how to write a case report for medical journal

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• Published: 30 January 2023

A student guide to writing a case report

• Maeve McAllister 1  

BDJ Student volume  30 ,  pages 12–13 ( 2023 ) Cite this article

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As a student, it can be hard to know where to start when reading or writing a clinical case report either for university or out of special interest in a Journal. I have collated five top tips for writing an insightful and relevant case report.

A case report is a structured report of the clinical process of a patient's diagnostic pathway, including symptoms, signs, diagnosis, treatment planning (short and long term), clinical outcomes and follow-up. 1 Some of these case reports can sometimes have simple titles, to the more unusual, for example, 'Oral Tuberculosis', 'The escapee wisdom tooth', 'A difficult diagnosis'. They normally begin with the word 'Sir' and follow an introduction from this.

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Guidelines To Writing a Clinical Case Report. Heart Views 2017; 18 , 104-105.

British Dental Journal. Case reports. Available online at: www.nature.com/bdj/articles?searchType=journalSearch&sort=PubDate&type=case-report&page=2 (accessed August 17, 2022).

Chate R, Chate C. Achenbach's syndrome. Br Dent J 2021; 231: 147.

Abdulgani A, Muhamad, A-H and Watted N. Dental case report for publication; step by step. J Dent Med Sci 2014; 3 : 94-100.

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Maeve McAllister

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McAllister, M. A student guide to writing a case report. BDJ Student 30 , 12–13 (2023). https://doi.org/10.1038/s41406-023-0925-y

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A guide to writing and using case reports

A thematic series published in Journal of Medical Case Reports .

A valuable resource for clinicians in the form of a special series of editorials, which comprise a guide to writing and using case reports.

Another important publication in the journal for reference when writing and using case reports is, “ A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes ”, which was published in 2013 and written by Richard Rison.

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Affiliation.

• 1 Presbyterian Intercommunity Hospital Health Stroke Program, Los Angeles County Medical Center, University of Southern California Keck School of Medicine, 12401 Washington Blvd, Whittier, CA 90602, USA. [email protected].
• PMID: 24283456
• PMCID: PMC3879062
• DOI: 10.1186/1752-1947-7-239

Case reports are a time-honored, important, integral, and accepted part of the medical literature. Both the Journal of Medical Case Reports and the Case Report section of BioMed Central Research Notes are committed to case report publication, and each have different criteria. Journal of Medical Case Reports was the world's first international, PubMed-listed medical journal devoted to publishing case reports from all clinical disciplines and was launched in 2007. The Case Report section of BioMed Central Research Notes was created and began publishing case reports in 2012. Between the two of them, thousands of peer-reviewed case reports have now been published with a worldwide audience. Authors now also have Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple publishers. This informal editorial outlines the process and mechanics of how and when to write a case report, and provides a brief look into the editorial process behind each of these complementary journals along with the author's anecdotes in the hope of inspiring all authors (both novice and experienced) to write and continue writing case reports of all specialties. Useful hyperlinks are embedded throughout for easy and quick reference to style guidelines for both journals.

For authors

What we publish, how to submit.

• BMJ Case Reports Author Guide

Case report templates

Author statements, reviewer guidance, editorial policy, patient consent and confidentiality, peer review, competing interests, what will it cost, open access, rapid responses.

• flowcharts that show clinical course time lines
• illustrative diagrams that facilitate the interpretation of clinical images
• graphs of results
• management algorithms
• referenced guidelines
• assess the efficacy or effectiveness of new interventions, new drugs, unlicensed substances, or lifestyle changes
• describe drug efficacy, drug interactions or adverse drug effects in patients enrolled in ongoing clinical trials
• describe single-instance, off-label or experimental use of an existing drug or a combination of drugs used for a new clinical indication or the results of phase 2 clinical trials
• have been previously submitted to a preprint server as there are patient confidentiality concerns
• have more than one case (case series). If we feel that an article is strengthened by the inclusion of more than one case, we may consider the article provided it includes no more than three patients. Please contact the editor-in-chief before submitting a case series
• the learning outcomes should be important and novel
• there should be a detailed and balanced review of relevant up-to-date literature
• include diagrams, flowcharts and algorithms that you have drawn so that each case may be used as a textbook case
• there should be comprehensive and critical appraisal of relevant global health literature
• include published public health and epidemiological data
• include an in-depth understanding of the anthropological background of the case
• Videos are published under the same copyright terms as the associated article
• The content and focus of the video must relate directly to the case report
• If audio narration is used, please, ensure that this is clear
• Annotate and label essential structures in videos
• Do not add background music or colourful animation
• Use the compression parameters that video sharing sites use. Often these are standard options in your editing software. A comprehensive guide is available from Vimeo
• Do not show any identifiable features of living patients and/or identifiable personal details in the foreground or background
• Clinical Case Report reviewer guidance >>
• Global Health Case Report reviewer guidance >>
• Images in/Videos reviewer guidance >>
• be involved in the clinical care of the patient
• give final approval of the manuscript
• be responsible for drafting of the text, sourcing and editing of clinical images, results of clinical investigations, drawing of original diagrams and management algorithms, and critical revision for important intellectual content
• agree to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated and resolved.
• authors are required to declare in the author statement that they are the patient in the case report, this statement will appear in the case report
• we do not publish case reports where the patient is the sole author or the patient is a relative of the author
• the report will require careful anonymisation - patients with concerns about anonymity are advised not to co-author manuscripts but to add their patient perspective instead
• we require consent from everyone whose medical information is disclosed in the manuscript (e.g., parents, siblings, etc)
• signature of the consent form should be after the patient has seen and approved the manuscript
• if the manuscript is substantially changed as a result of revisions, the authors should confirm that the patient has seen and approved the final manuscript
• patients should be made aware that published online content may be picked up by non-BMJ or non-medical media
• after publication of a case report, should authors wish to submit a second manuscript describing the progress of the same patient, up to date informed consent will be needed with a new consent form signed by the patient
• anonymise all details of patients in the text, tables, figures, figure legends and within the patient perspective section
• unless clinically relevant, ethnicity and occupation should not be included
• when describing family history in the case report use “first degree relative” or ”second degree relative” for parents or siblings or grandparents or cousins
• exclude specific ages, instead use “early”/”mid”/”late” “20s”, “30s”, “40s”….
• childhood age ranges include preterm neonatal, term neonatal (birth – 27 days), infancy (28 days – 12 months), toddler (13 months – 2 years), early childhood (2 – 5 years), middle childhood (6 – 11 years), early adolescence (12 – 18 years) and late adolescence (19 – 21 years)

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Main article content, cardiac tamponade as the initial presentation of childhood systemic lupus erythematosus: a case report, bassey kevin.

Systemic Lupus erythematosus (SLE) is an autoimmune disorder characterized by the proliferation of autoantibodies and immune dysregulation resulting in damage to many body organs. Pediatric SLE usually presents with fever, joint pain, rashes, and lupus nephritis. It is uncommon to have large pericardial effusions in children with SLE and cardiac tamponade as the initial presentation of SLE is even rarer. An 11-year-old female presented to our Children Emergency Unit with fever and fast breathing for two weeks, bilateral leg swelling of four days, and cough of two days duration. She was acutely ill, tachypneic, and dyspneic with marked orthopnea, bilateral leg edema, and raised JVP. She was tachycardic with a diffuse apex beat. Chest X-ray showed a large globular heart. 2D-Echocardiography showed a large circumferential pericardial effusion with a dilated non-collapsing IVC and diastolic collapse of the right ventricle. She had a pericardiotomy done and 650mls of serous pericardial fluid was drained. The inner pericardium had a fibrinoid exudate with a “bread-and-butter” appearance. Pericardial fluid cytology showed no malignant cells while pericardial biopsy showed suppurative granulomatous inflammation. Antinuclear antibody (ANA) was strongly positive. The patient was managed with corticosteroids, colchicine, and hydroxychloroquine, and has remained stable on follow-up. While cardiac tamponade as an initial presenting complaint in SLE is rare, it is important that children presenting with large pericardial effusions and tamponade be evaluated for rheumatologic disorders. This can be crucial to revealing the correct diagnosis and instituting appropriate care.

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South Carolina Pastor’s Wife Died by Suicide, Medical Examiner Says

The Robeson County Sheriff asked the public "to please await the full timeline of events before making assumptions and coming to conclusions" in Mica Miller's death

Mica Miller/Facebook; WPDE ABC15/YouTube

The cause of death has reportedly been released for Mica Miller, the wife of South Carolina pastor John-Paul Miller, amid an ongoing investigation.

Miller died from a self-inflicted gunshot wound, Robeson County Medical Examiner Dr. Richard Johnson told WPDE on Monday, May 6. PEOPLE reached out to the medical examiner's office, which did not confirm the report. 

“Based on the nature of the wound, that it is consistent with a self-inflicted gunshot wound. And it was not in the back of the head, as it has been speculated,” Johnson told WPDE. Johnson said that although he wasn’t the on-call medical examiner when Miller died, he was present at the scene. 

Mica died on April 27 at Lumber River State Park, according to the Robeson County Sheriff's Office. She was 30. 

In a statement on Facebook Monday, the Robeson County Sheriff's Office said it was "aware that information pertaining" to Miller's death was "released by the North Carolina Medical Examiner's Office."

"Sheriff Burnis Wilkins has scheduled a meeting with the family of Mica and will be releasing more detailed information to substantiate the medical examiner findings tomorrow evening," the sheriff's office continued. "Sheriff Wilkins is also asking for everyone to please await the full timeline of events before making assumptions and coming to conclusions."

Before her cause of death was determined, her husband John-Paul Miller told WDPE on May 2 Miller's death was a suicide. He also told his congregation the day after she died that her death was "self-induced." However, some of Miller's friends questioned that.

"This has to be at least looked into deeply. There’s got to be some accountability here,” Kenn Young, a friend of Miller's, told WDPE on May 2. "Because yeah, a tragic life was lost, and it’s not just as simple as mental health issues."

On Sunday, May 5, Miller’s friends and family held a rally outside the Solid Rock Church calling for justice .

Her family also held a memorial service that same day. At the same time as the memorial service, John-Paul hosted a memorial service at the church.

On Monday, May 6, John-Paul was released from his ministerial functions for "a time of healing, counsel, and guidance, pursuant to our governing instrument,” per WPDE . The church's website was also suspended over the weekend.

Miller and John-Paul were in the process of divorcing, reports ABC 30 . Weeks before her death, Mica posted a video on Facebook on the topic of abuse, sharing advice for those who may be in an abusive relationship.

Never miss a story — sign up for PEOPLE's free daily newsletter to stay up-to-date on the best of what PEOPLE has to offer, from celebrity news to compelling human interest stories.

If you or someone you know is considering suicide, please contact the 988 Suicide and Crisis Lifeline by dialing 988, text "STRENGTH" to the Crisis Text Line at 741741 or go to 988lifeline.org .

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OSF, other medical professionals found liable in $41 million malpractice lawsuit in Illinois

A jury in the Circuit Court of Cook County has awarded $41 million to a 72-year-old lawyer whose cerebral artery stroke was brought on by medical mismanagement at the Peoria-based OSF HealthCare System , according to a news release from the law firm representing him.

Craig Pierce was awarded the verdict on Tuesday against OSF, an Illinois nephrologist, a kidney care corporation and a dialysis service. According to his lawyers, this is the largest award in Illinois history for a medical malpractice case with a plaintiff over 70 years old.

When contacted by the Journal Star on Friday afternoon, OSF HealthCare spokesperson Shelli Dankoff said the healthcare network has no comment at this time.

“The jury’s verdict is bittersweet for this wonderful family, which has been devastated by Craig Pierce’s injury and the loss of his ability to function independently and practice law,” Christopher Hurley, founding partner at the Chicago-based Hurley McKenna & Mertz, which represented Pierce, wrote in a release.

“Craig was a pillar of his community as a successful lawyer and member of his local school board. During the month-long trial, the jury carefully considered all of the evidence and rendered a just verdict. Craig Pierce will now receive the twenty-four hour per day care that he needs and deserves.”

Peoria: Estranged wife of councilman says he coaxed her to lie about domestic violence case

The jury found that in 2016, Pierce, then living in Bushnell, Illinois — located about 60 miles west of Peoria — suffered a catastrophic stroke as a result of medical mismanagement by OSF HealthCare System, Fresenius Medical Care of Illinois, RenalCare Associates and Dr. Sudha Cherukuri. According to the lawsuit, the medical professionals failed to properly manage Pierce’s blood thinning medication, Coumadin, a brand name for the commonly prescribed anticoagulant, Warfarin.

Pierce was admitted to OSF HealthCare Saint Francis Medical Center in Peoria in February 2016 to undergo treatment for pneumonia, according to a Friday news release from the Chicago-based TC Public Relations. During the hospital admission, Pierce developed an acute kidney injury due to his pneumonia treatment, which required short-term dialysis and consultation by nephrologists.

OSF HealthCare System cardiologist Dr. Barry Clemson diagnosed Pierce with atrial fibrillation (AFib), a common heart condition characterized by an abnormal heart rhythm that increases a patient’s risk of cardioembolic stroke, thereby requiring anticoagulant medicine to minimize that risk, according to the release.

Pierce was prescribed Coumadin and recommended for daily blood testing to ensure that the drug was keeping the patient in the therapeutic range for an international normalized ratio (INR), which is a measure of how quickly blood clots. When Pierce was discharged in March 2016, according to the release, his INR level was below the therapeutic range. He was given a prescription for Coumadin, and was to receive short-term outpatient dialysis for his kidney injury. However, there was no post-discharge plan to monitor his INR levels, according to the release.

Over the next four weeks, Pierce received four dialysis treatments at a Fresenius Medical Care of Illinois dialysis facility in Macomb, Illinois. Nephrologist Dr. Sudha Cherukuri was the facility’s medical director and an employee of RenalCare Associates.

According to the release, Fresenius dialysis nurses drew Pierce’s blood three times during that period for lab testing, which included INR levels. By April 5, 2016, Pierce’s INR levels had dropped dangerously low, leaving him at high risk for stroke, the release said. None of the involved health care providers increased Pierce’s Coumadin dose to get him into the therapeutic INR range and reduce his stroke risk, the release said.

Peoria business: Girl awarded $2 million in damages for botched Peoria medical procedure

The morning of April 13, 2016, Pierce suffered a large right middle cerebral artery stroke in his brain. CT imaging that day revealed that a large clot had lodged in his brain and cut off blood circulation to nearly all of the brain’s right side.

Since the time of the stroke, Pierce has been paralyzed on the left side of his body and has suffered from severe cognitive deficits, the release said. He has been unable to practice law or function independently at all, and his wife, Susan, and grandchildren have provided him with around-the-clock care in his home.

Hurley McKenna & Mertz filed a medical malpractice lawsuit in 2020 on behalf of Pierce and his wife against Fresenius Medical Care of Illinois, RenalCare Associates and Cherukuri. After Cherukuri said in her deposition that she believed OSF HealthCare System personnel were handling Pierce’s INR levels, OSF was added as a defendant in an amended complaint.

The lawsuit charged that OSF HealthCare System staff was negligent in failing to monitor Pierce’s INR levels and increase his Coumadin dosage, relying instead on kidney care providers Fresenius and Cherukuri to manage Pierce’s heart condition.

The trial began April 10 and lasted just under a month.

Ascension hospitals facing widespread cyberattack. Here's what we know so far

Ascension confirmed Wednesday that some of its hospitals across the United States were facing disruptions from a possible cyberattack .

In a statement posted to its website, Ascension said that “select technology systems” were affected by what it called a “ cyber security event ,” though the non-profit health system didn’t elaborate on the exact nature of the attack.

Here is what we know about the Ascension hospital cyberattack .

Ascension hospital cyberattack: Ascension Sacred Heart Hospital facing disruptions after cyberattack

When did the Ascension cyberattack happen?

Ascension confirmed to the News Journal that it had detected “unusual activity on select technology network systems” early Wednesday afternoon. Ascension Florida spokesperson Gary Nevolis told the News Journal in a written statement that the health system responded immediately.

How many people are affected by the Ascension cyberattack?

Ascension is still investigating the impact of the cyberattack. News reports from Wisconsin, Texas, Oklahoma, Indiana and Michigan have confirmed similar disruptions.

Employees report to the News Journal that charting, scheduling and prescription writing systems are down.

Ascension has not released many details other than a short statement on its website just after 2:30 p.m. Wednesday.

Was there a data breach in the Ascension cyberattack?

Ascension is not yet aware if the attack resulted in a data breach. In its statement, Ascension said it would notify and support anyone impacted.

What is happening to Ascension patients?

Ambulances are diverting new patients to other hospitals. Escambia County spokesperson Davis Wood confirmed to the News Journal that Escambia County EMS is "on a bypass" for Sacred Heart and is currently transporting patients to other area hospitals.

"Access to some systems have been interrupted as this process continues. Our care teams are trained for these kinds of disruptions and have initiated procedures to ensure patient care delivery continues to be safe and as minimally impacted as possible.”

How many Ascension hospitals are there in Florida?

• Ascension Sacred Heart Pensacola, 5151 N. Ninth Ave., Pensacola, FL
• Ascension Sacred Heart Hospital Emerald Coast, 2300 Mack Bayou Loop #11, Santa Rosa Beach, FL
• Ascension Sacred Heart Bay, 615 Bonita Ave. A, Panama City, FL
• Ascension Sacred Heart Hospital Gulf, 3801 U.S. 98, Port St. Joe, FL
• Ascension St. Vincent’s Clay County, 1670 St. Vincents Way, Middleburg, FL
• Ascension St. Vincent’s St. Johns County, 205 Trinity Way, St. Johns, FL
• Ascension St. Vincent’s Southside Hospital, 4201 Belfort Road, Jacksonville, FL
• Ascension St. Vincent’s Riverside Hospital, 1 Shircliff Way, Jacksonville, FL

How many Ascension hospitals are there in the US?

Ascension employs approximately 134,000 associates, has 35,000 affiliated providers and 140 hospitals that serve communities in 19 states and the District of Columbia.

Ascension full statement

"On Wednesday, May 8, we detected unusual activity on select technology network systems, which we now believe is due to a cyber security event. At this time we continue to investigate the situation. We responded immediately, initiated our investigation and activated our remediation efforts. Access to some systems have been interrupted as this process continues.

Our care teams are trained for these kinds of disruptions and have initiated procedures to ensure patient care delivery continues to be safe and as minimally impacted as possible. There has been a disruption to clinical operations, and we continue to assess the impact and duration of the disruption.

We have engaged Mandiant, a third party expert, to assist in the investigation and remediation process, and we have notified the appropriate authorities. Together, we are working to fully investigate what information, if any, may have been affected by the situation. Should we determine that any sensitive information was affected, we will notify and support those individuals in accordance with all relevant regulatory and legal guidelines.

Out of an abundance of caution we are recommending that business partners temporarily suspend the connection to the Ascension environment. We will inform partners when it is appropriate to reconnect into our environment.

This is an ongoing situation and we will provide updates as we learn more."

Who is Madiant?

Ascension said it had hired cybersecurity firm Madiant to assist in the investigation and response to the incident.

Madiant is a subsidiary of Google that the tech giant bought in 2022.

• Case report
• Open access
• Published: 11 May 2024

Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging’ revisited: a case-report

• Hussein Samir Elrukby   ORCID: orcid.org/0009-0002-4485-1950 1 ,
• Khalid Mohamed Abd Elhafiz Mohamed 2 &
• Elamin Mohamed Elamin Hamed 3  

Journal of Medical Case Reports volume  18 , Article number:  240 ( 2024 ) Cite this article

133 Accesses

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People with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature.

Case presentation

In this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient’s unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach.

Conclusions

The limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Peer Review reports

In clinical practice, Commonplace fractures occasionally manifest in exceptional scenarios. We encountered a situation involving a young achondroplastic adult with intra-articular fractures

Achondroplasia is the most common cause of disproportionate skeletal dysplasia. It leads to abnormally short stature, commonly referred to as dwarfism [ 1 ]. The genetic mutation—that inhibits subchondral bone growth—involves the gene encoding fibroblast growth factor receptor 3 (FGFR3) [ 2 ]. Defective endochondral bone formation results in a wide range of skeletal abnormalities. They include rhizomelic short-limbed stature, flared metaphyses, metaphyseal angulation at the knee joint, and genu-vara [ 2 ].

Sleep apnea, neural foraminal compressions, spinal deformities, and the increased risk of cardiopulmonary morbidities in achondroplastic patients contribute to the significant anesthetic challenges faced during surgical procedures [ 3 ].

The clinical diagnosis of achondroplasia is typically straightforward, with few differential diagnoses [ 3 ].

Individuals with achondroplasia have normal intelligence, and most of them can expect a normal lifespan. However, access to appropriate healthcare services is crucial for minimizing complications [ 1 ].

A multidisciplinary team approach, along with active family participation in decision-making regarding achondroplasia health-related issues, is recommended [ 1 ].

Clinical presentation

A young adult North African male was referred to our trauma center following a road traffic accident. The patient’s height measured 125 cm, and he weighed 44 kg. He displayed typical morphological features consistent with achondroplasia, including frontal bossing, megalocephaly, a depressed nasal bridge, mandibular enlargement, rhizomelic limb shortening, and thoracolumbar kyphoscoliosis [ 3 ].

The patient was not receiving formal follow-up care for health issues related to achondroplasia due to the unavailability of such services in his locality. Additionally, both the patient and the family accept the patient’s unique appearance, having encountered similar cases within their own family.

The patient’s neurovascular exam revealed normal findings, except for the left knee which was painful and swollen.

The anesthetic assessment revealed minimal cervical range of motion restriction, adequate mouth opening (Mallampati score 3), and thoracolumbar kyphoscoliosis.

Investigations

Knee X-rays revealed complete intra-articular fractures affecting both condyles of the left femur (classified as AO/OTA 33-C1). Additionally, there was a concurrent ipsilateral patellar fracture (classified as AO/OTA 34-C1) (Fig.  1 ).

X-ray images showing the distal femoral and patellar fractures as denoted by the arrow indicators

A CT scan with 3D reconstruction showed minimal comminution of the fracture (Fig.  2 ).

Computed tomography of the left knee showing the fractured distal femoral condyles

Blood parameters, including complete blood counts, serum creatinine levels, serum calcium levels, and serum phosphate levels, were normal. The patient’s cardiovascular and respiratory evaluations also yielded normal results, including a normal echocardiogram.

In the case of a patient with rhizomelic thighs, none of the available tourniquet cuffs were applicable without compromising the surgical field. Consequently, we decided not to utilize them. Instead, we maintained meticulous hemostasis throughout the surgery.

The surgery was performed under spinal anesthesia, the patient was supine, and the left knee was flexed to 30 degrees. An anterior midline incision and a lateral parapatellar approach were employed.

After careful assessment of the atypical anatomy of the fractured distal femoral condyles, successful reduction of the parts was achieved. Subsequently, preliminary fracture fixation using three crossing K-wires was performed (Fig.  3 ).

Medical photo showing the preliminary fixation of the condyles

Both the lateral and medial menisci and the anterior cruciate ligament were intact.

Intraoperative templating and swift discussion regarding the available implants led us to choose a precontoured medial tibial plateau L-plate. This plate was further contoured intraoperatively to match the anatomy of the lateral aspect of the distal femur.

With C-arm assistance, the stability of the construct was confirmed. The patellar fracture was fixed by cerclage compression wiring, and normal patellar tracking was confirmed (Fig.  4 ).

Intraoperative C-arm images showing the final fracture fixation

The decision was made against the insertion of a drain.

A posterior slab was applied for two weeks to facilitate adequate wound and soft tissue healing.

The wound healed without complications. Partial weight-bearing was initiated at 6 weeks, with advice to gradually increase weight under the supervision of a physiotherapist. Due to financial constraints, the patient could not stay in the city for an extended period and returned to his locality 12 weeks after the surgery. The patient was provided telephone numbers to contact the surgeon and the physiotherapist. In-person follow-up was scheduled at 6 months and 1 year after the surgery.

The patient was discharged from follow-up at one year. Both the right and left knees exhibited similar ranges of motion. The construct was stable, and the fractures exhibited satisfactory evidence of healing. At discharge, the patient was encouraged to maintain unrestricted mobility.

Three years post-surgery, the patient visited the center and expressed no complaints. During this visit, we took the opportunity to obtain X-rays (Fig.  5 ).

3 years post operative X-ray images showing the consolidation of the fractures

The patient expressed satisfaction with the outcomes of his fracture treatment and reported no decline in previous activities when asked about the impact on the quality of his life.

In a developing country where resources significantly influence decision-making, we rely heavily on the variety of interventions described in the literature to select the most suitable procedures for our context. This approach allows us to optimize patient care while navigating resource constraints.

The management of fractures following trauma in achondroplastic patients is underrepresented in the literature.

We encountered a complex intra-articular fracture of the distal femur (AO/OTA 33-C1), along with a concurrent ipsilateral patellar fracture (AO/OTA 34-C1). We heavily relied on CT scanning with 3D reconstruction to understand the fracture geometry. Addressing this fracture pattern necessitates anatomical reduction, rigid fixation, and early mobilization [ 4 , 5 ].

Successful spinal anesthesia with low doses of anesthetic drugs has been described in several case reports on achondroplastic patients undergoing surgical interventions [ 6 , 7 ].

The literature outlines several implant options for treating distal femoral fractures [ 8 ]. In light of the patient’s atypical bony morphology and the unavailability of patient-specific implants, we prepared a range of fixation devices for the upcoming surgery. Our preparations included plates, dynamic compression screws (DCSs), wires, and Ilizarov frames. The latter served as our final option, ensuring that we were well- equipped to address any challenges during the procedure.

We concur with Murphy et al . that the shortened thighs (rhizomelia) of achondroplastic patients preclude the convenient use of tourniquets [ 2 ]. Instead, it’s crucial to maintain meticulous hemostasis to proactively manage any concerns related to excessive blood loss.

The distinctive morphology of the femoral condyles requires careful reduction of the fractured segments. The preliminary fixation of the condylar fractures served as a foundation for intraoperative implant templating, facilitating decisions regarding implant selection, and fitting to the distal femoral topography. None of the prepared implants were an optimal fit for the bony surface. Finally, we decided to utilize a precontoured medial tibial plate, which was further intraoperatively contoured to achieve precise fixation of the intercondylar fractures.

The literature includes two case reports that closely resemble the currently described situation. However, our case stands out due to the complete intraarticular nature of the fracture in a young, active adult. This necessitated precise anatomical reduction with absolute rigidity of fixation, which diverges from the treatment approaches described in the two existing case reports. Specifically, Murphy et al . employed three percutaneous screws to address a partially articular distal femur (AO/OTA 33B2) fracture in an elderly achondroplastic individual with significant comorbidities [ 2 ]. Another report addressed a supracondylar extraarticular distal femur (AO/OTA 33A3) fracture and employed a humeral nail for fixation. However, this approach does not align with our patient’s fracture geometry [ 9 ]. Given these distinctions, our approach prioritized anatomical reduction and rigid fixation to optimize outcomes for this young and active patient. Our approach underscores the importance of tailoring treatment to individual circumstances, even when the literature provides limited guidance. We opted for an open surgical approach to address both the distal femoral and patellar fractures, ensuring accurate anatomical reduction. The anterior longitudinal midline incision and lateral parapatellar approach combined with the patellar fracture provided excellent exposure of both the medial and lateral sides of the distal femur. Furthermore, it permits the possibility of subsequent revision to total knee arthroplasty (TKA), using the same approach if necessary [ 10 , 11 ].

No drain was placed following meticulous hemostasis, in line with recommendations from the literature advocating against its use [ 12 ].

While individuals with achondroplasia typically exhibit normal intelligence, we recognize that their physical differences can already pose significant challenges. Our approach aimed to minimize any additional difficulties they may experience by carefully considering the most effective management options.

The patients’ commitment to pre- and postoperative instructions was outstanding. Patient compliance likely plays a crucial role in achieving positive outcomes.

Encountering rare cases: We mitigated uncertainties by consulting the available literature and engaging in discussions with the surgical team.

Applying principles of fracture fixation: Despite the unusual situation, we carefully considered providing the best possible choice according to the principles of fracture management.

Recognizing anesthetic risks: We involved the anesthesiologist early in the process, given the special risks associated with achondroplasia (such as spine deformities, difficult intubation, and cardiothoracic complications).

Planning and templating: In achondroplasia patients, standard implants may not fit their unique skeletal morphology. Therefore, intraoperative fitting and contouring of implants are essential for optimal fixation.

Healing of fractures: Fractures of the distal femur in patients with achondroplasia tend to heal well [ 2 , 9 ].

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Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association

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Hussein Samir Elrukby

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Elrukby, H.S., Mohamed, K.M.A.E. & Hamed, E.M.E. Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging’ revisited: a case-report. J Med Case Reports 18 , 240 (2024). https://doi.org/10.1186/s13256-024-04566-4

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Received : 20 March 2024

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DOI : https://doi.org/10.1186/s13256-024-04566-4

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