Past Medical History:
- Lives alone
- Mobilizes with cane
- Allergic to Penicillin
- Smoked 20 cigarettes/day
- Mild asthma
- Depression
Examination:
She had 2 Ex-Fix scars on the outer aspect of the right thigh which were well healed with no signs of infection.
Her right leg was shortened by 5-6 cm and externally rotated to 30°. She had a 30° posterior angulation and approximately 30° of valgus. She had short leg gait which was improved with heel raise, however, she was also Telendelenburg positive.
The skin was pink in colour, non-tender over the fracture site. She had full range of motion at her right hip and knee. The right leg was neurovasularly intact distally.
Consultation:
Various options were discussed with her. She refused the Taylor Spatial Frame, and instead opted for an osteotomy and intramedullary nailing. She was advised to give up smoking, which she did three months prior to surgery.
Pre-operatively:
She was afebrile
Blood results
CRP (C-Reactive Protein) <2
Na (Sodium) 137 mmol/L
K (Potasium) 4.1 mmol/L
Ur (Urea) 4 mmol/L
WBC (White Blood Cells) 8.7 x10
Hb (Haemoglobin) 14.1 g/dl
PLT (Platelets) 135 x10
Neut (Neutrophils) 5.5 x10
PT (Prothrombin Time) 10.2 sec
APTT (Aquired Partial Tromboplastin Time) 25.0 sec
ESR (Erythrocyte Sedimentation Rate) 1 mm/hr
The standard MRSA screening swabs were all negative.
Intra-Operative findings:
During the operation, it was observed that at the fracture site there was a mucoid material in a small cystic area. This did not have the appearance of frank pus. It was 1.5 x 1.0 cm in size.
Osteotomy of the callus formation was applied. Proximal and distal intramedullary canals were identified, corrected and approximated. Then the nail was inserted in an antegrade fashion.
Post-Operative Course:
The patient was feeling well, leg length was restored satisfactorily
Blood results
CRP (C-Reactive Protein) 59
Na (Sodium) 136 mmol/L
K (Potasium) 4.0 mmol/L
Ur (Urea) 5.8 mmol/L
WBC (White Blood Cells) 9.7 x10
Hb (Haemoglobin) 8.6 g/dl
PLT (Platelets) 63 x10
Neut (Neutrophils) 6.7 x10
PT (Prothrombin Time) 12.2 sec
APTT (Aquired Partial Tromboplastin Time) 26.4 sec
ESR (Erythrocyte Sedimentation Rate) 50 mm/hr
On the clinical findings at operation, it was decided to commence Vancomycin to cover any potential gram positive infection.
5 days Post -Operatively
The patient was afebrile, mobilizing with a walker, pain free, full range of motion and neurovascularly intact.
Blood results
CRP (C-Reactive Protein) 78
Na (Sodium) 135 mmol/L
K (Potasium) 4.0 mmol/L
Ur (Urea) 4.0 mmol/L
WBC (White Blood Cells) 8.8 x10
Hb (Haemoglobin) 11.5 g/dl
PLT (Platelets) 117 x10
Neut (Neutrophils) 6.5 x10
Culture swab results from the mucoid mass seen at the fracture site had grown unexpectedly MRSA. After discussion with our infectious disease and microbiology colleagues, we have decided to discharge her on a course of oral Rifampicin and Doxycyclin.
