Closed fractured fracture of the lower third of the tibia with lateral and posterior offset
History of the disease in traumatology
Diagnosis: Closed fractured fracture of the lower third of the tibia with lateral and lateral displacement and the lower third of the fibular bone without displacement of the left leg .
Born in 1956, Ros and developed normally. Material conditions are satisfactory. Personal hygiene is observed. Meals are regular, in sufficient quantity. Of the diseases transmitted, frequent acute respiratory diseases are noted. Botkin’s disease, tuberculosis, diabetes mellitus, venereal diseases, mental illness denies. Allergoanamnesis is not burdened, hemotransfusions were not. Harmful habits;
smokes about 1 pack a day; alcohol consumes occasionally; denies drug use.
The general condition of a patient of moderate severity, the appearance corresponds to age, consciousness is clear, the condition of the body is forced, the expression of the face is normal, the physique is normostenic. Sores, hemorrhages, ulcers, no peeling. Turgor skin is normal, humidity is normal. Subcutaneous fat is developed moderately, no edema, subcutaneous emphysema is absent. Lymph nodes are not enlarged, the skin above them is not changed. Musculature is developed normally, symmetrically, soreness, there are no cramps. The movements are active and passive in full. When examining the spine, there is no scoliosis, the tenderness of spinal processes and paravertebral zones is absent. Head of normal shape and magnitude of tremors and deformations is not
Chest shape normostenic, without deformations and asymmetry. Intercostal gaps are not extended, both sides are uniformly involved in the act of respiration, the type of respiration is mixed, ЧДД-20 in min. The rhythm is correct, shortness of breath, no suffocation. Palpation of the chest painless, voice tremor not changed, the same on both sides. With a comparative percussion on the entire surface of the lungs, clear lung sounds. At topographic percussion: the Krenig field is 5 cm on both sides, the height of standing of the apices of the lungs: in the front 3 cm above the collarbones, at the level of the spine process 7 of the cervical vertebra, the lower boundary of the lungs:
Heart hump is not present. Vertebral and cardiac stimulation is not visually determined. There is no ripple of the aortic arch and peripheral arteries. Swelling of jugular veins and undulation of the veins of the neck, liver pulse is not present. the expansion of the subcutaneous veins of the chest and abdominal cavity is not observed, the apical impulse is not palpated, pulse rate 88 in min. Pulse of satisfactory qualities. For percussion: 1. The boundaries of the relative
– right on 1 cm outside from the right edge of the sternum
– left to 1.5 cm in the inside from the left mid-clavicular line
– the upper-3 rib
The heart has a normal configuration, the diameter of the heart is 11 cm, the diameter of the vascular beam is 5 cm, with auscultation, the tone of the heart is clear, the heart rhythm activity is correct, BP 120/80 mmHg
When examining the oral cavity, the gum is of normal color, bleeding, no ulcers . The language is moist, not overlapped, the coloration of the mucous membrane of the throat is normal, the surface is smooth, the tonsils of normal color are not enlarged, the abdomen of the usual form, uniformly participates in the act of respiration, bands, scars, pigmentation is not present. There are no divergences of the direct muscles of the abdomen. When palpation the abdomen is soft, painless. With deep palpation of the abdomen, all sections of the intestine are defined as painless, stinging cylinders with a smooth surface. The border of a large curvature of the stomach is 3 cm above the navel, in the form of a roller, palpation of the stomach is painless, the gatekeeper is palpated in the form of a strain. The chair is usual, once a day, painless.
The liver and spleen are not palpated. The size of the liver according to Kurlov 9-8-7 cm. The size of the spleen by Kurlov is 6-4 cm. The gallbladder is not palpable.
When examining the lumbar region, swelling, hyperemia, no swelling The symptom of effusion is negative on both sides. The urination is not disturbed, painless.
NERVOUS SYSTEM AND ORGANS OF SENSES
The patient is well oriented in space and time, the psycho-emotional sphere without deviations. Speech, hearing, sight, sense of smell, sensation in norm.
Deformation, crepitation, pathological motility of fragments, moderate soft tissue edema, hyperemia are determined on the left leg in the lower third. Vascular and nervous disorders on the left leg and foot are not present.
Closed fractured fracture of the lower third of both bones of the left leg with shuffling off.
FINAL CLINICAL DIAGNOSIS
Closed fractured fracture of the lower third of the fibular bone, lower
RATIONALE OF CLINICAL DIAGNOSIS The diagnosis is based on:
1 complaints of the patient – pain in the left shin, impossibility of support on the left foot.
2 anamnesis of the disease: slipped, fell to the left leg. He could not stand independently. The ambulance car was delivered to the city hospital № 4 with the immobilization of the Kramer bus in 1h 20 min.
3 local status;
4 X-ray examination of the left shin is determined on the left lower leg in the lower third, deformity, crepitation, pathological motility of the fragments, moderate soft tissue edema, hyperemia. conclusion; fractured fracture of the lower third of the tibia with lateral and posterior offset, lower third of the fibular bone without displacement of the left leg
10/04 -00 g. Patient does not complain, the general condition is satisfactory. Sleep, appetite is normal. In the lungs breath is vesicular, no wheezing. The tones of the heart are clear, rhythmic, the rhythm is correct. Abdominal palpation is soft, painless, pulse 70 in *, blood pressure 120/80 mm.rt.st. Body temperature 36.6 * С. It is recommended to continue the treatment started:
skeletal stretching and electrophoresis 15 / 04-00. There is no complaints from the patient. The general condition is satisfactory. Sleep, appetite is normal. Chair, diuresis not disturbed. In the lungs breath is vesicular, no wheezing. The tones of the heart are clear, rhythmic, the rhythm is correct. Abdominal palpation is soft, painless. Pulse = 75 in * DR 125/75 mm. ht Art. Body temperature 36,6 C. It is recommended to continue the treatment started: skeletal stretching, electrophoresis. 19 / 04-00. There is no complaints from the patient. The general condition is satisfactory. Sleep, appetite is normal. Chair, diuresis not disturbed. There is no vesicular / wheezing in the lungs. Tone of heart is rhythmic, clear, rhythm is correct. The abdomen of the pryshlipation is soft, painless. Pulse 70 in *, BP 120/80 mm. mercury Temperature (36.6 С. Recommended to continue treatment:
From anamnesis of the disease: slipped and fell near the entrance of your house, could not stand on its own . Objectively revealed: deformation, crepitation, pathological motility of fragments, moderate soft tissue edema, and hyperemia are determined on the left leg in the lower third. Vascular and nervous disorders on the foot and neck. From data of laboratory and instrumental methods of research: general blood test
Conclusion: the norm of the biochemical analysis of the blood:
Conclusion: norm the general analysis of urine:
X-ray examination of the left leg: fractured fracture of the lower third of the bony uterus with lateral and posterior displacement, in the lower third of the fibular bone without displacement left leg After the examination, the diagnosis was made: a closed fractured fracture of the lower third of the bone marrow with lateral and posterior displacement, in the lower third of the fibula without displacement of the left leg. Treatment was prescribed for the bed, diet number 15, conservative treatment: blockade of the fracture site Sol. Novocaine 0.3% -40.0. The skeletal stretch for the heelbone is loaded with a load of 4 kg. The leg is laid on the Beler bus. Medicinal treatment: Sol. Analgini 50% -2 ml / m 3 times a day, Sol.Dimedroli 1% – 1 ml / m 2 times a day. Electrophoresis with novocaine on the lower third of the left leg. It is recommended to continue the prescribed treatment.
1 for life- favorable
2 for complete recovery- favorable
3 for the restoration of disability- favorable