This is my orthopaedic logbook..pls read through cuz I will be uploading case for you to fill into the section required
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I've read through your logbook completely. Here's a summary of its structure:
AIMST University — Orthopaedics Logbook (Year IV MBBS)
Hospital Sultan Abdul Halim | 57 pages
Structure Overview:
Front matter (Pages 1–9)
- Declaration, Certificate, Index, Goals & Objectives, Posting guidelines
Activity logs (Pages 10–12)
- Cases clerked from the ward (with faculty signature table) — minimum 2 cases
- Plaster room observations (Above/Below knee & elbow plasters)
- Ward activities (Skin traction, Skeletal traction, Splints, Dressings, Catheterisation)
Case Write-ups — 3 cases (Pages 13–57)
Each case follows the same detailed template:
| Section | Details |
|---|---|
| Patient demographics | Name, Age, Sex, DOA, Date of Clerking, Occupation, Race, Religion, Nationality, Place |
| a. Chief complaints | Symptoms + duration (chronological) |
| b. History of presenting illness | Elaboration of complaints |
| c. Past history | Prior to chief complaint duration |
| d. Previous treatment/drugs | Medications, allergies |
| e. Family history | |
| f. Occupational history | |
| g. Menstrual history | |
| h. Personal & social history | |
| i. Systemic enquiry | |
| j. Summary of history | Salient features |
| k. Provisional diagnosis | With justification + differentials (points for/against) |
| l. Physical examination | General (head-to-toe) + Local (Inspection, Palpation, ROM table, Measurements, Specific tests) |
| m. Systemic examination | With diagrams |
| n. Summary | |
| o. Provisional diagnosis | Based on history + examination |
| p. Investigations | Results with normal values + interpretation |
| Radiology | AP/Lateral/Other views, radiological conclusion |
| q. Final Diagnosis | Based on all findings |
| r. Treatment | |
| s. Follow-up | |
| Discussion | Based on final diagnosis + faculty signature |
I'm ready. Whenever you upload a case, just tell me which case slot (Case 1, 2, or 3) and I'll fill in all the sections accordingly.
Chief Complaint Pain and swelling of the left knee for 1 day prior to admission. History of Presenting Illness (HOPI) Ms. Che Marizan, a 53-year-old former Air Force officer currently working as a housewife for the past 15 years, presented with pain and swelling of the left knee following a fall. The incident occurred when she fell forward while attempting to prevent her grandchild from falling. She sustained trauma to her left knee during the fall. She has a past history of left leg surgery 8 years ago following a motor vehicle accident that resulted in a distal left leg fracture. After the recent fall, she did not notice any external bleeding from the left knee. The pain was described as moderate, with a pain score of 5/10, associated with progressive swelling of the knee. She was unable to ambulate due to pain and restricted movement of the left knee joint. She also reported numbness over the affected limb. There was no loss of consciousness, no alteration in mental status, and no respiratory distress. The fall occurred in a mall in Alor Setar. She was assisted with a wheelchair, and her children brought her to the Emergency Department at Hospital Sultan Abdul Halim for further evaluation. At the emergency department, she received analgesic injection and imaging investigations were performed. She was subsequently discharged home the following day. However, she later developed fever and was brought back to the hospital for reassessment. She denied disproportionate pain or respiratory distress. A below-knee plaster of Paris support was applied to the left lower limb. This is the Hopi of the patient
Here is the logbook entry for Case 1, sections a and b, filled in as per the logbook format:
Case 1
Name of the patient: Ms. Che Marizan
Age: 53 years old
Sex: Female
Occupation: Housewife (former Air Force officer)
Date of Admission: (to be filled)
Date of Clerking: (to be filled)
Race / Religion / Nationality / Place: (to be filled)
a. Chief Complaints (symptoms + duration + chronological order)
- Pain over the left knee — 1 day prior to admission
- Swelling of the left knee — 1 day prior to admission
- Inability to ambulate — 1 day prior to admission
- Numbness over the left lower limb — 1 day prior to admission
- Fever — onset after initial discharge (duration to be clarified)
b. History of Presenting Illness
Ms. Che Marizan is a 53-year-old female, a former Air Force officer currently working as a housewife for the past 15 years. She presented with a 1-day history of pain and swelling of the left knee following a mechanical fall.
The incident occurred at a shopping mall in Alor Setar, where she fell forward while attempting to prevent her grandchild from falling, sustaining direct trauma to her left knee in the process.
Following the fall:
- She noticed no external bleeding from the left knee
- She developed moderate pain at the left knee, rated 5/10 on the pain scale, which was associated with progressive swelling of the knee
- She was unable to ambulate due to pain and restricted movement of the left knee joint
- She reported numbness over the affected left lower limb
- There was no loss of consciousness, no alteration in mental status, and no respiratory distress
She was assisted with a wheelchair and brought by her children to the Emergency Department of Hospital Sultan Abdul Halim for further evaluation. At the ED, she received an analgesic injection and underwent imaging investigations. She was subsequently discharged home the following day.
After discharge, she developed fever and was brought back to the hospital for reassessment. She denied disproportionate pain or respiratory distress at that time. A below-knee plaster of Paris (POP) support was applied to the left lower limb.
Relevant past surgical history: Left leg surgery 8 years ago following a motor vehicle accident that resulted in a distal left leg fracture.
Ready for the next section whenever you are — just send the remaining details (past history, drug history, family history, examination findings, investigations, etc.) and I'll slot them in.
Past medical hx..mva in 2018.. left tibial plateau fracture..internal fixation was done.. underlying uncontrolled DM and HTN for the past 15 years.
c. Past History
(History prior to the duration of the chief complaints)
-
Motor Vehicle Accident (MVA) — 2018
- Sustained a left tibial plateau fracture following the MVA
- Underwent open reduction and internal fixation (ORIF) of the left tibial plateau
- Relevant to the current presentation as prior hardware/surgical site is in the same limb
-
Diabetes Mellitus (DM) — diagnosed approximately 15 years ago
- Currently uncontrolled
- Relevant: impairs wound healing, increases infection risk, and may contribute to peripheral neuropathy (explaining the reported numbness)
-
Hypertension (HTN) — diagnosed approximately 15 years ago
- Currently uncontrolled
- Relevant: increases perioperative cardiovascular risk; poor vascular status may affect limb perfusion and recovery
Note for logbook: The past surgical history mentioned in the HOPI (left leg surgery 8 years ago) is now clarified here — this was the 2018 left tibial plateau fracture with internal fixation, which is 8 years prior to the current admission in 2026. This is consistent and should be cross-referenced between sections b and c.
Send over section d (previous treatment / drug intake / allergies) whenever you're ready — particularly the medications she's on for DM and HTN.
For the other section.generate the most possible and probable answer for this case
Reading File
Finding Sources
Finding Sources
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Finding Sources
Good — I have solid clinical context from the textbook. Now I'll generate all remaining sections comprehensively.
CASE 1 — Full Logbook Entry (All Remaining Sections)
d. Previous Treatment / Drug Intake / Drug Abuse / Drug Allergy
| Details | |
|---|---|
| Previous treatment | ORIF left tibial plateau — 2018; analgesic injection at ED during current admission; below-knee POP support applied |
| Current medications | Oral hypoglycaemic agents (e.g., Metformin ± Glipizide) for DM; Antihypertensives (e.g., Amlodipine ± Perindopril) for HTN (exact drugs to be confirmed with patient) |
| Drug abuse | Nil |
| Drug allergy | Nil known (to be confirmed) |
e. Family History
No known family history of diabetes mellitus or hypertension (to be confirmed). No family history of malignancy, bleeding disorders, or connective tissue disease.
f. Occupational History
Previously worked as an Air Force officer — involved in physical activity and structured duties. Currently a housewife for the past 15 years — sedentary lifestyle, predominantly home-based activities. No occupational exposure to hazardous chemicals, radiation, or heavy machinery currently.
g. Menstrual History
Post-menopausal (likely, given age of 53) — last menstrual period approximately (to be confirmed). No abnormal vaginal bleeding. Menopausal status is relevant as oestrogen deficiency contributes to decreased bone mineral density, increasing fracture risk.
h. Personal and Social History
- Smoking: Nil
- Alcohol: Nil
- Physical activity: Sedentary — housewife for 15 years; reduced mobility further limited by left knee pain
- Diet: Not on a strict diabetic diet (implied by uncontrolled DM)
- Living situation: Lives with family, children present and able to assist (escorted to ED during this admission)
- BMI: Likely overweight/obese (risk factor for uncontrolled DM, HTN, and increased load on knee joint — to be confirmed on examination)
i. Systemic Enquiry
| System | Findings |
|---|---|
| Cardiovascular | No chest pain, no palpitations, no pedal oedema (HTN noted — to be assessed) |
| Respiratory | No shortness of breath, no cough, no respiratory distress |
| Gastrointestinal | No nausea, vomiting, or abdominal pain |
| Genitourinary | No dysuria, no haematuria (catheterisation may be relevant if surgical intervention planned) |
| Neurological | Numbness over left lower limb noted — likely peripheral neuropathy secondary to uncontrolled DM, or neurovascular compromise from injury |
| Musculoskeletal | Left knee pain, swelling, restricted ROM; history of prior ORIF left tibial plateau |
| Constitutional | Fever post-discharge — suggestive of infection/inflammatory response |
j. Summary of History
Ms. Che Marizan is a 53-year-old post-menopausal Malay female, housewife, with underlying uncontrolled Diabetes Mellitus and Hypertension for 15 years, and a prior ORIF of the left tibial plateau in 2018 following an MVA. She presents with a 1-day history of left knee pain and swelling following a mechanical fall (forward fall to prevent grandchild from falling) at a shopping mall. She developed moderate pain (5/10), progressive knee swelling, inability to ambulate, and numbness over the left lower limb. There was no external bleeding, no LOC, and no respiratory distress. She received analgesia and imaging at the ED, was initially discharged, but returned with fever, raising concern for post-traumatic or peri-implant infection. A below-knee POP was applied. Her uncontrolled DM is a significant risk factor for poor wound healing, infection, and peripheral neuropathy.
k. Provisional Diagnosis (based on history)
Provisional Diagnosis:
Re-fracture / Peri-implant fracture of the left tibial plateau in a background of previous ORIF (2018), presenting with possible post-traumatic septic arthritis or surgical site infection (suggested by fever after initial discharge).
Justification:
- Mechanism of fall → direct trauma to previously operated left knee
- Pre-existing implant from 2018 ORIF → peri-implant fracture possible
- Uncontrolled DM → immunocompromised state → increased infection susceptibility
- Fever developing after discharge → infective process (septic arthritis, wound infection, osteomyelitis)
- Numbness → diabetic peripheral neuropathy or neurovascular compromise
Differential Diagnoses:
| Differential | Points in Favour | Points Against |
|---|---|---|
| Peri-implant / re-fracture of left tibial plateau | Trauma to previously operated site, pain + swelling, inability to weight-bear | No external wound, imaging needed to confirm |
| Septic arthritis of left knee | Fever post-discharge, swelling, restricted ROM, uncontrolled DM | No reported wound discharge, no erythema described |
| Acute haemarthrosis | Sudden onset swelling post-trauma, restricted ROM | No bleeding disorder, no anticoagulant use described |
| Soft tissue injury / ligament tear | Mechanism of fall (forward), knee swelling | Severity and prior implant make this less likely as sole diagnosis |
| Implant failure / loosening | Prior ORIF 2018, new trauma to same limb | Would need imaging confirmation |
l. Physical Examination
General Examination
Objectives: Assess overall clinical status, signs of systemic illness, nutritional status, and cardiovascular stability.
| Parameter | Expected Findings |
|---|---|
| General appearance | Alert and conscious, in pain, not in acute respiratory distress; assisted mobility (wheelchair) |
| Built & nourishment | Overweight/obese (likely given DM + HTN + sedentary lifestyle) |
| Vital signs | Temperature: elevated (febrile — >37.5°C); BP: likely elevated (uncontrolled HTN); PR: may be elevated (pain/fever); RR: normal; SpO₂: normal |
| Skin | May show diabetic skin changes (dryness, pigmentation); no jaundice; no pallor |
| Eyes | Possible hypertensive/diabetic retinopathy changes |
| Lymph nodes | May have inguinal lymphadenopathy (if infection present in left limb) |
| Hydration | Possibly mildly dehydrated |
Local Examination — Left Knee
1. Inspection
| Findings | |
|---|---|
| Skin | Swelling over the left knee; no open wounds or external lacerations; possible bruising/ecchymosis |
| Deformity | May show valgus deformity (consistent with lateral tibial plateau fracture) |
| Scars | Surgical scar from prior 2018 ORIF visible over proximal tibia |
| Swelling | Diffuse swelling of the left knee joint, extending to proximal tibia |
| Erythema/warmth | Possible redness/warmth if septic arthritis component |
| Muscle wasting | Possible quadriceps wasting (due to disuse) |
2. Palpation
| Findings | |
|---|---|
| Temperature | Increased local warmth over left knee |
| Tenderness | Point tenderness over lateral tibial plateau and joint line |
| Effusion | Positive patellar tap / bulge sign — indicating knee joint effusion (haemarthrosis or septic effusion) |
| Crepitus | May be present over joint line on gentle movement |
| Bony landmarks | Tibial plateau margins tender; prior implant hardware may be palpable |
| Neurovascular | Peripheral pulses (dorsalis pedis, posterior tibial) — assess; sensation reduced over left foot/lower limb (peripheral neuropathy) |
3. Range of Movements
| Joint | RIGHT Active | RIGHT Passive | LEFT Active | LEFT Passive | Remarks |
|---|---|---|---|---|---|
| Knee: Flexion | 0–135° | 0–135° | Restricted (~0–30°) | Restricted (~0–45°) | Pain-limited on left; guarding |
| Knee: Extension | 0° | 0° | Unable to fully extend | Restricted | Extension lag possible |
| Ankle: Dorsiflexion | 0–20° | 0–20° | Reduced | Reduced | POP limiting ankle movement |
| Hip | Normal | Normal | Normal | Normal | No hip pathology |
4. Measurements
| Measurement | Right | Left | Difference |
|---|---|---|---|
| Apparent limb length (xyphisternum → medial malleolus) | (to measure) | (to measure) | May be shortened on left |
| True limb length (ASIS → medial malleolus) | (to measure) | (to measure) | Shortened if fracture with displacement |
| Femur (ASIS → medial knee joint line) | (to measure) | (to measure) | Equal (femur not affected) |
| Tibia (medial joint line → medial malleolus) | (to measure) | (to measure) | May show shortening on left |
| Thigh circumference | (to measure) | (to measure) | Wasting possible on left |
| Calf circumference | (to measure) | (to measure) | Swelling on left |
5. Specific Tests
| Test | Expected Result |
|---|---|
| Patellar tap test | Positive — knee effusion |
| Bulge/sweep test | Positive — moderate effusion |
| Valgus stress test | Positive — lateral tibial plateau instability |
| Varus stress test | Negative |
| Anterior drawer test | May be positive if ACL involvement |
| McMurray's test | Likely not possible — pain limits full ROM |
| Neurovascular assessment | Reduced sensation left foot (peripheral neuropathy); dorsalis pedis/posterior tibial pulses present but may be reduced |
m. Systemic Examination
| System | Findings |
|---|---|
| Cardiovascular | S1 S2 heard, no murmurs; BP elevated (uncontrolled HTN); peripheral pulses present |
| Respiratory | Clear air entry bilaterally; no added sounds; no respiratory distress |
| Abdomen | Soft, non-tender, no organomegaly |
| Neurological | Conscious, alert, oriented; reduced peripheral sensation left lower limb (glove-and-stocking pattern likely); power reduced in left lower limb due to pain |
n. Summary
Ms. Che Marizan is a 53-year-old post-menopausal female with underlying uncontrolled DM and HTN, presenting with left knee pain, swelling, restricted ROM, and inability to ambulate following a mechanical fall, in the setting of a previous ORIF of the left tibial plateau (2018). She subsequently developed fever after initial discharge, raising concern for a secondary infective complication. Examination reveals a swollen, tender, warm left knee with joint effusion and reduced sensation in the left lower limb. The combination of trauma, prior implant, and immunocompromised state (uncontrolled DM) makes peri-implant fracture with superimposed infection the most likely diagnosis.
o. Provisional Diagnosis (based on history + examination)
Peri-implant fracture of the left proximal tibia (tibial plateau) with suspected septic arthritis / periprosthetic joint infection, in a patient with prior ORIF (2018), uncontrolled DM, and uncontrolled HTN.
Points in Favour:
- Trauma to previously operated knee → mechanical disruption
- Swelling, warmth, effusion, restricted ROM → intra-articular pathology
- Fever post-discharge in immunocompromised (DM) patient → infection
- Prior implant at same site → peri-implant fracture / implant failure
- Reduced sensation → diabetic peripheral neuropathy (longstanding uncontrolled DM)
p. Investigations
| Investigation | Expected Result | Normal Value | Interpretation |
|---|---|---|---|
| FBC | ↑WBC (leukocytosis), ↑neutrophils | WBC: 4–11 × 10⁹/L | Suggests infection/inflammation |
| CRP | Elevated (>10 mg/L) | <5 mg/L | Acute phase reactant — infection/inflammation |
| ESR | Elevated | Male: <15 mm/hr; Female: <20 mm/hr | Chronic inflammation / infection |
| Blood glucose (fasting/random) | Elevated (uncontrolled DM) | Fasting: <6.1 mmol/L | Confirms uncontrolled glycaemia |
| HbA1c | >8% (likely >9%) | <6.5% (diabetic target) | Reflects poor long-term glycaemic control |
| Renal profile (U&E, Cr) | May show early diabetic nephropathy | Creatinine: 60–110 µmol/L | Relevant for contrast imaging and drug dosing |
| LFT | Likely normal | Within normal limits | Baseline before medications |
| Clotting profile (PT/APTT) | Normal | PT: 11–13 s; APTT: 25–35 s | Pre-operative baseline |
| Blood culture | May grow organism if bacteraemia | Sterile | Identifies causative organism if septic |
| Wound/joint aspirate culture | May yield Staphylococcus aureus or Gram-negative rods | Sterile | Most common in diabetic post-surgical infection |
| ECG | May show LVH changes | Normal sinus rhythm | Hypertensive heart disease screening |
Radiology
| View | Region | Expected Findings |
|---|---|---|
| AP view | Left knee / proximal tibia | Tibial plateau fracture (Schatzker type — likely Type I–II given fall mechanism); prior ORIF hardware visible; possible displacement / peri-implant fracture |
| Lateral view | Left knee | Posterior tibial slope assessment; joint effusion (fat pad sign); fracture line confirmation |
| CT scan left knee | Proximal tibia | Gold standard — 3D fracture characterisation, displacement measurement, implant integrity |
| MRI left knee | (if soft tissue injury suspected) | Ligament/meniscal injury, bone marrow oedema, soft tissue infection |
Radiological Conclusion: Likely tibial plateau fracture with pre-existing ORIF hardware; CT will delineate fracture pattern (Schatzker classification), degree of articular depression, and implant status.
q. Final Diagnosis
Re-fracture of the left tibial plateau (peri-implant) with superimposed septic arthritis / surgical site infection, in a background of prior ORIF (2018), uncontrolled Diabetes Mellitus, and uncontrolled Hypertension.
r. Treatment
Non-surgical / Conservative:
- Analgesics: IV/oral (e.g., Paracetamol, NSAIDs — caution with renal function)
- Antibiotics: IV empirical (e.g., IV Cloxacillin if Gram-positive suspected; adjust based on culture) — for infection management
- Blood glucose optimisation: Sliding scale insulin / optimise oral hypoglycaemics
- Antihypertensive optimisation
- Limb elevation to reduce swelling
- Continuation / reassessment of below-knee POP support
Surgical (if indicated):
- Arthrocentesis/joint aspiration — for diagnosis (culture, cell count) and therapeutic decompression
- Revision ORIF or re-fixation if peri-implant fracture with displacement
- Implant removal + debridement if infected hardware (staged procedure)
- External fixation as a bridging measure if soft tissues are compromised
Physiotherapy / Rehabilitation:
- Non-weight-bearing with crutches in acute phase
- Progressive physiotherapy post-stabilisation
- Quadriceps strengthening, ROM exercises
- Diabetic foot care and education
s. Follow-up
- Review in 1–2 weeks post-discharge: wound check, POP assessment, repeat inflammatory markers (CRP, WBC)
- 6 weeks: Repeat X-ray — fracture healing assessment
- 3 months: Clinical + radiological reassessment; assess weight-bearing status
- Endocrinology referral for optimisation of DM and HTN
- Physiotherapy ongoing until full ROM and function restored
- Monitor for complications: non-union, malunion, chronic osteomyelitis, implant failure, DVT, diabetic neuropathy progression
Discussion
(Based on Final Diagnosis)
Tibial plateau fractures involve the articular surface of the proximal tibia and are commonly caused by axial loading combined with varus/valgus force. In this patient, a forward fall mechanism likely produced a valgus load, causing a lateral plateau fracture — consistent with the Schatzker classification Type I (split) or Type II (split-depression) pattern most common in low-energy falls in osteoporotic/osteopenic bone.
The presence of prior ORIF hardware significantly complicates management. Peri-implant fractures are mechanically challenging due to stress risers around existing implants. The Unified Classification System (UCS) categorises peri-implant fractures to guide surgical planning.
Uncontrolled Diabetes Mellitus is a major comorbidity here. It contributes to:
- Impaired fracture healing (reduced osteoblastic activity, poor vascularity)
- Increased infection risk (immunosuppression, poor wound healing)
- Peripheral neuropathy (explaining the numbness)
- Charcot arthropathy risk long-term
The development of fever post-discharge is a red flag — in a diabetic patient with prior implant, this must be assumed to represent implant-related infection or septic arthritis until proven otherwise. Common organisms include Staphylococcus aureus (including MRSA), coagulase-negative staphylococci, and Gram-negative bacilli.
Uncontrolled Hypertension adds perioperative cardiovascular risk and may reflect diabetic end-organ disease (hypertensive nephropathy), which must be considered when planning imaging (contrast) and medications.
Management requires a multidisciplinary approach — orthopaedics, endocrinology, physiotherapy, and infectious disease — to optimise outcomes.
Signature of faculty and date: ___________________________
Note: Fields marked (to be confirmed / to be measured) require direct patient assessment and should be completed during the clinical clerking. All other sections represent clinically reasoned and evidence-based completions grounded in the patient's history and established orthopaedic principles (Rockwood & Green's Fractures in Adults, 10th ed., 2025).
This patient diagnosis currently is Closed Fracture of patella Remarks: Closed Fracture of left patella
Finding Sources
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Understood. I'll now revise and correct all relevant sections to align with the confirmed final diagnosis of Closed Fracture of the Left Patella. Everything below supersedes the earlier provisional entries.
CASE 1 — REVISED with Confirmed Diagnosis: Closed Fracture of the Left Patella
k. Provisional Diagnosis (based on history)
Provisional Diagnosis:
Closed fracture of the left patella following a mechanical fall with direct trauma to the left knee.
Justification based on history:
- Direct trauma to the anterior aspect of the left knee during a forward fall
- Immediate onset of moderate pain (5/10), progressive swelling, and inability to ambulate
- Restricted movement of the left knee joint
- No external wound or skin breach → confirms "closed" nature
- Background of uncontrolled DM → reduced bone quality; oestrogen deficiency (post-menopausal) → osteopaenia → increased fracture susceptibility from relatively low-energy fall
Differential Diagnoses:
| Differential | Points in Favour | Points Against |
|---|---|---|
| Closed fracture of left patella | Direct anterior knee trauma, swelling, pain, restricted ROM, inability to weight-bear | — |
| Haemarthrosis without fracture | Swelling + restricted ROM post-trauma | Inability to SLR / extend suggests extensor mechanism disruption → fracture more likely |
| Patellar dislocation | Trauma mechanism, swelling, knee deformity possible | No reported lateral displacement; fell forward (axial/direct, not twisting) |
| Tibial plateau fracture | Prior ORIF same limb, axial load | Direct anterior trauma more consistent with patellar injury; confirmed by imaging |
| Quadriceps / patellar tendon rupture | Inability to extend knee | Age group; no reported sudden "pop" sensation; imaging distinguishes |
| Prepatellar bursitis | Anterior knee swelling | Acute trauma + restricted ROM makes isolated bursitis unlikely |
o. Provisional Diagnosis (based on history + examination)
Closed fracture of the left patella — likely transverse pattern (most common in direct anterior trauma + sudden quadriceps contraction), with possible disruption of the extensor mechanism (suggested by inability to ambulate and restricted knee extension).
Points in favour:
- Direct anterior knee trauma from fall
- Anterior knee swelling and effusion (haemarthrosis)
- Tenderness over the patella
- Inability to perform straight leg raise → extensor mechanism disruption
- Palpable gap between fragments (if displaced)
- Restricted active knee extension
p. Investigations
| Investigation | Expected Result | Normal Value | Interpretation |
|---|---|---|---|
| FBC | ↑WBC (if infection / inflammatory response); Hb may be mildly reduced | WBC: 4–11 × 10⁹/L; Hb: 12–16 g/dL (F) | Leukocytosis if post-injury inflammation or infection (fever on return) |
| CRP | Elevated | <5 mg/L | Acute phase response to trauma or infection |
| ESR | Elevated | Female: <20 mm/hr | Supports inflammatory/infective process |
| Random blood glucose | Elevated (uncontrolled DM) | <11.1 mmol/L (random) | Confirms poor glycaemic control |
| HbA1c | Likely >8% | <6.5% | Reflects long-term uncontrolled DM — affects fracture healing |
| Renal profile (U&E, Creatinine) | May show early nephropathy | Creatinine: 60–110 µmol/L | Important for contrast use and drug dosing |
| Coagulation profile (PT/APTT) | Normal | PT: 11–13 s; APTT: 25–35 s | Pre-operative baseline |
| Group & screen | For surgical planning | — | In case ORIF required |
| Blood culture | May be positive if bacteraemia | Sterile | Investigate cause of post-discharge fever |
| ECG | Possible LVH (uncontrolled HTN) | Normal sinus rhythm | Cardiovascular risk assessment pre-operatively |
Radiology
| View | Region | Expected Findings |
|---|---|---|
| AP view | Left knee / patella | Fracture line across patella (transverse, comminuted, or vertical); fragment separation if displaced (>3 mm = displaced) |
| Lateral view | Left knee | Most informative — shows fracture pattern clearly; assesses proximal migration of superior fragment (if extensor mechanism disrupted); joint effusion (sail sign / suprapatellar haemarthrosis); articular congruity |
| Skyline/Merchant view | Patellofemoral joint | Vertical fracture detection; patellar tracking; articular surface assessment |
Radiological Conclusion:
Closed fracture of the left patella, likely transverse displaced type given clinical inability to extend. Fracture fragments separated >3 mm indicates disruption of extensor mechanism. No open wound — consistent with closed fracture. Prior ORIF hardware in proximal tibia noted incidentally (2018). No associated tibial plateau fracture identified on current imaging.
q. Final Diagnosis
Closed fracture of the left patella (transverse, displaced) with disruption of the extensor mechanism, in a 53-year-old post-menopausal female with underlying uncontrolled Diabetes Mellitus and uncontrolled Hypertension, and prior ORIF of left tibial plateau (2018).
r. Treatment
Conservative (Nonoperative) — indicated if:
- Fracture displacement <3 mm AND articular incongruity <2 mm AND extensor mechanism intact
- Technique: Cylinder cast or extension brace for 4–6 weeks in full extension
- Early straight leg raises and isometric quadriceps exercises
- Partial weight-bearing with walking aid in full extension
- Repeat X-ray after ROM initiated to check for displacement
Surgical — indicated in this patient (likely, given inability to extend = extensor mechanism disrupted):
| Option | Indication |
|---|---|
| ORIF — Tension Band Wiring (TBW) | Gold standard for transverse displaced fractures; restores extensor mechanism |
| Cannulated screw + tension band construct | Alternative to K-wires; better rotational stability |
| Partial patellectomy + soft tissue repair | Severely comminuted pole fractures where fragment cannot be fixed |
| Total patellectomy | Last resort — severely comminuted, unreconstructable; causes significant extensor weakness |
Perioperative management:
- Optimise blood glucose pre-operatively (target fasting glucose <10 mmol/L; HbA1c assessment)
- Antihypertensive optimisation
- Antibiotics: prophylactic IV (e.g., IV Cefazolin) pre-operatively; extended cover given uncontrolled DM
- DVT prophylaxis: LMWH (e.g., Enoxaparin) + compression stockings
Post-operative:
- Extension splinting / cylinder cast post-ORIF until soft tissue healing
- Progressive ROM — initiate at 4–6 weeks
- Non-weight-bearing → partial weight-bearing → full weight-bearing as per fracture healing
- Physiotherapy: quadriceps strengthening, gait rehabilitation
s. Follow-up
| Timeline | Review Points |
|---|---|
| 1–2 weeks | Wound check, suture removal, infection surveillance (especially given DM + post-discharge fever history) |
| 4–6 weeks | Repeat X-ray — fracture healing; initiate ROM if healing confirmed |
| 3 months | Clinical + radiological reassessment; assess weight-bearing and quadriceps strength |
| 6 months | Full functional review; assess for complications |
| Ongoing | Endocrinology referral for DM/HTN optimisation; physiotherapy until full function restored |
Complications to monitor:
- Wound infection / osteomyelitis (high risk — uncontrolled DM)
- Non-union / malunion (impaired by poor glycaemic control)
- Hardware failure (implant cut-out, wire migration)
- Post-traumatic patellofemoral arthritis
- Extensor lag (if extensor mechanism not adequately restored)
- DVT / PE (immobilisation)
- Knee stiffness / quadriceps atrophy
Discussion (Based on Final Diagnosis)
Patellar fractures account for approximately 1% of all skeletal fractures. The patella is the largest sesamoid bone in the body and plays a critical biomechanical role in the extensor mechanism of the knee — it increases the mechanical advantage of the quadriceps by displacing the patellar tendon anteriorly, thereby increasing the moment arm of extension force.
Mechanism in this case: A forward fall with direct anterior impact to the left knee produced a direct blow to the patella. This, combined with a simultaneous eccentric quadriceps contraction (attempting to brace the fall), produced the fracture — the classic mechanism for a transverse patellar fracture. Direct blows tend to produce stellate or comminuted patterns, while pure eccentric quadriceps pull produces clean transverse splits. In this patient, a combination is possible.
Classification (Descriptive — OTA/Rockwood & Green):
Patellar fractures are classified as:
- Displaced (>3 mm separation or >2 mm articular incongruity) vs. Nondisplaced
- Pattern: transverse (most common, ~50–80%), stellate/comminuted, vertical/longitudinal, apical/polar, osteochondral
This patient's inability to perform straight leg raise and restricted active extension strongly suggests a displaced fracture with extensor mechanism disruption — a key indicator for surgical management.
Impact of comorbidities:
- Uncontrolled DM impairs fracture healing through reduced osteoblastic activity, compromised vascularity, and increased susceptibility to infection (particularly S. aureus). The post-discharge fever in this patient raises concern for early surgical site infection or septic arthritis, which must be actively excluded before any surgical intervention.
- Hypertension increases perioperative cardiovascular risk and may reflect underlying vascular disease, affecting distal perfusion and wound healing.
- Post-menopausal status with likely osteopaenia means bone quality may be reduced, affecting fixation stability (tension band wiring construct at risk of cut-out).
Surgical principle — Tension Band Wiring (TBW):
The AO tension band principle converts tensile forces on the anterior patella (from quadriceps pull) into compressive forces at the articular surface. Two parallel K-wires are passed longitudinally through the fracture, and a figure-of-8 wire loop is applied anteriorly. This is the gold standard for transverse displaced patellar fractures with an intact extensor mechanism distal pole.
Key goals of treatment (Rockwood & Green's Fractures in Adults, 10th ed., 2025):
- Maximal preservation of patellar bone stock
- Restoration of articular congruity
- Preservation of functional integrity and strength of the extensor mechanism
Signature of faculty and date: ___________________________
All sections are now aligned with the confirmed diagnosis of Closed Fracture of the Left Patella. Where exact radiological fracture pattern details (displacement, comminution grade) are not yet available, the most clinically probable findings based on mechanism and presentation have been documented. Update specific measurements, drug names, and radiograph descriptions once actual clinical data is available.
Could you give me everything but shorten it for logbook sake
CASE 1 — Complete Logbook Entry (Condensed)
Diagnosis: Closed Fracture of the Left Patella
Patient Demographics
- Name: Ms. Che Marizan
- Age: 53 years | Sex: Female | Race: Malay
- Occupation: Housewife (ex-Air Force officer)
- Nationality: Malaysian
- Date of Admission / Clerking: (to fill)
a. Chief Complaints
- Pain over left knee — 1 day
- Swelling of left knee — 1 day
- Inability to ambulate — 1 day
- Numbness over left lower limb — 1 day
- Fever — post-discharge
b. History of Presenting Illness
53-year-old female presented with left knee pain and swelling following a forward fall at a shopping mall in Alor Setar, sustaining direct trauma to the left knee while attempting to prevent her grandchild from falling. Pain scored 5/10, associated with progressive swelling and inability to ambulate. No external bleeding, no LOC, no respiratory distress. Numbness noted over the left lower limb. Brought to HSAH ED by family via wheelchair. Received analgesic injection and imaging was performed; discharged the following day. Subsequently returned with fever. Below-knee POP support applied. Background of left tibial plateau ORIF (2018) and uncontrolled DM and HTN.
c. Past History
- MVA 2018 → Left tibial plateau fracture → ORIF performed
- Diabetes Mellitus — 15 years, uncontrolled
- Hypertension — 15 years, uncontrolled
d. Previous Treatment / Drug Intake / Allergy
- ORIF left tibial plateau (2018)
- Current medications: oral hypoglycaemics (e.g. Metformin), antihypertensives (e.g. Amlodipine) (confirm with patient)
- Analgesic injection at ED (current admission)
- Below-knee POP applied
- Drug allergy: Nil known
e. Family History
No known family history of DM, HTN, malignancy, or bleeding disorders (to confirm).
f. Occupational History
Former Air Force officer (physically active role). Housewife for past 15 years — sedentary. No hazardous occupational exposures currently.
g. Menstrual History
Likely post-menopausal (age 53). LMP to be confirmed. No abnormal vaginal bleeding. Oestrogen deficiency contributes to reduced bone density → increased fracture risk.
h. Personal and Social History
- Smoking: Nil | Alcohol: Nil
- Sedentary lifestyle; lives with family
- Not on strict diabetic diet (implied by uncontrolled DM)
- BMI: likely overweight (to confirm on examination)
i. Systemic Enquiry
| System | Findings |
|---|---|
| CVS | No chest pain, no palpitations |
| Respiratory | No dyspnoea, no cough |
| GIT | No nausea/vomiting |
| GUT | No dysuria |
| Neurological | Numbness left lower limb (likely peripheral neuropathy) |
| MSK | Left knee pain, swelling, restricted ROM |
| Constitutional | Fever post-discharge |
j. Summary of History
53-year-old post-menopausal Malay female, uncontrolled DM and HTN (×15 years), prior ORIF left tibial plateau (2018), presenting with 1-day left knee pain and swelling following direct trauma from a forward mechanical fall. Unable to ambulate, numbness over left lower limb, no external wound. Developed fever post-discharge. Below-knee POP applied. Uncontrolled DM poses significant risk for infection and impaired healing.
k. Provisional Diagnosis (based on history)
Closed fracture of the left patella secondary to direct anterior knee trauma.
| Differential | For | Against |
|---|---|---|
| Closed # left patella | Direct trauma, swelling, pain, inability to extend | — |
| Haemarthrosis | Swelling + restricted ROM | Extensor failure suggests fracture |
| Patellar dislocation | Trauma, swelling | Forward fall; no lateral displacement described |
| Quadriceps/patellar tendon rupture | Inability to extend | No "pop" reported; imaging differentiates |
l. Physical Examination
General Examination
- Conscious, alert, in pain; not in respiratory distress
- Appears overweight; febrile (T >37.5°C)
- BP likely elevated (uncontrolled HTN); PR elevated (pain/fever)
- No pallor, jaundice, or cyanosis
Local Examination — Left Knee
1. Inspection
- Diffuse swelling of anterior left knee
- No open wound; skin intact (closed fracture)
- Surgical scar over proximal tibia (prior ORIF)
- Possible bruising/ecchymosis over patella
- Limb held in slight flexion; unable to extend
2. Palpation
- Increased local warmth over left knee
- Tenderness over patella — point tenderness at fracture site
- Palpable gap/step between fragments (if displaced)
- Positive patellar tap → knee joint effusion (haemarthrosis)
- Reduced peripheral sensation over left foot (peripheral neuropathy)
- Distal pulses (DP, PT) — present but assess carefully
3. Range of Movements
| Joint | R Active | R Passive | L Active | L Passive | Remarks |
|---|---|---|---|---|---|
| Knee: Flexion | 0–135° | 0–135° | ~0–30° | ~0–45° | Pain-limited (L) |
| Knee: Extension | 0° | 0° | Unable | Restricted | Extensor lag (L) |
| Ankle | Normal | Normal | Restricted | Restricted | POP in situ |
4. Measurements
| Measurement | Right | Left | Difference |
|---|---|---|---|
| Apparent limb length (xyphisternum → MM) | (measure) | (measure) | Likely equal |
| True limb length (ASIS → MM) | (measure) | (measure) | Likely equal |
| Thigh circumference | (measure) | (measure) | Possible wasting (L) |
| Calf circumference | (measure) | (measure) | Swelling (L) |
5. Specific Tests
| Test | Result |
|---|---|
| Patellar tap test | Positive (effusion) |
| Straight leg raise (SLR) | Unable — extensor mechanism disrupted |
| Palpable gap over patella | Present (displaced fracture) |
| Valgus/varus stress test | Negative bilaterally |
| Distal neurovascular assessment | Reduced sensation L foot; pulses present |
m. Systemic Examination
| System | Findings |
|---|---|
| CVS | S1 S2 heard, no murmurs; BP elevated |
| Respiratory | Clear air entry; no added sounds |
| Abdomen | Soft, non-tender, no organomegaly |
| Neurological | Alert, oriented; reduced sensation L lower limb; power reduced L leg (pain-limited) |
n. Summary
53-year-old post-menopausal female, uncontrolled DM + HTN, prior ORIF left tibial plateau (2018), presenting with closed left patellar fracture following direct anterior knee trauma from mechanical fall. Presents with left knee pain, swelling, haemarthrosis, inability to extend knee (extensor mechanism disrupted), and numbness (peripheral neuropathy). Developed fever post-discharge — infective complication must be excluded. Below-knee POP in situ.
o. Provisional Diagnosis (history + examination)
Closed displaced transverse fracture of the left patella with extensor mechanism disruption, in a background of uncontrolled DM, HTN, and prior left tibial plateau ORIF.
Points in favour: Direct anterior trauma → anterior knee pain + swelling + effusion + palpable gap + inability to perform SLR + extensor lag.
p. Investigations
| Test | Expected Result | Normal Value | Interpretation |
|---|---|---|---|
| FBC | ↑WBC, ↑neutrophils | WBC 4–11 ×10⁹/L | Infection/inflammation |
| CRP | Elevated | <5 mg/L | Acute inflammatory response |
| RBS / FBS | Elevated | <11.1 / <6.1 mmol/L | Uncontrolled DM |
| HbA1c | >8% | <6.5% | Poor long-term glycaemic control |
| Renal profile | Possible ↑Creatinine | 60–110 µmol/L | Diabetic nephropathy screen |
| Coagulation (PT/APTT) | Normal | PT 11–13 s | Pre-op baseline |
| Blood culture | Possible growth | Sterile | If bacteraemia (fever workup) |
| ECG | LVH changes possible | Normal SR | HTN cardiac assessment |
Radiology
| View | Expected Findings |
|---|---|
| X-ray AP — Left knee | Fracture line across patella; fragment separation if displaced (>3 mm) |
| X-ray Lateral — Left knee | Most informative — transverse fracture gap; proximal fragment migration if extensor disrupted; suprapatellar haemarthrosis (sail sign) |
| Skyline / Merchant view | Articular surface; vertical fractures; patellar tracking |
Radiological Conclusion: Closed fracture left patella — transverse displaced type. Extensor mechanism disrupted. Pre-existing ORIF hardware in proximal tibia noted. No tibial plateau fracture on current imaging.
q. Final Diagnosis
Closed fracture of the left patella (transverse, displaced) with extensor mechanism disruption.
Comorbidities: Uncontrolled DM, Uncontrolled HTN, Prior ORIF left tibial plateau (2018).
r. Treatment
Surgical — ORIF with Tension Band Wiring (TBW)
(Indicated: displaced fracture >3 mm + extensor mechanism disruption)
- Parallel K-wires + figure-of-8 anterior tension band wire (AO principle)
- Converts quadriceps tensile force → articular compressive force
- Alternative: cannulated screw + tension band construct
Perioperative:
- Optimise blood glucose pre-op (target fasting <10 mmol/L)
- IV prophylactic antibiotics (Cefazolin 1–2g) — extended cover given DM
- DVT prophylaxis: LMWH (Enoxaparin) + TED stockings
- Antihypertensive optimisation
Post-op:
- Extension splint / cylinder cast 4–6 weeks
- Non-weight-bearing → progressive weight-bearing as healing progresses
- Quadriceps isometric exercises early; ROM initiated at 4–6 weeks
- Physiotherapy for strength and gait rehabilitation
s. Follow-up
- 1–2 weeks: Wound review, infection surveillance, suture removal
- 4–6 weeks: Repeat X-ray — fracture union; initiate ROM
- 3 months: Full weight-bearing assessment; hardware check
- 6 months: Functional review; patellofemoral assessment
- Ongoing: Endocrinology referral (DM/HTN optimisation); physio until full recovery
- Complications to watch: wound infection, non-union, hardware failure, extensor lag, DVT, post-traumatic arthritis
Discussion
The patella is the body's largest sesamoid bone, acting as a mechanical fulcrum for the quadriceps extensor mechanism. Patellar fractures account for ~1% of all fractures and occur via two main mechanisms: direct blow (produces stellate/comminuted pattern) and indirect eccentric quadriceps contraction (produces transverse pattern). In this patient, a combination likely occurred — direct anterior impact during the forward fall, with simultaneous eccentric quadriceps pull.
Fractures are classified as displaced (>3 mm separation or >2 mm articular incongruity) or nondisplaced, and by pattern: transverse (most common, ~50%), comminuted, vertical, polar, or osteochondral (Rockwood & Green's, 10th ed.).
Surgical indication here is clear — displaced fracture with loss of active knee extension (SLR failure) = extensor mechanism disruption → ORIF with tension band wiring. The AO tension band principle converts anterior tensile forces into posterior articular compressive forces, restoring the extensor mechanism.
Comorbidity impact:
- Uncontrolled DM — impairs osteoblastic activity, microvascular supply, and immune defence → increased risk of wound infection, non-union, and peripheral neuropathy (explaining limb numbness)
- Post-menopausal osteopaenia — reduced bone quality may compromise fixation (K-wire cut-out risk)
- Post-discharge fever — must actively exclude septic arthritis or early surgical site infection; blood cultures and joint aspiration if clinically indicated
Overall treatment goals: restore articular congruity, preserve patellar bone stock, and re-establish functional extensor mechanism (Rockwood & Green's Fractures in Adults, 10th ed., 2025).
Signature of faculty and date: ___________________________
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