Ortho Case Write-Up

PASCUA, RODELIA C. MD/MBA 080106 ORTHOPEDIC ROTATION This is the case of C.Y., 40 year-old female, married, Filipino, Roman Catholic, from Rizal who went in due to broken left leg and was subsequently admitted. Informant: Patient herself  Reliability: Reliability: 95% Date of Admission and Procedure: December 19, 2011 History of Present Illness: DOI: December 18, 2011 TOI: 4:30 pm (reached TMC at around 6:00 pm) POI: Cainta, Rizal MOI: fall  The patient was apparently well until one day prior to admission, the patient was going down their stairs and slipped past 4 steps of stairs. Patient landed landed with foot dorsiflexed on the left knee associated with swelling and pain, 10/10 on walking and 3/10 while sitting. The patient claims that she was not able to stand up for about 15 minutes. Her husband brought her dorsiflexed foot to its normal position and rushed her to TMC. Past Medical History: MVA, 1998; admitted at St. Luke’s due to comminuted Hip fracture where she had casting and was advised to have bed rest only No significant medical condition: no Pneumonia, Tuberculosis, Diabetes, Hypertension, Hypertension, Asthma, or Kidney Disease No known allergies to food and medicine •

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Family Medical History: Both paternal and maternal sides have history of hypertension. Her paternal side has diabetes mellitus. There is no other significant medical condition in the family: no asthma, lung or liver diseases, no cancer, no CVD/stroke Personal/Social History:  The patient is a college and a devoted housewife. She is non-smoker, non-alcoholic beverage drinker and denied illicit drug use. She lives with his husband and four children in a semi-concrete, well-ventilated well-ventilated owned house. There are no nearby factories or man roads.  The garbage is collected 2-3 times in a week. Review of Systems: General: no fever, no weight loss for the past month, no easy fatigability • Musculoskeletal/Dermatologic Musculoskeletal/Dermatologic:: no rashes, sores or joint pains; no changes in color HEENT: no headache, dizziness and blurring of vision; no tinnitus; no hoarseness or dysphagia Cardiovascular: Cardiovascular: no palpitations, palpitations, syncope, or orthopnea Gastrointestinal: Gastrointestinal: no nausea, vomiting, or changes in bowel movement Genitourinary: Genitourinary: no changes in urination • •

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STAKEHOLDER ANALYSIS Stakehold Interest in Issue er 1. Husban  Treatment of her wife and to d function normally again (in terms of  ADLs, IADLs)

Role Primary care-giver and decision-maker

Level of   Influence High

2. Children 3. Philheal h 4. LGU

Treatment of their mother and to function normally again Sustainability and marketing of  strategy of the business and of the PhilHealth as well Prevention of acquisition the disease; health-seeking behavior and ‘myths’ or mindset towards the disease

Secondary care-giver

High

Financing and other benefits

High

Ensure healthy living environment and mobilize the community to participate in the preventive health programs

Medium

PHYSICAL EXAMINATION Vital Signs: BP: 110/70 mmHg • HR: 80 beats per minute • RR: 20 breaths per minute •  Temperature: 36.3°C • Others: Height – 157 cm • Weight – 68.18 kg BMI – 27.66 kg/m2 General Survey:  The patient is conscious, awake, not in cardiorespiratory distress HEENT: Anicteric sclerae; pink palpebral conjunctivae; no TPC; no CLAD; not distended/flat neck veins Cardiopulmonary: Symmetric and equal chest expansion; clear breath sounds; no rales/crackles; no wheezes; adynamic precordium, no heaves, no thrills; apex beat at 5 th ICS mid-clavicular line; normal rate and regular rhythm; good and distinct S1 and S2 Abdomen: flat; normoactive bowel sounds; tympanitic in all quadrants; no tenderness, no organomegaly Extremities: dried wounds, minimal soft tissue swelling surrounding incision sites; full and equal peripheral pulses; CRT < 2 secs; no edema, no cyanosis with good skin turgor Neurological Examination:  The patient is conscious, awake, right-handed, conversant, heavy-built female Cranial nerves: CN I- not assessed CN II- not assessed CN III, IV, VI – full EOMs CN V – intact V1, V2, and V3 sensation and V3 motor • CN VII – no facial asymmetry, able to raise eyebrows and smile • CN VIII – intact gross hearing CN IX, X – can swallow, normal palatal elevation • CN XI – can raise shoulders CN XII – midline tongue; no tongue protrusion, atrophy, or fasciculation • • • •

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Motor: 5/5 in both upper extremities; 5/5 right lower extremities; 4/5 left lower extremities Reflexes: not assessed Cerebellar: can do finger-to-nose test; can do rapid alternating hand movement Sensation: paresthesia and numbness on the left lower extremity; 100% sensation in all extremities Musculoskeletal Examination: Inspection (Look): cannot walk, minimal soft tissue swelling surrounding incision • site; (+) Trendelenberg gait;

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Palpation (Feel): minimal warmth and tenderness on the incision site; full and equal popliteal and dorsal pedis arteries; paresthesia/numbness associated with shooting pain, Left lower extremity Maneuvers (Move): Range of Motion (Upper Extremities): WITHIN NORMAL LIMITS o Normal ranges of motion for the cervical spine include 50 degrees of  flexion, 60 degrees of extension, 45 degrees of lateral, or side bending, and 80 degrees of rotation. Common upper extremity ranges of motions for the shoulder include 170 to 180 degrees of flexion, 50 to 60 degrees of extension, 170 to 180 degrees of abduction for moving the arm away from the body, 80 to 90 degrees of internal rotation, and 90 to 100 degrees of external rotation. Ranges of motion in the elbow and forearm include 90 degrees of supination and pronation, or rotating the forearm. It also includes 145 to 155 degrees of elbow flexion and 0 degrees of  extension due to the bony anatomy of the joint. Wrist range of motion includes 80 to 90 degrees of flexion and 75 to 85 degrees of extension. 

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Range of Motion (Lower Extremities): WITHIN NORMAL LIMITS FOR THE RIGHT LOWER EXTREMITIY  Lower extremity ranges of motion for the hip include 120 to 130 degrees of flexion, 10 to 20 degrees of extension, 45 degrees of  abduction away from the body, 30 degrees of adduction toward body, 45 degrees of internal rotation, and 50 degrees of external rotation. Knee range of motion consists of the flexion and extension arc of  motion which totals 135 to 145 degrees. Ankle range of motion includes 50 degrees of plantar-flexion, or toes pointing toward the ground, and 20 degrees of dorsi-flexion with the toes pointing toward head. It also includes 20 degrees of inversion and 5 degrees of  eversion. LEFT LOWER EXTREMITY: (+) Limitation of Motion: flexion, abduction and adduction, external and internal rotation 

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PRIMARY DIAGNOSIS: Closed, Complete Spiral and minimally displaced fracture of the left distal third tibia s/p Closed interlocked intramedullary (IM) nailing, distal third tibia, left MANAGEMENT Keep leg elevated on 1-2 pillows Continue Cefazolin, 1g IV every 8 hours x 2 postoperative doses then shift to Cefalexin 500 mg/cap, 1 capsule 3x a day Encourage ankle pumps and quadriceps sits May move left lower extremity as tolerated May ambulate with 2 crutches, toe touch weight bearing on the left lower extremity Home medication: Cefalexin 500mg/cap, 1 capsule every 6 hours for 7 days • •

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 The ideal implant for stabilization of pertrochanteric fractures is still under debate. Many authors consider the sliding hip screw with a plate the best choice, extenuating its favorable results, the low rate of hardware failure and non-union. A recent metaanalysis compared the sliding screw and plate with intramedullary nails (IMN). Total fixation failure rate was higher in the IMN group, without reaching

statistical significance. However, intramedullary nails gain a continuous popularity for both stable and unstable fractures, due to certain theoretical advantages and ease surgical technique. Additionally, the small incisions result in less blood loss intraoperatively. A variety of intramedullary devices have been used with different design characteristics. However, the adequacy and stability of fixation plays an important role, determing the success of the surgical treatment of pertrochanteric fractures. (Philippine Orthopedic Institute, May 2010). PROGNOSIS Good PUBLIC HEALTH IMPLICATIONS   There should be more emphasis on the primary prevention of other musculoskeletal diseases that affects the general population through education and delivery of health services that is affordable, accessible and available. On the macro level, this includes poverty eradication and economic sustainability.