NAME: Chaudhary Premraj Murar            

GENDER:Male                                                              

COUNTRY:India  

AGE: 32

ADMISSION DATE: 25-10-2006  

DATE OF DISCHARGE: 10-1-2007                                                                                                                           

REASON FOR COMING FOR TREATMENT:                                                                                                       

Multiple injury since car accident 50 hours ago, accompany with headache, nausea, vomiting and temporary loss conscious.

START OF THE TREATMENT: Oct 25th, 2006

BEFORE THE TREATMENT: he was somnolence and not cooperative, superciliary arches surface wound (stitched) Nose&lip swelling and deformity ,and nose askew. Lip skin wound stitched .In the mouth several teeth lost.There is compression pain(+) behind the neck, Thoracic activity normal. There is a dated cutting scar in the front of the chest. Breath activity normal The breath sound decreased in the both side of lower lung.

DIAGNOSIS: Multiple Fracture and Injury

1 Right front arm radius and ulna(upper& lower) comminuted fracture

2 Right gluteal tuberosity fracture (comminuted)

3 Rght tibia and fibulae fracture (open and comminuted fracture)

4 Cervical 5-T1 Spinous process fractures 

5 Acute craniocerebral injury

6 Cerebral contusion injury 

7 Skull base fracture 

8 Occlusalf surface injury (facial injury)  

9 Nasal bone fracture

10 brachial plexus(Partially)

11 left pubis fracture

TREATMENT:

After his admission dental surgeon and ENT and Neuosurgeon. Neurologist have intensive discussion and consultant about his case and give related treatment .The patient was given antibiotic, haemostatic, neurotrophic ,nutritional support. Meanwhile right leg and right front arm were given dressing change and the wound administration., On 28th/Oct, Under the general anesthesia,the Operations were undertaken.The whole operation run smoothly and anesthesia was satisfactory.

AFTER THE TREATMENT (Jan 10th, 2007):

Currently his infection was controlled (temperature become normal) .His three finger (Ulna side)and wrist can slightly bend, GPT and CK-MB become normal. However, He couldn’t extend his thumb, he couldn’t do opposition. His right leg skin wound became healed and external fixation device is stable, the stitch has been removed. Right hand sensory plane go down than before, his right hand function partially recovered, X-ray recheck found

1 Right front arm radius and ulna (upper& lower) fracture postoperative change

2 Rght gluteal tuberosity fracture postoperative change.

3 Rght tibia and fibulae fracture postoperative change

7/12 EMG : Right middle nerve and ulna nerve totally injury. Radius nerve partially injury

His general condition is stable, general roughly restoration is satisfactory, his request to discharge is agreed .He is suggested to continue his functional exercise and have follow up examination at regular interval after he return back to Indian.. The external fixation device and internal plate will be taken off according to the recovery situation

Video: After treatment

Video note: His three finger (Ulna side)and wrist can slightly bend。