Case Presentation

Presented By:

Dr. Md. Mizanur Rahman

D-Ortho student
Department of Orthopedic Surgery,
BSMMU
Particulars of the patient:
• Name : Purnima
• Age : 50 years
• Sex : Female
• Religion : Hindu
• Occupation :Housewife
• Address :Hobiganj, Sylhet
• Date of admission : 17. 07. 2023
• Date of Examination:18.07.2023
Presenting Complaints:

• H/o accidental entry of wearing garments into motor vehicle

10 days back.
• Pain and swelling of left forearm for same duration.
History of present illness:
• According to patient statement, she was reasonably well 10
days back.
• Then she had h/o accidental entry of wearing garments(shari)
into motor vehicle (Tomtom) that was wrapped her left
forearm.Then she felt severe pain in her left forearm with
deformity.Then she got treatment from local hospital,diagnosed
as a case of closed fracture of shaft of radius ulna and referred
to Dhaka for better management.
 History of present illness:

• Then she came to BSMMU Orthopaedic department and got

admitted in RED unit.
• She is non diabetic, normotesnsive, non asthmatic.
• Her bowel & bladder habit is normal.
Treatment history :
• Nothing significant
General and Systemic Examination:
• General Condition : Anxious , average built, co-operative.
• Non anaemic, Non Icteric, Non Dehydrated
• Pulse : 82/min
• BP : 130/80 mm of Hg
• Temp : 98.4 F
• R/R : 18/ min
• Respiratory/ CVS/ Alimentary and other systemic examination
reveals no abnormality.
Local Examination: (Left upper limb)
Look:

(After careful removal of splint)

• There is no overlying skin injury
except swelling of forearm
Feel:

• Temperature : Normal
• Tenderness : present
• Distal neurovascular status : intact
Move:

• Movement of left elbow joint & wrist joint can not be elicited
due to pain.
Radiological Evaluation
Diagnosis:

• A case of 14 days old closed fracture shaft of radius ulna (left)

(AO type:22A3) in a 50 yrs old right hand diminant female.
• Unit plan:Open reduction &intetnal fixation
(ORIF) with small DCP.