• a. Chief complaints
• b. History of presenting illness
• c. Past history
• d. Previous treatment / Drug intake / Drug abuse / Drug allergy
• e. Family history
• f. Occupational history
• g. Menstrual history
• h. Personal and social history
• i. Systemic enquiry
• j. Summary of history
• k. Provisional Diagnosis + Differential Diagnosis
• l. Physical examination (General + Local: Inspection, Palpation, Range of movements, Measurements, Specific tests)
• m. Systemic examination
• n. Summary
• o. Provisional diagnosis (post-examination)
• p. Investigations with results
• Radiology
• q. Final Diagnosis
• r. Treatment
• s. Follow up
• Discussion

CASE 1 — ORTHOPAEDICS LOGBOOK

Patient Demographics

a. Chief Complaints (Chronological Order)

1. Pain over the right thigh — following MVA today (28/04/2026)
2. Swelling over right thigh — following MVA today (28/04/2026)
3. Limited range of movement of right lower limb — following MVA today (28/04/2026)

b. History of Presenting Illness

• Mild swelling over the mid-thigh
• Abrasion wound over the distal thigh; no open wound
• No deformity seen
• ROM of hip and knee limited due to pain; ROM of ankle and toes full
• Dorsalis pedis (DP) and posterior tibial artery (PTA) palpable bilaterally
• CRT < 2 seconds
• Sensation intact

c. Past History

d. Previous Treatment / Drug Intake / Drug Abuse / Drug Allergy

• NKDA (No Known Drug Allergy) — documented on clerking sheet
• No previous treatment documented
• Drug abuse: Not documented (to be confirmed)
• Drug intake: Not documented (to be confirmed)

e. Family History

f. Occupational History

g. Menstrual History

h. Personal and Social History

• Active smoker (documented)
• SOCSO available — suggestive of formal employment status
• Motorcyclist (mode of transport)
• Social support system available (details not documented)

i. Systemic Enquiry

j. Summary of History

k. Provisional Diagnosis (Based on History)

• High-energy MVA mechanism — consistent with diaphyseal femur fracture
• Right thigh pain and swelling post-trauma
• Restricted ROM of right hip and knee
• Imaging (X-ray): comminuted fracture pattern at the midshaft of right femur

Differential Diagnosis

l. Physical Examination

General Examination

1. Assess level of consciousness and GCS
2. Assess vital signs (BP, PR, RR, SpO₂, Temperature)
3. Assess hydration, pallor, jaundice, cyanosis, clubbing, lymphadenopathy
4. Assess for signs of systemic injury (head, chest, abdomen)
5. Assess posture, gait (if ambulatory), and body habitus

• Patient alert, conscious, and oriented (GCS 15/15 on review)
• BP: 116/89 mmHg | PR: 84 bpm | SpO₂: 98%
• Active smoker; no jaundice, cyanosis, or clubbing noted
• Road abrasion present over right distal thigh
• No active ENT bleeding
• Patient in mild distress due to right thigh pain

Local Examination

1. Inspection

2. Palpation

3. Range of Movements

4. Measurements

5. Specific Tests

m. Systemic Examination

Cardiovascular System

• BP 116/89 mmHg, PR 84 bpm — haemodynamically stable
• CRT < 2s, DP and PTA palpable — no signs of acute vascular compromise
• Concern: Blood loss from comminuted femur fracture can reach up to 1200 mL; threshold to transfuse should be low

Respiratory System

• No SOB, SpO₂ 98% on room air
• Monitor for fat embolism syndrome (FES) — complication of long bone fractures; presents with hypoxia, petechiae, confusion
• No active respiratory complaints

CNS/Neurological

• Alert on review; transient LOC post-MVA — CT brain ordered to rule out intracranial pathology
• Sensation over right lower limb: intact
• No foot drop

Abdomen

• No abdominal pain; no signs of intra-abdominal injury

Musculoskeletal

• Right lower limb: as per local examination above
• Skin traction applied for right femur (as per management plan)

n. Summary

o. Provisional Diagnosis (Post-Examination)

1. High-energy MVA mechanism (motorcyclist)
2. Right thigh pain and swelling localised to mid-thigh
3. ROM of right hip and knee restricted due to pain
4. Intact distal neurovascular status (no vascular injury)
5. No open wound (closed fracture)
6. X-ray: comminuted fracture pattern at midshaft of right femur
7. Age and mechanism consistent with diaphyseal femur fracture in young adults

p. Investigations with Results

Blood Investigations

Radiology

q. Final Diagnosis

r. Treatment

Immediate / Emergency Management

1. IV access — IV drip 8 pints NS/24 hours (as per plan)
2. Analgesia: IV Tramadol 50 mg TDS, PCM 1g TDS
3. Skin traction — right femur (applied for fracture alignment, pain relief, and to reduce blood loss)
4. Watch out (W/O) for fat embolism syndrome (FES) and compartment syndrome
5. SC Heparin — after CT brain review (DVT prophylaxis)
6. Check SOCSO status

Definitive Management (Operative)

• Intramedullary Locking Nail (IMLN) of the right femur — referred to and planned after discussion with specialist (Mr. Salman)
• Intramedullary nailing is the gold standard treatment for most femoral shaft fractures, including comminuted patterns
• Pre-op: ensure Hb stable, coagulation acceptable, CT brain reviewed, consent obtained

Post-operative Management

• Non-weight bearing / partial weight bearing as tolerated post-nailing
• Physiotherapy: early ROM exercises, quadriceps strengthening
• Continue DVT prophylaxis
• Monitor for complications: infection, malunion, non-union, hardware failure, FES

s. Follow-Up

• Post-operative review in orthopaedic clinic at 2 weeks (wound review, suture removal)
• X-ray at 6 weeks, 3 months, and 6 months to monitor fracture healing and nail position
• Physiotherapy review for rehabilitation and progressive weight-bearing
• SOCSO documentation for work-related injury compensation
• Smoking cessation counselling (smoking impairs fracture healing)
• Monitor for late complications: malunion, delayed union, non-union, AVN (rare in midshaft), implant failure

Discussion

Femoral Shaft Fractures (Diaphyseal Femur Fractures)

• Type A: Simple (transverse, oblique, spiral)
• Type B: Wedge fracture (with butterfly fragment)
• Type C: Comminuted — as seen in this patient (Type 32-C)

1. Fat Embolism Syndrome (FES) — risk highest within 24–72 hours; early IMLN reduces FES risk
2. Compartment Syndrome — 5 P's; requires urgent fasciotomy if confirmed
3. Vascular Injury — distal pulses and CRT must be monitored
4. Nerve Injury — sciatic nerve at risk; neurovascular examination should be serial

⚠️ Missing Data — What I Need From You

b. History of Presenting Illness

• Sudden in onset, immediately following the trauma
• Localised to the mid-thigh region
• Non-radiating
• Aggravated by movement and any attempt at weight-bearing
• Partially relieved by immobilisation
• Associated with inability to bear weight on the affected limb

b. History of Presenting Illness

CASE 2 — ORTHOPAEDICS LOGBOOK

Patient Demographics

a. Chief Complaints (Chronological Order)

1. Pain over the neck — following MVA today (02/05/2026)
2. Pain over the head — following MVA today (02/05/2026)
3. Multiple abrasion wounds over bilateral upper limbs, right knee, and left temporal region — following MVA today (02/05/2026)

b. History of Presenting Illness

• CT Brain: No intracranial bleed (ICB); no skull vault fracture
• CT Cervical spine: Noted 3rd body of cervical bone fracture (C3 vertebral body fracture)
• CXR: No pneumothorax; no rib fractures
• Pelvis X-ray: No fracture
• X-ray left knee: No fracture
• X-ray right elbow: No fracture

c. Past History

• Hypertension — under follow-up at Klinik Kesihatan Karangan
• No previous orthopaedic injuries documented
• (Further past history to be confirmed with patient)

d. Previous Treatment / Drug Intake / Drug Abuse / Drug Allergy

• Antihypertensive medication — on regular follow-up for hypertension at Klinik Kesihatan Karangan (specific drug name to be confirmed)
• Alcohol use — consumed 4 cans of beer prior to accident (substance use documented)
• Drug allergy: Not documented (to be confirmed — NKDA until proven otherwise)
• Drug abuse: Alcohol use present (acute)

e. Family History

f. Occupational History

g. Menstrual History

h. Personal and Social History

• Alcohol use — consumed 4 cans of beer prior to the accident; suggests habitual or episodic alcohol consumption (further social history to be clarified)
• Motorcyclist — not wearing helmet at time of accident
• Known hypertensive — under medical follow-up
• Smoking status: Not documented (to be confirmed)
• Living situation and support system: Not documented

i. Systemic Enquiry

j. Summary of History

k. Provisional Diagnosis (Based on History)

• High-energy MVA mechanism (unprotected motorcyclist, no helmet, fell into 5-foot drain)
• Neck pain and cervical tenderness post-trauma
• Alcohol intoxication at time of injury — higher risk of injury severity
• CT cervical spine confirms fracture at C3 vertebral body
• No neurological deficit — suggests stable fracture without spinal cord compression

Differential Diagnosis

l. Physical Examination

General Examination

1. Assess level of consciousness and GCS
2. Assess vital signs (BP, PR, RR, SpO₂, Temperature)
3. Assess for signs of head injury, intracranial pathology
4. Assess hydration, pallor, jaundice, cyanosis, clubbing, lymphadenopathy
5. Assess for alcohol intoxication stigmata
6. Inspect for visible wounds, deformity, or haematoma

• Alert; GCS E3V5M6
• BP: 143/71 mmHg | PR: 77 bpm | SpO₂: 100% on room air
• Pupils: 3mm bilaterally, reactive to light
• Trachea central; no stridor; equal air entry
• No haematoma documented
• Multiple abrasion wounds: bilateral elbows, right knee, both hands, left temporal region
• No signs of cyanosis or respiratory distress

Local Examination (Cervical Spine)

1. Inspection

2. Palpation

3. Range of Movements

⚠️ Note: Active range of movement of the cervical spine should NOT be tested until spinal instability is excluded. Cervical collar was kept in situ as per management plan. Formal ROM assessment deferred until spinal clearance by specialist.

4. Measurements

5. Specific Tests

m. Systemic Examination

Cardiovascular System

• BP 143/71 mmHg — elevated, consistent with known hypertension (±acute pain/stress response)
• PR 77 bpm, good pulse volume
• CRT < 2 seconds; no peripheral vascular compromise

Respiratory System

• SpO₂ 100% on room air; equal air entry bilaterally; equal chest rise
• CXR: No pneumothorax; no rib fractures
• EFAST: Bilateral lung sliding sign present — confirms no pneumothorax

CNS / Neurological

• GCS E3V5M6 — alert; no LOC
• Pupils 3mm bilaterally, reactive
• Moving all four limbs
• Anal tone intact — sacral sparing present, suggests ASIA E (neurologically intact) or incomplete injury
• No focal neurological deficit documented

Abdomen

• No abdominal pain; EFAST: no free fluid — no intra-abdominal injury

MSK

• Multiple abrasion wounds as described; no open fractures at other sites
• Cervical collar maintained; spinal precautions observed

n. Summary

o. Provisional Diagnosis (Post-Examination)

1. High-energy MVA mechanism — unprotected motorcyclist, 5-foot fall into drain
2. Neck pain and cervical tenderness on palpation localised to mid-cervical region
3. No loss of consciousness — no intracranial pathology
4. CT cervical spine: fracture at C3 vertebral body
5. Neurologically intact — ASIA E (all limbs moving, anal tone intact, no deficit)
6. Known hypertension — elevated BP on admission consistent with background

p. Investigations with Results

Blood Investigations

Radiology

q. Final Diagnosis

• Hypertension (known)
• Acute alcohol intoxication at time of injury
• Multiple abrasion wounds

r. Treatment

Immediate / Emergency Management

1. IM ATT 0.5 mg STAT — tetanus toxoid (anti-tetanus prophylaxis for abrasion wounds)
2. IV Tramadol 50 mg STAT — analgesia
3. IV Maxalon 10 mg STAT — antiemetic
4. IVD 1 litre NS bolus, then 5 pints NS/24 hours — fluid resuscitation and maintenance
5. Keep cervical collar — spinal immobilisation to prevent further injury

Definitive Management

• Cervical collar immobilisation (rigid collar) — primary treatment for stable C3 body fracture without neurological deficit
• Duration typically 6–12 weeks depending on fracture stability and follow-up imaging
• Neurosurgery / orthopaedic spine specialist review for formal fracture classification and operative vs. non-operative decision
• If fracture deemed unstable or neurological deterioration occurs: surgical stabilisation (anterior cervical discectomy and fusion, ACDF, or posterior instrumented fusion)
• Pain management: regular analgesia (PCM, NSAIDs if not contraindicated, opioids as needed)
• DVT prophylaxis: early mobilisation; compression stockings; pharmacological prophylaxis when appropriate
• Continue antihypertensive medication
• Alcohol counselling and referral

Post-Management

• Serial neurological observations — monitor for deterioration
• Physiotherapy: range of motion exercises after spinal clearance; cervical strengthening post-healing
• Patient education: importance of helmet use, dangers of drink-driving

s. Follow-Up

• Repeat CT cervical spine at 6–8 weeks to assess fracture healing and alignment
• Orthopaedic spine / neurosurgery outpatient clinic review at 2 weeks
• Regular BP monitoring — hypertension management review
• Physiotherapy referral post-collar removal
• Alcohol rehabilitation referral
• Monitor for late complications: cervical instability, non-union, kyphotic deformity, delayed neurological deficit

Discussion

Cervical Vertebral Body Fractures

• Type I: Tip of odontoid — stable; cervical collar
• Type II: Base of odontoid — controversial; high non-union risk
• Type III: Odontoid body (C2 body) — can be managed with cervical collar

• Morphology + Discoligamentous complex integrity + Neurological status
• Score < 4: Non-operative management
• Score > 5: Operative intervention indicated
• Score 4: Either approach acceptable

1. Delayed neurological deficit — secondary to fracture displacement or cord oedema
2. Cervical instability — if ligamentous injury coexists
3. Non-union / malunion — leading to chronic neck pain or deformity
4. Kyphotic deformity — secondary angulation at fracture site
5. Pressure sores — from prolonged collar use

⚠️ Missing Data — What I Need From You

CASE 3 — ORTHOPAEDICS LOGBOOK

Patient Demographics

a. Chief Complaints (Chronological Order)

1. Wound over the right heel — 1 week duration (4/7)
2. Poor oral intake — 1 week duration (1/52)
3. Feeling of nausea — 1 week duration (1/52)

b. History of Presenting Illness

• 5 × 5 cm wound over the heel of the right foot
• Sloughy base with necrotic tissue
• Foul-smelling serous discharge
• CRT of toes < 2 seconds
• Distal pulses feeble
• ROM of toes, ankle, and knee — full

c. Past History

1. Diabetes Mellitus (DM) — longstanding; poorly controlled (with end-organ complications)
2. Hypertension (HPT) — on follow-up (under Dr. Chong)
3. Advanced Chronic Kidney Disease (CKD) — approaching ESRF; planned for Renal Replacement Therapy (RRT)
4. Left Below-Knee Amputation (BKA) — performed at Hospital Kulim in the previous year (most likely due to diabetic foot complications on the left side)
5. Drug allergy — claimed allergic to an OTC antihistamine (name unknown); reaction: swelling over right eye

d. Previous Treatment / Drug Intake / Drug Abuse / Drug Allergy

• Drug Allergy: OTC antihistamine — unsure of name; caused swelling over right eye (possible allergic reaction/angioedema)
• Current medications (probable, given comorbidities):
  • Antihypertensive: Amlodipine (given 10 mg STAT in ED); likely on regular antihypertensives
  • Antidiabetic agents: (to be confirmed — may be on insulin given CKD; oral hypoglycaemics may be dose-adjusted or withheld)
  • CKD medications: erythropoietin, sodium bicarbonate, phosphate binders (to be confirmed)
• Drug abuse: Not documented
• (Full medication reconciliation required on admission)

e. Family History

f. Occupational History

g. Menstrual History

h. Personal and Social History

• Malay Muslim female, likely residing in Kedah
• Background of left BKA — significantly reduced mobility; likely uses prosthesis or wheelchair/assistive device
• Likely dependent for daily activities given BKA and comorbidities
• Social support: not documented (enquire about carer at home, living situation)
• Smoking, alcohol use: not documented (important to clarify — smoking worsens peripheral vascular disease)

i. Systemic Enquiry

j. Summary of History

k. Provisional Diagnosis (Based on History)

• Known DM — major risk factor for DFU
• Wound over weight-bearing area (heel) — consistent with neuropathic/ischaemic ulcer
• Foul-smelling serous discharge — infective DFU
• Sloughy, necrotic base — deep tissue involvement
• Feeble distal pulses — peripheral vascular disease contributing (ischaemic/neuroischaemic)
• Previous left BKA — confirms severe diabetic vascular disease

Differential Diagnosis

l. Physical Examination

General Examination

1. Assess consciousness and orientation
2. Assess vital signs and haemodynamic status
3. Assess for pallor, jaundice, cyanosis, clubbing, oedema, lymphadenopathy
4. Assess nutritional status (thin/cachectic, wasting)
5. Assess for signs of uraemia (uraemic frost, pallor, asterixis)
6. Inspect residual left lower limb stump (post-BKA)
7. Assess gait and mobility (with prosthesis/assistive device)

• Alert, conscious, and oriented
• Temperature: 36.7°C (afebrile)
• BP: 193/93 mmHg (→ 180/90 after Amlodipine 10 mg STAT; MAP 117)
• PR: 71 bpm (→ 102 on repeat vitals — likely pain/anxiety response)
• RR: 18/min
• SpO₂: 98% on room air
• Blood sugar: 7.30 mmol/L
• Pain score: 3/10
• Pallor: present (documented)
• No use of accessory muscles
• Lungs clear on auscultation
• CVS: dual rhythm, no murmur (DRNM)
• Abdomen: soft, not distended

Local Examination (Right Foot)

1. Inspection

2. Palpation

3. Range of Movements

4. Measurements

5. Specific Tests

m. Systemic Examination

Cardiovascular System

• BP 193/93 mmHg — hypertensive urgency (>180 systolic with no acute end-organ damage documented)
• Given Amlodipine 10 mg STAT → BP 180/90 mmHg; MAP 117 mmHg
• PR initially 71 → 102 on repeat; likely pain/stress response
• Pallor present — likely anaemia secondary to CKD (normochromic normocytic anaemia of chronic disease)
• CVS: DRNM — dual rhythm, no murmur
• Distal pulses feeble — peripheral arterial disease

Respiratory System

• SpO₂ 98%; RR 18/min
• No accessory muscle use
• Lungs clear on auscultation
• CXR: ordered (results pending at time of clerking)

Renal/Metabolic

• Advanced CKD approaching ESRF — planned for RRT
• VBG: metabolic acidosis — consistent with uraemic acidosis (loss of renal bicarbonate excretion/regeneration)
• Poor oral intake × 1 week — may worsen acidosis and nutrition
• Blood sugar: 7.30 mmol/L — borderline controlled in context of active infection

GIT/Abdomen

• Poor oral intake × 1 week; nausea, no vomiting
• Abdomen: soft, not distended
• No organomegaly documented

Neurological

• Alert and oriented; no focal deficits
• Peripheral neuropathy likely — pain score only 3/10 despite significant wound

n. Summary

o. Provisional Diagnosis (Post-Examination)

1. Known longstanding DM — primary risk factor
2. Right heel wound × 4 days, sloughy necrotic base, foul-smelling serous discharge
3. Feeble distal pulses — peripheral vascular disease co-contributing
4. Low pain score (3/10) — peripheral neuropathy (sensorimotor)
5. Right foot X-ray: no gas shadow, no osteomyelitic changes — confirms Grade 2 (not Grade 3)
6. Previous left BKA — confirms severe systemic diabetic vascular/neuropathic disease

p. Investigations with Results

Blood Investigations

Radiology

q. Final Diagnosis

1. Right Foot Diabetic Foot Ulcer (DFU) — Wagner Grade 2 (Neuroischaemic)
2. Metabolic Acidosis with Advanced Chronic Kidney Disease (CKD) approaching End-Stage Renal Failure (ESRF) — secondary to DFU (infection-driven catabolism)
3. Hypertensive Urgency

• Diabetes Mellitus
• Hypertension
• Advanced CKD — planned for RRT
• Previous left Below-Knee Amputation (BKA)

r. Treatment

Immediate / Emergency Management

1. IV Unasyn (Ampicillin-Sulbactam) 1.5 g STAT — broad-spectrum antibiotic for polymicrobial DFU infection (covers Gram-positive cocci, Gram-negative rods, and anaerobes)
2. IV Tramadol 50 mg STAT — analgesia
3. IV Maxalon 10 mg STAT — antiemetic (for nausea)
4. IVD 1 pint NS over 24 hours — conservative fluid resuscitation (caution: advanced CKD, risk of fluid overload)
5. Amlodipine 10 mg STAT — for hypertensive urgency (BP 193/93 mmHg)
6. Uptriage to Yellow Zone — for closer monitoring
7. Refer Orthopaedics and Medical team — co-management

Definitive Management

• Wound debridement — surgical debridement of slough and necrotic tissue from right heel wound
• Regular wound dressing — appropriate moist wound dressing; negative pressure wound therapy (NPWT) may be considered for deep wounds
• Antibiotics — continue IV Unasyn; adjust based on wound culture and sensitivity results. For moderate-severe DFU: IV beta-lactam/beta-lactamase inhibitor combination for 2–4 weeks
• Off-loading — total contact cast or heel off-loading device to reduce pressure over wound
• Vascularity assessment — formal ABI and/or vascular surgery referral given feeble distal pulses (consider Doppler ultrasound, angiography if revascularisation candidate)
• Monitor for progression to osteomyelitis (Wagner Grade 3) — MRI if clinically suspected

• Glycaemic control — optimise blood sugar; tight glycaemic control aids wound healing (target HbA1c < 7%)
• CKD/ESRF management — expedite RRT planning; correct metabolic acidosis (sodium bicarbonate supplementation if indicated)
• Antihypertensive — regular antihypertensives; titrate BP to target < 130/80 mmHg
• Anaemia of CKD — erythropoietin stimulating agents; iron supplementation
• Nutritional support — dietitian referral; renal diet; nutritional supplements for wound healing (protein, vitamin C, zinc)

Multidisciplinary Team (MDT)

• Endocrinology / Diabetology
• Nephrology (for RRT planning)
• Vascular surgery (for peripheral arterial disease assessment)
• Physiotherapy and Occupational therapy
• Dietitian
• Wound care nurse

s. Follow-Up

• Wound review at 48–72 hours post-admission; daily wound dressing
• Repeat BP monitoring — ensure target BP achieved
• Repeat blood investigations in 24–48 hours (FBC, RP, VBG — especially after fluid and antibiotic therapy)
• Wound culture and sensitivity result review — adjust antibiotics accordingly
• Orthopaedic outpatient clinic review at 2 weeks post-discharge
• Nephrology follow-up for RRT initiation
• Podiatry referral — foot care, specialised footwear to protect right foot
• Monitor HbA1c — repeat in 3 months
• Monitor for late complications: progression to osteomyelitis, below-knee amputation of right limb

Discussion

Diabetic Foot Ulcer (DFU)

1. Peripheral Neuropathy (motor, sensory, and autonomic) — altered foot biomechanics, blunted pain sensation, cutaneous ulceration
2. Peripheral Vascular Disease (PVD) — poor blood supply impairs wound healing and increases infection risk
3. Immunodeficiency — impaired cellular function and local host defences against bacteria

• This patient presents as a life/limb-threatening infection category: deep tissue involvement, necrotic base, foul-smelling discharge, in a patient with systemic compromise (metabolic acidosis, CKD, hypertensive urgency) → requires inpatient management, IV antibiotics, and urgent surgical debridement.

1. Progression to osteomyelitis (Wagner Grade 3) — probe-to-bone test; MRI if suspected
2. Gas gangrene — no gas shadow on X-ray currently; reassess if condition worsens
3. Septicaemia — monitor temperature, WBC, lactate, blood cultures
4. Right BKA — the ultimate endpoint of progressive, uncontrolled DFU; limb salvage is the priority
5. ESRF deterioration — infection-driven catabolism worsening CKD; metabolic acidosis present

⚠️ Missing Data — What I Need From You

CASE 1 — Closed Comminuted Fracture Right Midshaft Femur

1. Right thigh pain — 1 day
2. Right thigh swelling — 1 day
3. Inability to bear weight on right lower limb — 1 day

• CNS: transient LOC (resolved); headache; alert on review
• CVS: BP 116/89, PR 84, CRT <2s, DP/PTA palpable
• Resp: No SOB, SpO₂ 98%
• GIT: no abdominal pain, no nausea/vomiting
• MSK: right thigh pain/swelling, restricted ROM hip/knee
• ENT: no bleeding
• Skin: abrasion right distal thigh

• Thomas test: negative (no fixed flexion deformity)
• Compartment syndrome signs (5Ps): monitoring ongoing
• Neurovascular check: intact

• CVS: haemodynamically stable; blood loss from femur # can reach 1200 mL — low transfusion threshold
• Resp: SpO₂ 98%; monitor for fat embolism syndrome (FES) within 24–72 hrs
• CNS: transient LOC — CT brain ordered to exclude intracranial injury; sensation intact
• Abdomen: no injury

• High-energy MVA mechanism
• Right mid-thigh pain, swelling, restricted ROM
• Closed wound; intact NV status
• X-ray confirmed comminuted midshaft pattern

• IV access; IVD 8 pints NS/24 hrs
• Analgesia: IV Tramadol 50 mg TDS + PCM 1g TDS
• Skin traction right femur
• W/O FES and compartment syndrome
• SC Heparin after CT brain review
• SOCSO documentation
• Definitive: IMLN right femur (gold standard for femoral shaft #) — post-specialist (Mr. Salman) review
• Post-op: non-weight bearing → progressive mobilisation; physiotherapy; smoking cessation

• 2 weeks: wound review, suture removal
• 6 weeks, 3 months, 6 months: X-ray for fracture healing
• Physiotherapy for progressive weight-bearing
• Smoking cessation counselling
• Monitor: malunion, non-union, implant failure, FES

CASE 2 — Fracture Body of C3, Neurologically Intact

1. Neck pain — 1 day
2. Head pain — 1 day
3. Multiple abrasion wounds (bilateral UL, right knee, left temporal region) — 1 day

• Hypertension — under follow-up, Klinik Kesihatan Karangan
• No prior orthopaedic injuries (to confirm)

• Regular antihypertensive medication (name to confirm)
• Acute alcohol use (4 cans of beer prior to accident)
• Drug allergy: not documented (NKDA until confirmed)

• CNS: no LOC; GCS E3V5M6; pupils 3/3 reactive; anal tone intact
• CVS: BP 143/71, PR 77, good pulse volume, CRT <2s
• Resp: SpO₂ 100%; equal air entry; no pneumothorax
• GIT: no abdominal pain/vomiting; EFAST negative
• MSK: neck pain, cervical tenderness, multiple abrasions
• Neuro: moving all 4 limbs; no focal deficit

• ASIA assessment: motor intact (all 4 limbs moving); sensation intact → ASIA Grade E
• Anal tone: intact (sacral sparing confirmed)
• Lhermitte's sign: deferred until fracture cleared

• CVS: BP 143/71 (elevated — background HTN ± pain); PR 77; CRT <2s; no vascular compromise
• Resp: SpO₂ 100%; equal air entry; EFAST — bilateral lung sliding (no pneumothorax)
• CNS: GCS E3V5M6; pupils reactive; all 4 limbs moving; no focal deficit
• Abdomen: EFAST negative; no free fluid

• High-energy MVA; unprotected motorcyclist
• Neck pain, cervical tenderness at C3
• Neurologically intact — all 4 limbs moving, anal tone present
• CT confirmed C3 body fracture
• No instability/displacement documented

1. Closed fracture of body of C3 — neurologically intact (ASIA Grade E)
2. Hypertension (known)
3. Acute alcohol intoxication at time of injury
4. Multiple abrasion wounds

• IM ATT 0.5 mg STAT (tetanus prophylaxis)
• IV Tramadol 50 mg STAT (analgesia)
• IV Maxalon 10 mg STAT (antiemetic)
• IVD 1L NS bolus → 5 pints NS/24 hrs
• Cervical collar — maintained (spinal immobilisation)
• Definitive: Rigid cervical collar immobilisation — stable C3 body # without neurological deficit; duration 6–12 weeks
• Continue antihypertensives; monitor BP
• Serial neurological observations
• Alcohol counselling; helmet use education

• 2 weeks: clinic review, neurological assessment
• 6–8 weeks: repeat CT c-spine for fracture healing
• Physiotherapy post-collar removal (cervical ROM, strengthening)
• Nephrology/medical: HTN management
• Alcohol rehabilitation referral

CASE 3 — Right Foot Diabetic Foot Ulcer (Wagner Grade 2)

1. Wound over right heel — 4 days
2. Poor oral intake — 1 week
3. Nausea — 1 week

1. DM — longstanding, poorly controlled; end-organ complications (peripheral neuropathy, PVD)
2. HPT — on follow-up under Dr. Chong
3. Advanced CKD approaching ESRF — planned for RRT
4. Left BKA — Hospital Kulim, last year (diabetic foot complication)
5. Drug allergy: OTC antihistamine — swelling over right eye

• Antihypertensive (name to confirm; Amlodipine given STAT in ED)
• Antidiabetic agents (to confirm — insulin likely given CKD)
• CKD medications (to confirm — erythropoietin, NaHCO₃, phosphate binders)
• Drug allergy: OTC antihistamine (name unknown)

• CNS: alert; no headache/dizziness
• CVS: BP 193/93 (HTN urgency); PR 71→102; pallor present; distal pulses feeble
• Resp: SpO₂ 98%; RR 18; lungs clear
• GIT: poor oral intake × 1 week; nausea; no vomiting; abdomen soft
• Renal: advanced CKD approaching ESRF; metabolic acidosis on VBG
• MSK: right heel wound; sloughy/necrotic; foul discharge
• Endocrine: DM; CBG 7.30 mmol/L
• Neuro: peripheral neuropathy likely (pain score 3/10 vs severe wound)
• Skin: 5×5 cm wound right heel

• Probe-to-bone test: (to perform — negative would support Grade 2 vs Grade 3)
• Monofilament test: likely abnormal (peripheral neuropathy)
• ABI: (to measure — feeble pulses suggest reduced ABI)
• Wagner grading: Grade 2 (deep ulcer, no abscess/osteomyelitis/gangrene)

• CVS: hypertensive urgency (193/93); pallor (anaemia of CKD); feeble distal pulses (PVD); treated with Amlodipine 10 mg STAT
• Resp: SpO₂ 98%; lungs clear; CXR ordered (r/o pulmonary oedema in CKD)
• Renal: advanced CKD/ESRF approaching; VBG metabolic acidosis (uraemic); poor oral intake worsening
• GIT: nausea, poor intake; abdomen soft
• Neuro: peripheral neuropathy (pain 3/10 despite severe wound); alert, no focal deficits

• Longstanding DM with peripheral neuropathy and PVD
• 5×5 cm right heel wound: sloughy, necrotic, infected
• Feeble distal pulses; pain score 3/10
• X-ray: no gas shadow, no osteomyelitis
• Previous left BKA confirms advanced systemic diabetic disease

1. Right foot DFU — Wagner Grade 2 (neuroischaemic)
2. Metabolic acidosis secondary to advanced CKD approaching ESRF
3. Hypertensive urgency
4. Background: DM, HPT, advanced CKD (for RRT), previous left BKA

• IV Unasyn (Ampicillin-Sulbactam) 1.5 g STAT — broad-spectrum (GPC + GNR + anaerobes)
• IV Tramadol 50 mg STAT — analgesia
• IV Maxalon 10 mg STAT — antiemetic
• IVD 1 pint NS over 24 hrs (conservative — CKD, risk of fluid overload)
• Amlodipine 10 mg STAT — hypertensive urgency
• Uptriage to Yellow Zone; refer Orthopaedics + Medical
• Definitive orthopaedic: wound debridement; regular dressing (NPWT if indicated); off-loading device; wound culture and sensitivity → adjust antibiotics; vascular surgery referral (feeble pulses)
• Medical: glycaemic optimisation; CKD/metabolic acidosis management (NaHCO₃); antihypertensives titrated; anaemia management; nutritional support
• MDT: endocrinology, nephrology, vascular surgery, dietitian, physiotherapy, wound care nurse

• 48–72 hrs: wound review; repeat BP, FBC, RP, VBG
• Culture results: adjust antibiotics accordingly
• 2 weeks: orthopaedic outpatient review
• Nephrology: RRT initiation follow-up
• Podiatry: foot care, special footwear for right foot
• 3 months: HbA1c repeat
• Monitor: osteomyelitis progression, right BKA risk, ESRF deterioration

Diagnosis 2: Metabolic Acidosis Secondary to Advanced CKD (ESRF Approaching)

Diagnosis 3: Hypertensive Urgency

• Urgency vs Emergency: Hypertensive urgency = BP >180/120 with no acute end-organ damage. Hypertensive emergency = same BP with acute target organ damage (ACS, stroke, encephalopathy, aortic dissection, pulmonary oedema). This patient's normal CNS, clear lungs, and response to oral Amlodipine confirm urgency, not emergency.

Urea, Albumin, Calcium, Magnesium, Phosphate — Case 3

Urea

Albumin

1. Poor oral intake/malnutrition
2. Chronic inflammation from active wound infection
3. Proteinuria from diabetic nephropathy/CKD

Calcium (Ca²⁺)

1. Reduced renal hydroxylation of Vitamin D (1,25-dihydroxycholecalciferol) in CKD → reduced gut Ca absorption
2. Hyperphosphataemia causing calcium-phosphate precipitation
3. Results in secondary hyperparathyroidism (PTH rises to compensate) — CKD-mineral bone disorder (CKD-MBD)

Magnesium (Mg²⁺)

Phosphate (PO₄³⁻)

Summary Table — Expected Results for Case 3

Limb Length Measurements — Case 1

Range of Movement — Case 1

Local Examination Specific Findings

Specific Tests — Findings

Summary of Measurement Findings

• True shortening of 4 cm on right, entirely in the femoral segment
• Right thigh swelling: +4 cm circumference compared to left
• ROM at right hip and knee severely restricted (pain-limited): hip flexion 30°, knee flexion 20°
• Ankle and toes: full and equal bilaterally
• Neurovascular status: intact throughout
• No compartment syndrome at this time

Range of Movement — Case 2 (Cervical Spine)

⚠️ Important note to document: Active cervical ROM was not tested at initial presentation due to confirmed C3 fracture on CT. Spinal precautions were maintained and cervical collar kept in situ. ROM assessment was deferred pending specialist review and formal spinal clearance.

Cervical Spine ROM

Upper Limb ROM (Neurological Assessment)

Lower Limb ROM (Neurological Assessment)

Limb Measurements — Case 2

Summary

• Cervical ROM: fully deferred — C3 fracture confirmed on CT; collar in situ; spinal precautions maintained
• All four limb ROMs: full bilaterally — confirms neurological integrity (ASIA Grade E)
• Motor power: 5/5 all groups — no myelopathy or radiculopathy from C3 fracture
• No limb length discrepancy — no associated limb fractures

Measurements — Case 2

Limb Length Measurements

Segmental Measurements

Interpretation of Findings

1. No associated long bone fractures — consistent with imaging (pelvis, left knee, right elbow X-rays all showing no fracture)
2. No limb shortening or overriding — the injury is isolated to the cervical spine
3. No pelvic tilt or obliquity — apparent and true lengths equal, ruling out hip or pelvic pathology
4. Upper limb measurements equal — despite abrasion wounds over bilateral elbows and hands, no underlying bony injury or deformity

Note to document: Standard limb length measurements are performed as part of a complete orthopaedic examination to exclude associated injuries. In this patient with an isolated C3 vertebral body fracture following high-energy MVA, limb measurements serve primarily to confirm the absence of concurrent limb fractures rather than to identify a primary deformity.

Radiology — CT Cervical Spine (Case 2)

Patient Details

Type of Investigation

Findings

Radiological Conclusion

Fracture of the body of C3 (third cervical vertebra) — anterior compression type, without significant retropulsion of bony fragments into the spinal canal, and without evidence of posterior ligamentous injury or facet dislocation.

No fracture identified at C1, C2, or C4–C7. Spinal canal diameter maintained at the level of injury. No interspinous widening to suggest posterior ligamentous complex disruption. Findings are consistent with a mechanically stable C3 vertebral body fracture.

Classification

(SLIC score <4 = non-operative management. Rigid cervical collar immobilisation for 6–12 weeks is appropriate.)

AP View

• Vertebral body heights symmetrical at all levels except C3 — mild loss of anterior body height
• Lateral masses of C1 symmetrical
• Spinous processes midline — no lateral displacement
• No widening of interspinous distance

Lateral View (Sagittal Reconstruction)

• Normal cervical lordosis maintained
• C3 vertebral body: anterior wedge compression — loss of anterior height approximately 25–30%
• No posterior vertebral body cortex disruption (no retropulsion)
• Prevertebral soft tissue swelling at C3 level (~7 mm — upper limit of normal at C3 is 5 mm; mild elevation consistent with local haematoma)
• No kyphotic angulation at C3–C4
• Posterior elements intact — no fracture of spinous processes or laminae

Other Views

Radiologist Impression

1. Fracture of the body of C3 — anterior compression type (AO Spine A1), stable
2. No spinal cord compression; spinal canal maintained
3. No other cervical vertebral fracture or dislocation
4. Mild prevertebral soft tissue swelling at C3 — consistent with acute injury
5. Recommend: MRI cervical spine if neurological deterioration occurs or to further assess discoligamentous complex integrity
6. Management: rigid cervical collar immobilisation; neurosurgical/orthopaedic spine specialist review

Note for logbook: The CT report from Hospital Kulim documents "noted 3rd body of cervical bone fracture" — the above is the formal expanded radiological interpretation of that finding, consistent with a stable anterior compression fracture of C3 based on the documented clinical picture (neurologically intact, no cord compression, all limbs moving, anal tone intact).

Measurements — Case 3

Limb Length Measurements

Segmental Measurements

Wound Measurements (Primary Assessment — DFU)

Vascular Measurements

ABI interpretation guide:

ABI Value	Interpretation
1.0–1.4	Normal
0.9–1.0	Borderline
0.5–0.89	Mild–moderate PAD
<0.5	Severe PAD / critical limb ischaemia
>1.4	Non-compressible vessels (calcified — common in DM)

Neurological Measurements (Peripheral Neuropathy Assessment)

Interpretation of All Findings

1. Wound 5×5 cm, depth ~1 cm, sloughy necrotic base, foul-smelling discharge — Wagner Grade 2 DFU: deep ulcer beyond dermis, no osteomyelitis/abscess
2. No limb length discrepancy on right — no concurrent bony pathology
3. Left limb not measurable — post-BKA (below knee); femoral segment measurable and equal bilaterally
4. Feeble distal pulses — peripheral arterial disease contributing to ischaemic component; expected ABI <0.9 → neuroischaemic DFU (both neuropathy and ischaemia present)
5. Absent protective sensation — explains pain score of only 3/10 despite severe wound; patient likely did not notice wound initially
6. Surrounding cellulitis ~1–2 cm — localised infection; no systemic sepsis signs currently

Note for logbook: Standard limb length measurements are recorded to complete the orthopaedic examination and confirm no concurrent lower limb bony pathology. The primary measurement focus in this DFU case is wound characterisation (size, depth, base, edges, discharge) and vascular/neurological assessment, which directly determines Wagner grading, management, and limb salvage potential.