Problem 5: Unable to Move

Troy, a 26 year old gymnast, had to be urgently hospitalized after he sustained a fall while
walking on the tightrope at the circus. He found it extremely painful to move his right
lower limb and X-rays revealed a posterior dislocation of the femoral head and a fracture
of the posterior rim of the acetabulum. The orthopaedic surgeon planned to perform an
open reduction and fixation, and soon after admission the patient was taken to the
operating theatre.

After Troy was put to sleep, the anaesthetist administered an intravenous bolus of
suxamethonium so as to facilitate intubation and artificial ventilation. Once the airway
was secured, a dose of vecuronium was given to maintain muscle relaxation for a longer
period for the operation. Troy unfortunately had a drastic adverse reaction to the
anaesthesia, which had to be ceased immediately, and was quickly administered
dantrolene to alleviate his condition. This meant his orthopedic surgery was delayed by
48 hours to allow for sufficient recovery from the unexpected episode and adaptation of
the surgery protocol.

Unfamiliar Terms:
1. Open reduction and fixation- surgical procedure to fix a severe bone fracture, or break where
surgery is needed to realign the bone fracture into its normal position
2. Suxamethonium- A shortacting depolarizing muscles relaxant commonly used immediately after inducing
general anaesthesia to facilitate the insertion of an endotracheal tube.
3. Intubation- Tracheal intubation, usually simply referred to asintubation, is the placement of a flexible
plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through
which to administer certain drugs.
4. Vecuronium-
a nondepolarizing neuromuscular blocking AGENT, used in the form of the bromide salt as an adjunct to ge
neralANESTHESIA to induce relaxation of skeletal muscle and to facilitate endotracheal intubation and mech
anical ventilation;administered intravenously.
5. Dantrolene - Dantrolene sodium is a postsynaptic muscle relaxant that lessens excitation-contraction
coupling in muscle cells. It achieves this by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores
by antagonizing ryanodine receptors.
Issues:
1. What is the significance of a posterior dislocation of the femoral head and a fracture of the posterior rim
of the acetabulum?
2. Why did the orthopaedic surgeon plan to do a open reduction and fixation?
3. What is the significance of intubation and artificial ventilation during a open reduction and fixation?
4. Why did muscle relaxation need to be maintained over the period of the operation?
5. What could have caused Troy to react adversely to anaesthesia?
6. How did dantrolene alleviate Troys condition?
7. What would a recovery from a adverse reaction to anaesthesia entail?
8. How would the surgery protocol be adapted for Troy after his adverse reaction to anaesthesia?
Hypotheses:
1. The dislocation and fracture would cause Troy severe pain on moving and would prevent him from
performing gymnastics.
2. The orthopaedic surgeon planned to do a open reduction and fixation to realign Troys bone fracture into
its normal position and facilitate healing and recovery.
3. Intubation and artificial ventilation are needed to facilitate breathing since normal breathing would be
impaired by the use of anaesthetics.
4. Muscle relaxation needed to be maintained to relax the chest muscles to allow Troy to breathe via the
intubation and artificial ventilation.
5. Troys adverse reaction could have been caused by an allergic reaction to the anesthetics used.
6. Dantrolene is a calcium channel blocker which helped to relax the muscles in Troys body and bring him
back to a stable state.
7. Troys recovery would entail waiting for all the side effects of the anesthetic to wear off and taking
appropriate medications to reduce them.
8. Different anaesthetics in the appropriate amount would need to be used as a substitute for
suxamethonium and vecuronium.