Case Study

The Accident

11-5-99

Bob’s accident occurred at 12:30pm while four wheel driving with friends in the high country Four Wheel driving fun.  While directing a vehicle Bob’s leg was stuck in the mud, moving to avoid the vehicle he tried to jump and twist, unfortunately his leg was stuck causing his body to twist while his leg stayed stationary.  At this time Bob heard an audible crack, and upon landing in a muddy water filled puddle noticed his right leg lying at a 90 angle to the other femur.  Bob’s partner and friend pulled him clear of the muddy water to lay beside the puddle where his partner applied traction to the broken leg by holding the ankle and pulling.  To help prevent hypothermia and shock, the friend was able to manoeuvre a space blanket underneath and wrapped over Bob.  While Bob’s partner continued to maintain traction his friend walked out of the area to try and obtain cell phone reception to call for help. (Bob's feelings)

After hours of lying in the mud, Bob was cold and wet,  because of previous mountain rescue training, he was concerned about a fat embolus from the break if he moved about too much, and his partner was becoming tired from maintaining the traction.   With Bob’s guidance his partner fashioned a splint for the broken leg out of wood found in a nearby tramping hut and the tow rope from one of the vehicles.  The friend returned after a few hours, but had been unable to obtain cell phone reception.   At this time using the soft top off one of the vehicles as a stretcher they dragged and lifted Bob into the back seat of his friends four wheel drive, and into shelter.   Bob’s friend left the scene to once again try for cell phone reception.   Once established in the back of the vehicle Bob found he could maintain his own traction by pushing down on the wood at the top of the splint.  (Bob's feelings)

As he was now in shelter and maintaining his own traction, Bob sent his partner using their vehicle to follow the friend and assist with trying to raise help.   Unfortunately their vehicle got stuck in the mud just a few metres from the accident sight.  Being unfamiliar with the vehicle Bob’s partner had to spend the next hour running from the vehicle to Bob to get instructions on how to use the winch system to extract the four wheel drive from its muddy resting place.  Finally with the vehicle freed she was able to follow in the quest for help.  Meanwhile Bob’s friend had finally obtained phone coverage, phoning emergency services, and help was on its way.  (Bob's feelings)

The Rescue

11-5-99

Rescue services were called at 16:49, and the Westpact Trust Rescue helicopter was despatched at 17:18 arriving at the accident scene at 17.58.  On arriving at the sight the air ambulance crew undertook an initial assessment of Bob and his condition.  This included a history of the accident and assessment of the patient.  Due to failing light and weather conditions the crew had to work fast.   The ambulance crew made an initial diagnosis of a closed fracture to Bob’s right femur, which they splinted using a hare splint.  Bob was pallid and tachycardic but had a good pedal pulse, a blood pressure was unobtainable due to Bob’s heavy clothing.

Link to Hare Splint

At 18:10 the helicopter left the scene heading for the nearest Public Hospital Picture of WestPacTrust Helicopter.  On route Bob remained conscious and orientated, responding to commands, vital signs as follows:

Times 18:15 18:30
Pulse 108 70
Blood Pressure (unobtainable)  
Respirations 16 14

Bob was administered oxygen via a hundson mask at 10L/S and an I.V. line was put in place.  Through the I.V. line Bob was administered the following medication during the flight:

Time Dose Drug Given
18:20 12.5ml I.V. Phenergan
18:20 5.0ml I.V. Morphine
18:50 700ml Normal Saline

At 18:51 the helicopter journey ended, arriving in the park next to the Public Hospital where Bob was transferred the short distance by ambulance to the accident and emergency department.  (Bob's feelings)

Accident & Emergency

11-5-99

Bob was admitted to the accident and emergency department at 19:07 following a hand-over from the air ambulance crew.  Due to the analgesia administered during the rescue flight Bob was pain free at this stage, the traction was removed, Bob’s wet trousers, socks and boots taken off, and the traction reapplied.  During the course of the evening a history of events was taken including a history of previous injuries and current medications, this assessment reads as follows:

Four wheel driving today.  Stepped back and turned with weight on right leg. Audible crack, saw that leg was deformed, bent at 90 in upper half of femur over to the left side.  Fell back into puddle of muddy water, trousers saturated on arrival.  Helicopter transfer to emergency department.   Bob has a history of left shoulder haemiarthroplasty with left deltoid weakness and a previous fracture of his right ankle for which he takes voltaren PRN.  Previous fracture of his right femur in 1982.

Bob was escorted to x-ray where an oblique fracture of the right subtrochanteric region was confirmed.  A surrounding callus was noted on the x-ray from the previous fracture in 1982 Xray of Fracture.

During his stay in accident and emergency Bob maintained a good pedal pulse, and good venous return, his feet were cold, damp and pale, but with normal sensation.  His vital signs in accident and emergency were as follows:

Time 19:15 19:45 20:30
Temperature 37.5    
Pulse 85 81 85
Respirations 22   18
Blood Pressure 122/80 122/82 122/73
O2 Sats 98%A 100%A 98%A
G.C.S. 15/15 15/15 15/15

No further analgesia was administered to Bob at the emergency department and he was transferred to the orthopaedic ward at 22:00 with I.V. fluids and oxygen 3L via nasal canula in situation.

Link to Oxygen Therapy

Link to I.V. Therapy

Acute Orthopaedic Ward

11-5-99

On arrival at the acute orthopaedic ward Bob was seen by the registrar.   It was decided to place him in skin traction overnight using 6kg weights and to elevate the foot of the bed for counterbalance.  Oxygen therapy was charted to continue at 6L via the hudson mask and 3L via nasal canula when eating.  Morphine was charted as pain relief to be administered via a P.C.A. pump.  I.V. fluid therapy was to continue with fluid balance monitoring.  Oxygen saturation levels and vital signs were to be monitored regularly and Bob was to be nil by mouth from 24:00 ready for surgery to reduce the fracture in the morning.  Bob was given a full sponge wash and something to eat and drink before 24:00.  Mouth and oral cares were administered and Bob was settled for the night in a stable condition with a BP of 130/80, pulse 80, O2 sat’s 98-99%, and passing urine within normal limits.

Link to Skin Traction

Theatre

12-5-99

The following morning Bob went to theatre for reduction of the fracture with a locked rod internal fixation and right femoral nail. Theatre report as follows:

Indications:   A closed subtrochanteric fracture of the right femur.  This is a Russell-Taylor type 1A fracture.  Bob has previously had a fracture in the same subtrochanteric region in 1982.  The rod had been removed.

Procedure: General anaesthetic, patient supine on Marquette Fracture table.  Left leg in lithotomy, right leg in traction.   Fracture reduced as well as could be under ll control, still had varus angulation at the fracture site.   Using guide wire technique, entry point was found in the proximal femur.  Then the femoral alignment device was used to introduce the guide wire across the fracture site.   Reamed up to 14.5mm to accept a 42cm 13mm ACE femoral rod.  1 distal locking screw, 1 oblique proximal locking screw.  Did not prove possible to completely remove varus angulation at the fracture site despite opening the fracture site up.  1 Vicryl to deep fascia lata and subcut fat 3/0 Monocryl subcuticular to skin.  1 Redivac drain left deep.  Post opsite dressing.

Post Op: IV Penicillin and Flucloxicillin, 2 and 2, 6-hrly x3 doses.  Drains out 24 hours.  Check haemoglobin and x-rays tomorrow.  Mobilise non weight bearing for 6 weeks.

Post surgery Bob was reinstated in the ward and maintained normal neurocirculatory status in his right leg.  Morphine was administered for pain relief via a P.C.A. pump.

Pre-operatively Bob’s haemoglobin was 132gm/L but dropped to 88gm/L post-operatively.  In Bob’s notes it reads that he was offered a blood transfusion but refused same.  Although in the notes it has been inferred that Bob was offered a transfusion promptly following surgery and refused the same.  Bob maintains that he was not offered the transfusion until four days post-operatively, and then in a very casual manner by a house surgeon from his room doorway.  By this stage with the aid and education from one of the nursing staff, Bob was addressing the issue of anaemia by dietary means such as sardines and spirilina, and did not feel that a blood transfusion would be of benefit as progress was being made.  (Bob's feelings)

Link to Anaemia

I.V. antibiotics were administered as charted.  I.V. fluid therapy and fluid balance continued, along with oxygen therapy and regular monitoring of vital signs.  Bob maintained a stable condition with good urine output.

13-5-9

During the night Bob’s temperature elevated to 38.3, panadol was given at 01:00 and his temperature was reduced to 37.4 at 05:00.  Other vital signs remained stable, circulatory checks were good, and Bob was tolerating fluids well with a good urine output.

The last dose of antibiotics was given at 07:00, Bob had his haemoglobin checked which had risen to 90gm/L, and a follow up x-ray was undertaken as follows:

X-ray report:  An intramedullary rod with fixing screws has been inserted in the right femoral shaft.  Separation of bone ends at the upper femoral shaft fracture has been reduced with only slight residual deformity here now X-ray after fixation showing top screw and fracture Xray after fixation showing bottom screw.

Regular panadol was commenced for elevated temperature.  In the afternoon Bob was showered on a shower chair with a leg extension attached.  Otherwise he remained on bed-rest.  His redivac drain was removed, and his dressing changed.  Bob was encouraged to do post-operative deep breathing exercises.  While dozing his oxygen saturation levels dropped to 91% and at 23:00 Bob’s temperature elevated to 38.6 at which time the house surgeon was notified, but was reluctant to do blood cultures at this stage.  At 23:00 the P.C.A. pump was removed at the patients request and panadol along with codeine phosphate was initiated for pain control.   Although in the notes it states only that the P.C.A. pump was removed at the patients request at this time, it was Bob’s understanding that the pump was taken down as it wasn’t working correctly. Circulatory checks and other vital signs remained satisfactory.  (Bob's feelings)

14-5-88

During the night Bob’s temperature spiked again at 39, the house surgeon was notified and blood cultures were taken along with a midstream urine sample, report as follows:

Blood Cultures  
Culture No growth aerobically or anaerobically after five days.
Midstream Urine  
Urine Mircroscopy White Cells  10
  Red Cells      0
Culture No Growth

Panadol was administered and cooling cares given to lower Bob’s temperature.  Oxygen therapy at 2L via the nasal canula continued.  Bob’s oxygen saturation levels continued to drop to 88-92% while sleeping for no apparent reason.  The P.C.A. pump was reinstated for pain relief at the patients request.  Bob was seen by the physiotherapist this morning and was to mobilise as able non-weight bearing.  He also continued with passive exercises including straight leg raises with the encouragement of his nurse.  Fluid balance was discontinued in the afternoon, but I.V. therapy continues on.  The wound sight was checked with no apparent ooze.  Bob continued to spike a temperature throughout the day.  (Bob's feelings)

15-5-99

Bob was self mobilising within the bed today, he is carrying out his physio exercises, and mobilising in a wheelchair or showerchair.  Further mobilisation onto crutches is difficult related to Bob’s previous injury and his inability to weight bear on his left shoulder, this needs to be discussed with the orthopaedic surgeon.  The P.C.A. pump has been continued today at Bob’s request.  There was no wound ooze, I.V. therapy has now been discontinued and Bob’s haemoglobin is 88gm/L today.

16-5-99

P.C.A. pump was discontinued today, panadol and codeine phosphate to be administered regularly for pain with meals and upon settling.  Bob is independent with mobilisation within his bed today, up to shower in shower chair, and independent with self cares.  The dressing was changed and the wound looked clean with nil ooze.   Bob’s temperature was stable and his haemoglobin is now 95gm/L.  The physiotherapist spoke with the consultant orthopaedic surgeon regarding Bob’s mobilisation.  It has been suggested that Bob try’s using a gutter frame as able.  Bob’s home situation was discussed with him by the physiotherapist today to assess his future needs.  It was suggested that he be discharged home in the near future with a gutter frame and wheelchair for mobility.  The occupational therapist would call on Monday to assess the property for access with a view to the installation of ramps.  (Bob's feelings)

17-5-99

Bob received oral morphine for pain during the night but is otherwise managing on panadol and codeine phosphate.  His temperature remains stable today and Bob’s haemoglobin is 95gm/L.  He is currently independent with cares and it has been suggested that Bob be discharged home once the proposed ramps are in place.

18-5-99

Bob’s temperature remains stable.  He is up in a chair and managing self cares well.  Bob went out on leave this morning and phoned the ward to say he was managing fine at home and would come back on Sunday to collect his belongings.  The discharge script was given to Bob before he went on leave.  (Bob's feelings)

Discharge Note

Diagnosis:  Fracture right femur

History:   Bob was admitted with a fractured right femur after an accident.

Relevant Investigations:  x-rays showed an oblique fracture of the right subtrochanteric region.

Treatment/ Procedures:  Taken to theatre for a femoral nail to be placed.  He made a rapid post-operative recovery despite having anaemia with a Hb88gm/L.  Bob declined a blood transfusion (see above notes) and began mobilising well despite a previous arthrodesis in his left arm.  No post-operative complications.

Discharge  Medications:   Paracetamol 1gm prn.

Plan:  For follow-up with the orthopaedic surgeon in 6 weeks and outpatient physiotherapy.

At Home

On the Monday following discharge the occupational therapist visited Bob at home to make arrangements for wheelchair access.  Both the Accident Compensation Corporation and the occupational therapist approved the installation of ramps, yet it still took a follow up call from Bob and one month to have these installed.   No explanation has been given for the delay and inconvenience.  After a week at home Bob was cleared to return to work one day a week in an office capacity.   Three weeks later Bob made the decision that he was able to manage three days a week at work which he has continued with since.  Apart from some discomfort and inconveniences Bob and his partner managed well with him at home.  (Bob's feelings)

Six Week Check Up (27-5-99)

At Bob’s six week check up, post-operative x-rays showed some mild varus angulation of the distal femoral fragment, which has been accepted Xray showing non-union.  He was touch weight bearing on his right leg and both proximal and distal wounds looked good.  The range of movement at the knee was from 5 of flexion to about 70.  The plan was to continue touch weight bearing on the right leg for a further four weeks at which time further x-rays would be taken to decide if partial weight bearing could begin.

Four Weeks Following (9-7-99)

Two months post injury Bob has progressed to partial weight bearing.   He is experiencing intermittent pain over the medial and lateral aspect of the proximal thigh.   On examination he had full range of movement in the right knee with full extension to 125 of flexion.  Bob’s hip movements were 100 flexion although there was some limit on internal rotation.  X-rays showed very little callus formation very little callus formation.  The plan was to continue partial weight bearing and to be seen again in a further months time with more x-rays.  (Bob's feelings)

One Months Time (6-8-99)

X-rays at this visit showed no sign of union at the fracture site still no union.  The fracture now was unlikely to unite.  There was mild distraction at the fracture site which was probably implicated in the union delay.  It was decided at this stage by the consulting orthopaedic surgeon that further surgery in the form of bone grafting and shingling of the fracture was necessary to stimulate bone union.

At this point Bob applied for Accident Compensation to pay for extended surgery. This was approved by Accident Compensation who were willing to pay full costs if Bob went through the public system, unfortunately this meant delaying surgery until January 2000.  Under the private system Accident Compensation were willing to pay only a fraction of the cost, and Bob’s medical insurance would have to pay for the rest, this however meant a much shorter delay allowing Bob the surgery in just over a months time.  Bob chose to have surgery sooner rather than later and attended the private hospital.  (Bob's feelings)

Following this appointment for ease of mobility, Bob approached the physiotherapist, and obtained a pair of elbow crutches which he now uses around home. (Bob's feelings)

Private Hospital Admission

29-9-1999

Bob was admitted to a local private hospital to undergo the bone grafting and shingling of his left femur as recommended during his last consultant visit.  The operation took place on the same morning as admission under general anaesthetic.  Operation record as follows:

Procedure:  Bone Grafting and Shingling of Ununited Fracture Right Femoral Shaft.

Indication:  Atrophic non-union of femoral shaft fracture at the junction of the proximal and middle thirds.

Procedure: The previous wound was opened.  Vastus lateralis was elevated and retracted anteriorly exposing the fracture non-union.  Fibrous tissue was resected from the bone end.  A lateral spike of bone was also resected.  The bone either side of the fracture was shingled with a quarter inch osteotome.  A cancellous bone graft obtained from the right iliac crest was then packed into the defect between the bone ends.   Haemastasis was secured.  Drains were inserted in the iliac crest wound and in the femoral shaft wound and the wound closed in layers with one vicryl and a 4-0 monocryl subcuticular skin suture.

The procedure took forty minutes and following a short stay in recovery Bob was admitted back to the ward.  On admission to the ward he had a two drains in situation, he was for hourly circulation checks, I.V. fluid therapy, I.V. antibiotics, and oral antibiotics, a P.C.A. pump with morphine for pain, with oral panadol and codeine phosphate charted.  Circulation checks and observations at this stage were stable.

Bob was tolerating fluids well and as he was thirsty following surgery, proceeded to drink unchecked.  Although Bob was on I.V. fluid therapy and had only been operated on that morning, he was not on fluid balance monitoring.  Drinking often Bob had not passed urine and felt no urge to go.  During the course of the evening this became uncomfortable and at 23:30 Bob expressed the urge to pass urine, at this time he could pass only 250ml of overflow, and he was unable to empty his bladder.  It should be noted that these events and the 250ml volume passed by Bob leading up to the subsequent ultrasound scan have not been charted in his notes, where no relevance has been placed on events until the consulting surgeon was notified at 03:00.  At 2:15 Bob underwent an ultrasound scan of his bladder which was found to be holding an excess of 762ml.  The consulting surgeon was notified arriving promptly, whereby he inserted a supra-pubic catheter to drain Bob’s bladder, which drained 1300ml immediately.(Bob's feelings)

Link  to Urinary Retention

Link to Supra-pubic Catheterisation

30-9-1999

I.V. and oral antibiotics continued today.  The P.C.A. pump remained in situation for pain control, along with oral panadol and codeine phosphate.   Bob began to spike a temperature at times, and the surgeon was notified.   Knowing of Bob’s previous history for spiking temperatures post-operatively from his last admission to the public hospital system, the surgeon issued no new orders.  There was nil-ooze from the wound site and the medinorm drains remained in situation.  Post-operative breathing exercises and passive leg exercises were encouraged.  Bob was up for a shower on a shower chair, but otherwise remained on bed-rest.  The supra pubic catheter continued to drain well and Bob remained reasonably comfortable.

31-9-1999

I.V. fluids and I.V. antibiotics were discontinued today, although the oral antibiotic continued.  The P.C.A. pump was discontinued and Bob continued to take panadol and codeine phosphate regularly for pain control.  There was some scant ooze from the wound site.  The medinorm drain and the supra pubic catheter were both removed, Bob is now passing urine satisfactorily on his own.  He is allowed up on crutches touch weight bearing only, which is to be queried related to his previous injury and not being able to weight bear with his left shoulder.  (Bob's feelings)

01-10-1999

The oral antibiotics were discontinued today.  Recordings were stable, Bob was up independently for a shower and has been up with the aid of a wheelchair.  Bob was discharged home today using a gutter frame and wheelchair for mobility.  No discharge note was obversed in Bob’s file and the author has pieced this information together herself.

At Home (post elective surgery)

At home post-operatively Bob sustained a rotator cuff injury while manoeuvring the wheelchair.  This was of such a nature that he required physiotherapy for the injury. Otherwise he continued to use the gutter frame to mobilise.

First Post-operative Check-up (11-10-99)

Bob had his first post-operative follow up visit today.  The wounds from his recent surgery have healed well, and he is mobilising predominantly with the aide of his wheelchair and the gutter frame.  Bob finds using crutches is still very difficult related to his left shoulder arthroplasty.  For follow up in in four weeks, with up to date x-rays to assess union of bone graft site.

Four Weeks Time (10-11-99)

Bob had a further review of his femur today, using current x-rays.  The x-rays showed little evidence of the fracture uniting.  The consulting orthopaedic surgeon, altough disappointed, thought that this could perhaps be expected at only six weeks post-operatively.  In the meantime Bob was to be partial-weight bearing, and for follow up in a further six weeks, with x-rays.

A Further Six Weeks (27-12-99)

There is some improvement shown by x-ray today bony buttress forming.  There is evidence that a bony buttress is now growing on the medial side of the graft.  Bob is now to begin load bearing gradually onto the leg as he feels able, this is to see if physiological stress will improve healing potential.  For review in another six weeks.  (Bob's feelings)

Last Visit (15-2-00)

At todays visit the x-rays are now showing that the bone graft is consolidating on the mend.  Bob is on the road to recovery after a long healing process.  He can now weight bear on his leg, although this still causes him some discomfort at present.  Bob can now begin to return to full-time work and other activities as he feels able, begining to pick up the pieces of his life as it was before the accident.  (Bob's feelings)

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