The patient is lying supine, propped up at 45 degree, comfortable, not in pain, not in respiratory distress. There’s
an inactive branula attached over dorsum of left hand – no thrombophlebitis. There’s a CBD bag collecting 200ml
urine, no haematuria.”

🌟Usually patient lies supine - in long bone fracture.

🌟If patient is propped up, ALWAYS ASK PATIENT: WHY?
- Is it because patient has SOB if completely supine? (Fat embolism syndrome)
- Is it because of patient’s preference?
🌟Ayat wajib setiap kali komen ada branula – “there’s no thrombophlebitis.”
🌟Ada CBD, check for haematuria + berapa ml urine.

✅Then, proceed with lower limb:

▶LOOK
“There’s a skin traction over left lower limb up to mid-thigh. The limb is elevated by pillow and attitude of the
limb is externally rotated. The skin traction is properly put on as evidenced by taut of string, weight of 3kg with
functioning pulley, the weight not lying on ground. There’s proper padding at bony prominence and an adequate
space below sole of foot. There’s no swelling over thigh.”

🌟Selak kain patient up to ASIS to check for any swelling. LOOK FOR SWELLING PROPERLY! Showmanship!
🌟Why need to elevate the lower limb:
- To prevent muscle spasm e.g in supracondylar fracture, gastrocnemius is relaxed, less muscle spasm + prevent
injury to popliteal artery

▶FEEL
“There’s tenderness over left mid-thigh. The thigh is not tense and soft on palpation.”

▶MOVE
“Dorsiflexion and plantarflexion are acceptable.”

▶SENSORY + PULSE
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Oncall teaching Mr Raffael:Short case: EXTERNAL FIXATOR (in this case, right tibia fracture)

✅Start with general first:

"The patient is lying supine, propped up at 45 degree, comfortable, not in pain, not in respiratory distress. The
patient is at propped up position because of his preference (ni lepas dah tanya patient why dia propped up. Wajib
tanya!). There’s an inactive branula attached over dorsum of left hand – no thrombophlebitis. There’s a CBD bag
collecting 200ml urine, no haematuria.”

✅Then, proceed with lower limb:

▶LOOK
“There’s an external fixator over anteromedial aspect of right tibia straight down to 2nd toe, with 4 pints and 2
rods, wrapped with bandage. Bandage not soaked/not dirty, no discharge/blood stain. No pressure ulcer noted (ini
kalau bandage takdak). There’s swelling over right foot. There’s a stick over first webspace for stir up foot exercise.”

🌟Showmanship itu penting. You can angkat kaki patient untuk tengok ada pressure ulcer tak kat bawah kaki
yang ada ext-fix.
🌟Patient ada bandage (besar): clue for fasciotomy scar beneath (compartment syndrome) or open wound (at least
fracture 3B wound).
🌟Stick (macam batang ice-cream) for stir up foot exercise (ada certain yang panggil ini horse-riding exercise) –
patient will pull the string to encourage passive ankle movement to prevent ankle stiffness

▶FEEL
🌟Palpate at:
- Pinsite
- Fracture site
- Each toe of the foot

“The pinsite is not tender, however there’s tenderness over fracture site. No tenderness over the foot.”

▶MOVE
🌟Always check for ankle movement – dorsiflexion and plantarflexion – if patient unable to move, ask patient, is
it due to pain? Or memang patient tak boleh gerak langsung?
🌟Check for passive dorsiflexion/plantarflexion jugak. (Kita yang gerakkan ankle dia).

“Patient unable to actively dorsiflex and plantarflex. For passive dorsiflexion/plantarflexion, the range of
movement is acceptable.”

▶SENSORY + PULSE
🌟Test for sensory guna lidi macam biasa, compare both limbs.
🌟Palpate pulses especially DPA, TPA – Sambil palpate, tengok patient! Jangan tengok kaki, jaga-jaga if patient
rasa pain.

“There’s reduced sensation over ____. The pulse is present/feeble (antara rasa tak rasa)/absent compared to other
side.”
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Oncall Teaching Mr Raffael 2.0: How to interpret X-ray

1. This is the Xray of my patient, taken yesterday/1 week ago/etc., before operation/post-operation…
2. This is the Xray of right/left femur/tibia/fibula/etc., of AP/lateral view...
3. The Xray shows fracture at midshaft of right tibia/etc., it is a communited fracture/etc., with distal segment
congruent/rotated/etc..
4. (Open fracture) There is soft tissue tear and aerogram noted.
5. (If post-operation Xray) I can see there is an external-fixator applied to the bone. The bony allignment is better
than the previous (pre-op) Xray...

‼Jangan sebut tarikh Xray taken, convert dulu ikut tarikh harini – “Xray taken yesterday/1 week ago/etc.”

✅Tips to know Xray view AP or lateral:

🔆tengok proximal portion as reference point
🔆e.g in radius/ulna Xray – reference point is elbow part, in tibia/fibula Xray – reference point is knee part.

🧐What is aerogram in Xray? – can be seen in open fracture cases. When there is overlying soft tissue tear, there’ll
be open wound, so air will be forced into the spaces between soft tissue like a vacuum.

5Miscellaneous:

▶Lethal triad: (we resuscitate to prevent all these)

1. Hypothermia
2. Coagulopathy
3. Metabolic acidosis

▶Common analgesics
1. IV/IM Tramal (Opioid) 50mg – for severe pain, but comes with side effect especially nausea vomiting
2. IM Voltaren (Diclofenac) 50mg – for severe pain, less side effect
3. T. Voltaren/T. PCM – for mild to moderate pain

▶Can compartment syndrome occur in open fracture? – Yes, but occur in other compartment (compartment
without open wound)

▶Antibiotics principle sometimes depends on where the patient sustained the injury:
- Dry wound – Cefuroxime
- Wet wound (e.g accident masuk longkang/parit) – cover with Flagyl/sometimes Gentamicin

▶Stir up foot exercise VS ankle pump exercise

- Stir up foot exercise: Passive mechanism. Patient will pull the string to encourage passive ankle movement to
prevent ankle stiffness.
- Ankle pump exercise: Active mechanism. To prevent DVT.
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Oncall teaching Mr Raffael 2.0: How do you manage open long bone fracture?

1. I would like to ensure the patient is conscious, alert, can speak in full sentences.
2. Then, I would like to check for the vital signs.
3. Then, I will put 2 large bore IV cannula and infuse normal saline to maintain/increase BP to compensate for
blood loss in long bone fracture.
4. Then, I will take blood and send for blood investigations (FBC ± RP/LFT/PT/APTT/etc.)
5. Then, I will administer ATT, analgesic, and antibiotics.
6. Then, I will make sure the limb is immobilized by putting splint/Thomas’ splint/etc.
7. Then, I will send the patient for X-ray.
8. Then, I would like to send patient for early wound debridement, then stabilize the fracture by ext-fix/etc., and
then wound closure since this is an open fracture.
9. After operation, I will make sure the limb is elevated, monitor the circulation, continue antibiotics+analgesics,
and make sure patient occasionally move the affected limb/do simple exercises to prevent muscle stiffness.

🧐Why you want to give normal saline?

🔆To increase BP to compensate the hypotensive effect due to blood loss in long bone fracture.

🧐How much do you want to give?

🔆Generally,
• 4-5 pints in young patients
• 3-4 pints in elderly (elderly has less fat, so lower risk for fat embolism syndrome)
🔆However, fluid resuscitation is based on degree of blood loss. For example, femur fracture, blood loss 1.5L –
2L, so we infuse 3 pints (1 pint=500ml, 3 pint=1.5L).
🔆Our intention is to increase BP by its haemodilution effect, so Hb will be low.
🔆It’s okay to overhydrate the patient, because at the same time we want to prevent fat embolism syndrome by
making sure no depository of fat globules from bone.

‼Generally, if patient <40y/o, NKMI, RP/LFT/Coagulation profile are not required!

‼However, if patient has DM or other co-morbidities, you take FBC + RP/LFT/Coagulation profile ± ECG/Chest
X-ray/etc.

🧐Why you want to take FBC? – For baseline reading.

🧐What do you want to look for in FBC? – The Hb level.

🧐How do you expect the Hb level will be after trauma? – Following trauma, usually the Hb level and haematocrit
will be normal. Hb won’t drop instantaneously. After infusing normal saline, Hb and haematocrit will be decreased.

🧐Are you surprised if Hb decreased after you infuse normal saline? – No, because it happens due to dilutional
effect of the normal saline.

🧐Is normal saline the best for resuscitation? – No, ideally blood transfusion is the best for resuscitation to
compensate blood loss in long bone fracture. However, infusing normal saline would be much easier + we can still
increase the BP.

🧐How do you decide for blood transfusion?

🔆If Hb >8, we observe first.
🔆If Hb <8, we may decide to transfuse blood especially in DM patients because we want to keep Hb >10 to
improve healing (but still, depends).
🔆If Hb <6, blood transfusion is almost always required (particularly in acute anaemia).
🔆If patients have anaemia symptoms, regardless of Hb level, blood transfusion is required.
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There is an ulcer
- Lateral side of the heel of the right foot
- Oval shape
- size about 3cm x 5 cm
-well demarcated margin ( suggestive of surgery had been
done before)
- presence of slough tissue at the inferior part of the ulcer
- no expose bone or tendon
- redness of the surrounding skin and macerated skin
around the wound

Additional??
- adequate number of toes
- interdigital lesion
- gangrene
- nail changes
- look also at post lateral and ant foot, check presence of
callousity.. for this pt there is also presence of callousity at
the base of middle phalange of sole of foot

Upon palpation
- Tenderness? Up to the??? Or surrounding the layer
- pus discharge? Upon milking?
- CRT< 2 sec
- sensation reducein stocking distribution from toes up to
the??.( pt ni reduce sensation up to midshin)
- PTA and DPA can be palpable?, if palpable but not same
between both foot, comments, palpable but reduce at L/R
foot..

Move
- toes can move??
- ankle can move??

I would like to do (Special test)

- simmes weinstein 5.07/10g monofilament test
- vibration test by using???? Tuning fork 518 Hz
- proprioception
- doppler ultrasound to look for DPA or PTA (IF NOT
PALPABLE)

#MsArdillaOrthoNotes
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Script management for dfu by the legendary Mr Adham : DFU

Ayat dia after sc selalunya, "my provisional dx is DFU. I will confirm it by checking the pt blood glucose level.
Next, i will sit down and take further history regarding pt's diabetic control. Pastu management mcm atas tu. Han
tertinggal ayat "I would like to REEDUCATE patient and his/her family member regarding diabetic control"

How to manage this pt?

1. I would like to do ABSI, how and why

2. I would like to do simmes weinstein monofilament test how and why
3. I would like to order ct angiography to know the level of amputation to evaluate proximal vascular status, if
there is a need for amputation or there is possibility for reperfusion, i will refer this patient to vascular team
4. I would also monitor septic status for this patient, do culture and sensitivity and administer prophylactic
antibiotics such as...
4. If there is a need for amputation, i will explain to the patient and to the family members regarding this
5. I will also do several investigation such as... To know the diabetic control of this patient. I would then refer this
patient to endocrine team for diabetic control and diet team for diabetic diet control and high protein diet for wound
healing
6. I would also refer this patient to rehabilitation team for prosthesis
7. I would like to educate this patient regarding foot care and foot wear
8. I would like to educate this patient regarding how to preform wudhuk and praying with the dressing
9. For the time being, i would prefer what type of dressing...

5. Read about the difference between empirical vs therapeutic vs prophylactic antibiotics.

▶ Empirical - give antibiotics that covers for what is most likely to be the organism.

▶ Therapeutic - give antibiotics after the culture result has come out. Specific to certain organism which
antibiotics works best.
▶ Prophylactic - before surgery / when you expect infection to occur.

▶ Use broad-spectrum antibiotics (empirical type - cover most common organisms)

▶ Culture is usually polymicrobial

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