患者蔡永普，34岁，男，因外伤后右下肢疼痛、活动受限1天于2019年1

患者蔡永普，34岁，男，因外伤后右下肢疼痛、活动受限1天于2019年10月01日入科。患者自诉1天前坐车时车辆与其他车辆发生碰撞，导致全身多处损伤，右下肢疼痛、麻木、活动受限明显，右侧肋部疼痛,行相关检查，发现“双侧肋骨骨折，右侧胫骨平台骨折”，建议手术治疗，门诊以“右侧胫骨骨折”收住入院。<BR><BR>专科查体可见下胸部腹带外固定，右下肢膝关节以下肿胀明显，可见皮肤局部青紫及擦伤，无明显活动性出血，压痛阳性，活动明显受限，膝关节屈伸活动疼痛明显，右足及右踝关节活动可，足背动脉搏动正常，右下肢感觉麻木。辅助检查 右下肢及胸部X片：右侧胫骨平台骨折、右侧肋骨骨折。入院诊断：右侧胫骨平台骨折,右侧胫骨上段骨折,双侧肋骨骨折。入院后完善相关检查，予患肢跟骨牵引，查血管彩超发现静脉血栓形成，予抗凝药物治疗，1周后复查彩超未见血栓，排除其他手术禁忌后于2019年10月14日在全麻下行右侧胫骨骨折切开复位内固定术，手术顺利，术后病情平稳，伤口无感染，予消肿镇痛、预防性抗感染治疗及抗凝治疗，后患者逐步开始康复锻炼，要求出院，遂予办理。

患者蔡永普，34岁，男，因外伤后右下肢疼痛、活动受限1天于2019年10月01日入科。 患者自诉1天前坐车时车辆与其他车辆发生碰撞，导致全身多处损伤，右下肢疼痛、麻木、活动受限明显，右侧肋部疼痛,行相关检查，发现“双侧肋骨骨折，右侧胫骨平台骨折”，建议手术治疗，门诊以“右侧胫骨骨折”收住入院。<BR><BR>专科查体可见下胸部腹带外固定，右下肢膝关节以下肿胀明显，可见皮肤局部青紫及擦伤，无明显活动性出血，压痛阳性，活动明显受限，膝关节屈伸活动疼痛明显，右足及右踝关节活动可，足背动脉搏动正常，右下肢感觉麻木。 辅助检查 右下肢及胸部X片：右侧胫骨平台骨折、右侧肋骨骨折。 入院诊断：右侧胫骨平台骨折,右侧胫骨上段骨折,双侧肋骨骨折。 入院后完善相关检查，予患肢跟骨牵引，查血管彩超发现静脉血栓形成，予抗凝药物治疗，1周后复查彩超未见血栓，排除其他手术禁忌后于2019年10月14日在全麻下行右侧胫骨骨折切开复位内固定术，手术顺利，术后病情平稳，伤口无感染 ，予消肿镇痛、预防性抗感染治疗及抗凝治疗，后患者逐步开始康复锻炼，要求出院，遂予办理。

Cai yongpu, 34 years old, male, was admitted to the Department on October 1, 2019 due to right lower extremity pain and limited movement after trauma. The patient complained that the vehicle collided with other vehicles one day ago, resulting in multiple injuries of the whole body, pain, numbness and limited movement of the right lower limb, and pain in the right rib. Relevant examination was carried out, and "bilateral rib fracture, right tibial plateau fracture" was found. It is recommended to operate and treat. The outpatient department accepted the patient with "right tibial fracture".<BR>Special physical examination showed that the lower chest and abdominal band were fixed externally, the right lower extremity was swollen obviously below the knee joint, the skin was blue and bruised locally, there was no obvious active bleeding, the tenderness was positive, the activity was obviously limited, the knee joint was painful in flexion and extension, the right foot and ankle joint were active, the dorsal foot artery pulsation was normal, and the right lower extremity felt numb. X-ray of right lower extremity and chest: tibial plateau fracture and rib fracture. Admission diagnosis: right tibial plateau fracture, right tibial upper segment fracture, bilateral rib fracture. After admission, relevant examination was improved, calcaneus traction was performed, venous thrombosis was found by color Doppler ultrasound, anticoagulant therapy was given, no thrombus was found by color Doppler ultrasound after 1 week, after exclusion of other surgical contraindications, open reduction and internal fixation of right tibial fracture was performed under general anesthesia on October 14, 2019, the operation was smooth, the condition was stable after operation, the wound was free of infection, swelling, analgesia and preventive anti sensitivity were given After the treatment of infection and anticoagulation, the patient began to recover gradually and asked to be discharged from the hospital.<BR>