Case 3

28 years old patient with

Chief complaints:

-of pain in the left hip region since 1 year.

history:

Patient sustained left hip injury in RTA  when he was 2nd grade student (about 6 years age).it was a significant injury as he was bed ridden due to pain in left hip.pt parents took him to the local bone setter where massage therapy was given for about 6 months. there was increase in pain and swelling due to massage with no satisfactory results, patient was still bed ridden during that course of treatment. approached orthopedics surgeon where he was admitted and given non invasive traction on limb and operated after 2 weeks of traction on his left hip (NO RECORDS WITH PATIENT). Patient was immobilize for about 3 months with plaster extending up to navel(hip spica).started weight bearing and regular activities after that. Completely asymptomatic after that.

Patient noticed that he has left lower limb shortened compared to other and limp while walking. Approached doctor and advised to use high sole shoe for that. Patient was comfortably squatting, sitting cross-legged, driving bike and playing with full comfort and satisfaction.

Complains of pain in left hip since 1 year, progressively increasing in intensity and duration. Initially occasional on excess of recreational activity and now starting at routine walk, need to take analgesic  thrice a week ( brufen).its sharp pain restricted around the rt hip, with no diurnal or seasonal and postural variation. Slight restriction in sitting cross legged and no problem with squatting.

No history of further trauma, no history of any fever swelling around the hip region.

No history of fever ,chills ,weight or appetite loss.

No history of any medications(other than NSAIDS)

No history of any pain in other joints.

No history of cough,sputum,any other systemic illness.

Past history:

History of hip surgery in child hood with no any intra/post op complication.

No history of any chronic illness/long term medications.

No history of any allerdies to drugs.

No significant past/personal history and general examination findings.

HIP EXAMINATION:

Inspection:

left lower limb in neutral position.

Apparently shortened limb.

Both ASIS at same level.no apparent scoliosis/lordosis

Scarpas triangle is free.

Loss prominent left greater trochanter .

Gluteal,thigh muscle wasting present.

Clean/healthy scar of previous ,

no sinuses,swellings,dilated veins or pulsations.

Palpation:

No local rise of temperature,ASIS at higher level at left side.

Joint tenderness ant and post.Greater trochanter nontender, relatively less prominent,poximally migrated,irregular,broadened.

Femur shaft nontender and normal.

Movement:

Flx:normal/equall to opposite side

 ADDUCTION/abduction restricted at extremes with terminal painfull movements.

EXTERNAL ROTATION/INTERNAL ROTATION equal to opposite side.

Measurements:

Apparent shortening 3cms.true shortening 3cms.

2cms wasting of thigh muscles.

3cms supratrochanteric shortening,confirmed by byrants triangle base.

specific tests:

Narath sign: negative.

Nelton’s line coinciding on rt side below level of umblicus.

Shoemaker’s line : trochanter is out side of the line.

.

Dd:

.UNREDUCED TRAUMATIC DISLOCATION –REDUCED AFTER 6 MONTHS AND RETAINED WITH PELVIC OSTEOTOMY DEVELOPED ACETABULAR DYSPLASIA…SECONDARY OSTO ARTHRITIS.

.POST TRAUMATIC AVASCULAR NECROSIS OF HEAD OF FEMUR AFTER DISLOCATION.

QUIRY:

1.WHAT WAS THE INJURY FRACTURE?/DISLOCATION…?

2.WHAT WAS THE SURGERY DONE?

3.WHAT MAY BE THE PRESENT DIAGNOSIS?

4.WHAT WILL BE THE POSSIBLE TREATMENT?