Tuesday, November 30, 2010

One day in orthopedics.

Let's go through a case shall we? Why?! I don't know I just despise orthopedics somehow. But it's so influential.

So, my patient was a 6 year-old Malay boy came for an elective surgical operation of his right leg. At the age of 18 months his mother noticed that he limped every time he walked. She also notice that his right leg is longer and bigger than the left. But he still can walk and run. The right leg keeps getting bigger and longer. The inequalities became more obvious as he grow up. But no loss of function still. When they went to see a doctor he was diagnosed to have left leg hypertrophy. He was suggested for surgery.

The hypertrophy was secondary to neurofibromatosis, type 1. He has multiple cafe-au-lait around his body. On further history his mother also has neurofibromatosis because she has multiple fibromas around her body (NF is autosomal dominant). He has a pelxiform type of neurofibroma.

This is how it looks like.
See. It is longer and bigger.
Apparent length difference : 5 cm
True length difference : 3.5 cm
The discrepancy was only below knee.
Femur not affected.

There were some discolorations at the posterior part.
I'm not sure if this is cafe-au-lait.
But I didn't take any pictures of other cafe-au-lait at his abdomen.

The x-ray of both lower leg.
The right tibia was also bigger and longer.

This was during the surgery.
The surgeon inserted two 8-plate at the right proximal tibia to arrest the bone growth.
An epiphysiodesis.
For right tibia shortening because discrepancy more than 3 cm.

This was after the plate insertion was done.
See, the plate was put from epiphysis to metaphysis.
We must avoid physis injury because he's a growing child.
The plates are temporary.

Anyway, I presented the case to Mr. Shuk afterward but I was so bad that I don't desrerve his signature. Oh yeah.


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