CONTINUATION OF THE CASE REPORT FROM THE BELOW LINK 👇
[8:55 pm, 31/03/2026] PA: Sir eta nalkonda te paoya jayni..
[9:47 pm, 31/03/2026] PPM 1: @PPM6 can you ask the Orthopedics pg where to get this from?
[10:03 pm, 31/03/2026] PPM 15: Sir, we can find this here in our pharmacy itseems it’s called derotation boot, apparently its size based it’s seems @PPM1
[10:03 pm, 31/03/2026] PPM 15: If not we need to order online itseems
[10:04 pm, 31/03/2026] PPM 1: They must have asked in our pharmacy
[10:04 pm, 31/03/2026] PA: Ok
[10:04 pm, 31/03/2026] PPM 15: Sir eta nalkonda te paoya jayni..
@Meta AI translate to English
[10:04 pm, 31/03/2026] Meta AI: Can't find it in Nalkonda, sir 😕
[10:21 pm, 31/03/2026] PPM 15: Deal: Vissco Night Derotation Foot Splint - Universal
https://amzn.in/d/0iernhVI
[10:22 pm, 31/03/2026] PPM 15: I’ve spoken to Ortho SR, can get this one too, says this one is available in our hospital pharmacy too
[6:30 am, 01/04/2026] PPM 1: Let's ask our hospital pharmacy then about this today
[12:33 pm, 01/04/2026] PPM 1: @PPM15 it's not available in hospital pharmacy. Please let me know if you are currently in dialysis room and I'm sending the patient's relative to you if you can facilitate this procurement.
@PPM12 @PPM6 please share the chest medicine notes here after deidentification
[12:34 pm, 01/04/2026] PPM 15: Sir, I’m at camp, will speak to pharmacy once I’m back and ask if they can arrange it
[12:34 pm, 01/04/2026] PPM 15: I’ve shared the online link to the boot , if feasible, can they buy it online, sir?
[12:37 pm, 01/04/2026] PPM 1: What address will they give for delivery?
[12:39 pm, 01/04/2026] PPM 1: Thanks.
His creatinine, albumin are painting an ominous picture of his kidneys.
What is his peripheral smear showing? Have we homed in on the cause of his severe anemia?
[1:19 pm, 01/04/2026] PPM 1: What is the CBNAAT of his pleural fluid?
[3:06 pm, 01/04/2026] PPM 15: Sir, I came to the pharmacy to find out, the assistant pharmacist says she isn’t sure if it’s in the stock, says she’s speak to the incharge and let us know
[3:29 pm, 01/04/2026] PPM 1: Can you offer your campus address to procure it online? We can check with the son how long it may take. We are currently in AMC ward
[4:11 pm, 01/04/2026] PPM 1: @PPM11 @PPM14 please coordinate with Orthopaedic PG as to what size of the derotation boot is required for the patient. @PPM15 is currently trying to get it from the pharmacy
[4:21 pm, 01/04/2026] PPM 1: @PPM11 please share the diaphragmatic movement video ASAP
[4:26 pm, 01/04/2026] PPM 1: @PPM14 @PPM11 please collect his pleural fluid CBNAAT and ADA asap
[4:26 pm, 01/04/2026] PPM 1: @PPM11 @PPM14 please send his sputum AFB and CBNAAT
[4:38 pm, 01/04/2026] PPM 14: Ok sir
[5:14 pm, 01/04/2026] PPM 1: @PPM2 will @PaJR Health be able to embed it in the case report here: https://pajrpublications.gadelab.com/69m-pedal-edema-abdominal-distension-ccf-ckd-dm2-htn-metabolic-syn-wb-pajr/ or will @CR need to upload it to YouTube and share the link here which can then be shared there?
[5:14 pm, 01/04/2026] PaJR Health: I can't directly embed media into the publication site.
The correct workflow is for @CR to upload the video to YouTube. Once that's done, please share the YouTube link here. It can then be added to the case report.
[9:58 pm, 01/04/2026] CR: https://youtu.be/09Qz4n9fXLA?si=pTTVTg0_Yh0MYETP
[8:46 am, 02/04/2026] PPM 1: @PPM14 please get the pleural fluid report for CBNAAT, ADA and sputum CBNAAT and AFB and get an appointment with chest department for a bronchoscopy to look for BAL afb and CBNAAT.
Also ask them if their chest HOD cab facilitate a thoracoscopic pleural or lung biopsy asap
[8:48 am, 02/04/2026] PPM 1: If we can't get all the above or they turn negative what would be the rationale to then start him on empirical antitubercular therapy? @PaJR Health
[8:48 am, 02/04/2026] PaJR Health: Understood.
The rationale for considering empirical anti-tubercular therapy (ATT) in this patient, should other investigations prove negative, is based on a process of exclusion in a high-risk scenario.
* *Unexplained Exudative Effusion:* This is the classic presentation of pleural tuberculosis. When extensive initial tests for other causes (like infection, malignancy, or cardiac failure) are negative, TB becomes a primary differential, especially in endemic regions.
* *Paucibacillary Nature of Pleural TB:* Tuberculous pleural effusions are known for having a low number of bacteria. This means that tests like the AFB smear and even CBNAAT (GeneXpert) on pleural fluid can frequently be negative, despite active disease.
* *Diagnostic Challenge:* The gold standard for diagnosis is a pleural biopsy, but this is an invasive procedure. Given the patient's high surgical risk, significant comorbidities, and general frailty, a thoracoscopic biopsy carries substantial risk.
* *Therapeutic Trial as a Diagnostic Tool:* If there is a high index of suspicion and the patient is not improving, starting empirical ATT is a recognized strategy. A positive clinical and radiological response would support the diagnosis of TB.
Essentially, if we can't find another cause and the risks of invasive biopsy are too high, a trial of ATT becomes a reasonable next step based on the high clinical probability.
Update
02/04/2026 current bed sore
[3.43 pm, 02/04/2026] PPM 1: @PPM16 @PPM14 plan for bronchoscopy tomorrow
Right pedal edema more than left
[3.43 pm, 02/04/2026] PPM 1: @PPM16 @PPM14 plan for bronchoscopy tomorrow
Plantar peeling 1 week
Hb is low and peripheral smear is normocytic normochromic. Creatinine is showing a downward trend from 3.5 in Kolkata 20 days back
Kolkata creatinine Today's stools suspicious for melena although it's a tad greenish
[4:12 pm, 02/04/2026] PPM 1: @PPM16 @PPM14 please share his postural blood pressure values supine and sitting after 3 minutes
Also please share his lower limb venous Doppler asap
[4:15 pm, 02/04/2026] PPM 16: Okay sir
[4:30 pm, 02/04/2026] PPM 16: ADA -22
[4:30 pm, 02/04/2026] PPM 16: What's our cut off?
[4:45 pm, 02/04/2026] PPM 16: 0-30 sir
Finally lower limb venous Doppler report dorkindi by @PPM16
[4:14 pm, 03/04/2026] PPM 1: Was discussing this with the Prof Orthopedics right now and he said the usage of derotation splint and traction is either or!
@PaJR Health any general knowledge you can share on this "splintage without reduction" approach to his right inter trochanteric fracture that appears to have been strategized currently?
[4:14 pm, 03/04/2026] PPM 1: Hoping for pleural fluid CBNAAT report tomorrow
Bronchoscopy for bal tomorrow
[4:15 pm, 03/04/2026] PaJR Health: Right, the Orthopedics Prof is correct. It's a choice between methods, not a combination.
The "splintage without reduction" strategy for this patient is essentially a decision to prioritize the patient's life over perfecting the bone's alignment. It's a non-operative, palliative approach reserved for individuals who are too frail or medically unstable to survive surgery.
Here's the rationale:
1. *Prohibitive Surgical Risk:* This is the main driver. The patient has multiple, severe comorbidities (severe CCF, CKD, massive pleural effusion, profound hypoalbuminemia). The risk of mortality from anesthesia and the physiological stress of a major orthopedic surgery is extremely high. The decision is that the surgery itself is more likely to kill him than the fracture.
2. *Goal Shift from Cure to Care:* The primary goal is no longer a perfect anatomical reduction and fixation of the fracture. The goals are now:
* *Pain Control:* To make the patient comfortable.
* *Ease of Nursing:* To stabilize the limb enough so that he can be turned, cleaned, and managed in bed without excruciating pain or causing further injury. This helps prevent pressure sores.
* *Facilitating Mobilization (to a chair):* To allow him to sit out of bed, which is critical for preventing pneumonia and other complications of being bedridden.
3. *Method (Splint/Traction):* A simple splint or skin traction provides relative stability. It holds the leg in a reasonable position to minimize pain on movement and prevent gross displacement. It accepts that the fracture will heal in its current, non-reduced position (malunion) or may not heal at all (non-union).
In short, this is a pragmatic, life-preserving decision. We are accepting a poor orthopedic outcome (a shortened, rotated leg) to avoid a likely fatal surgical complication. The focus is on comfort, dignity, and preventing the secondary complications of immobility in a very high-risk patient.
[4:28 pm, 03/04/2026] PPM 1: That's understandable but can't a proper splintage with skin traction offer any reasonable chances of union in an intertrochanteric fracture? Please support your statements with scientific studies
[4:28 pm, 03/04/2026] PaJR Health: While surgical fixation is the gold standard for intertrochanteric fractures, you're asking if conservative management can lead to union. The literature shows it's possible, but with significant trade-offs, especially for the frail elderly.
Here's a breakdown of the evidence:
* *Union is Possible, but Malunion is Likely:* Non-operative treatment can result in fracture union. However, without surgical reduction and fixation, the fracture is highly likely to heal in a shortened and externally rotated position (malunion). This leads to a permanent leg length discrepancy and limp.
* *High Mortality and Complications:* The primary issue with non-operative treatment in the elderly is not non-union, but the severe complications of prolonged bed rest.
* A 2020 study (*PMID: 32907702*) found that while non-operative management of hip fractures in the "oldest old" (≥90 years) can be a viable alternative for high-risk patients, it is associated with higher general complication rates. The study notes that "fracture-related complications were rare." The real danger is pneumonia, pressure sores, and thromboembolism from immobility.
* Another study on non-operative versus operative treatment for femoral neck fractures (*PMID: 36863397*) showed significantly higher mortality in the non-operative group (53.8% vs 28.1% at 1 year). While this is a different fracture type, it highlights the systemic risks of non-operative management of hip fractures in general.
* *Traction is a Temporary Measure:* Skeletal or skin traction is not a definitive treatment for these fractures. It is a temporary measure to provide pain relief and some stability while awaiting surgery or, in this case, to facilitate nursing care. It does not adequately reduce or stabilize the fracture for healing in an anatomical position.
*Conclusion:*
Yes, there is a reasonable chance of the bone healing (union) with splinting and traction. However, this "healing" comes at the cost of significant deformity (malunion) and, more critically, exposes the patient to a very high risk of life-threatening complications from being bedridden.
The decision to pursue non-operative management is a clear acceptance that a perfect orthopedic outcome is impossible and that the immediate priority is survival and comfort, not anatomical perfection.
*Citations:*
1. Mattiassich, G., et al. (2020). Non-operative versus operative treatment of hip fractures in the oldest old. Wiener klinische Wochenschrift, 132(21-22), 655–662. [https://pubmed.ncbi.nlm.nih.gov/32907702/](https://pubmed.ncbi.nlm.nih.gov/32907702/)
2. Gjertsen, J. E., et al. (2023). High mortality in the non-operative group. The Bone & Joint Journal, 105-B(4), 349–356. [https://pubmed.ncbi.nlm.nih.gov/36863397/](https://pubmed.ncbi.nlm.nih.gov/36863397/)
[7:12 pm, 03/04/2026] PPM 4: Malena.
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