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Arm Injury A Case Discussion

Arm Injury A Case Discussion. Case Presentation. Patient History. General Data. TO 14 year old male Lives in Palau Right-handed Informant: Patient, good reliability Chief Complaint: Wrist Injury. History of Present Illness. Fall 2 nd floor of house ~ 20ft

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Arm Injury A Case Discussion

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  1. Arm Injury A Case Discussion

  2. Case Presentation Patient History

  3. General Data • TO • 14 year old male • Lives in Palau • Right-handed • Informant: Patient, good reliability Chief Complaint: Wrist Injury

  4. History of Present Illness Fall 2nd floor of house ~ 20ft hitting R hand, fully extended • on sandy surface (+) loss of consciousness for a few seconds (+) deformity on R wrist (–) break in skin (–) bruising 8 days PTA

  5. History of Present Illness Consult at local hospital X-ray revealed fracture of the distal radius Given Tramadol Discharged (no ortho) (-) Change in sensorium (-) Nausea, vomiting, seizure (-) numbing of R hand 8 days PTA Admission

  6. Review of Systems General: no weight loss, Cutaneous: no lesion, no pruritus HEENT: with occasional headaches no redness no aural/nasal discharge no neck masses no sore throat Cardiovascular: no easy fatigability, fainting spells, no palpitation Respiratory: no cough, colds Abdominal: no change in bowel movement Genitourinary: no change in urination Endocrine: no polyuria, polydypsia, no heat/cold intolerance Hematopoietic: no easy bruisability, or bleeding

  7. Past Medical History • No asthma, hypertension, diabetes, allergies,heart disease, bone diseases • No maintenance medications • No previous surgeries • Does not recall previous immunizations • Hospitalized > 5 years ago 2o AGE

  8. Family History • Diabetes Mellitus, Heart Disease • No hypertension, asthma, cancer, stroke, or allergies

  9. Personal/Social History • 1st year high school student • Lives with his family in a 2 story house in Palau • Denies smoking, alcohol drinking, and drug abuse

  10. Case Presentation Physical Exam

  11. Physical Exam • General Survey • Awake, active, and not in cardiorespiratory distress • Vital Signs • Febrile at 37.5oC • RR 20 bpm • HR 71 bpm • Height:168cm weight:59kg BMI: 20.9

  12. Physical Exam • Skin • Dirty skin • No rashes, hemorrhages, scars • Moist • CRT 1-2 seconds

  13. Physical Exam Head no lesions Eyes anictericsclerae, slightly pale palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum midline, moist mucosa Throat mouth and tongue moist no TPC

  14. Physical Exam Neck no cervical lymphadonapathy supple Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 5th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

  15. Physical Exam Abdomen flat, no scars, no lesions normoactive bowel sounds tympanitic on all quadrants Soft nontender no masses, no organomegally

  16. Physical Exam Right upper extremity Shoulder and Elbow no deformity, no asymmetrical no discoloration, no lesions no tenderness, no swelling no limitation of movement full ROM

  17. Physical Exam Right upper extremity posteriorly deformed distal forearm bluish discoloration on the anterior wrist no lesions tenderness around the wrist Soft tissue swelling of the anterior wrist wrist ROM limitation due to pain intact radial, median, and ulnar nerves (motor and sensory) allen’s sign? ROM limitation due to pain

  18. Salient Features History • 14 year old male • R-handed • 8 days PTA • Fall from 20ft on sand • Right arm extended • (+) R wrist deformity • (–) break in skin • (–) bruising • (–) R hand numbness • Immobilized with short posterior arm splint Physical Exam • Right upper extremity • posteriorlydeformed distal forearm • bluish discoloration on the anterior wrist • (–) external lesions noted

  19. Pre-Operative Diagnosis • Fracture, closed, complete, transverse, displaced, distal radius, Right

  20. Procedure Done • Closed reduction, percutaneous pinning, application of long arm cast, Right

  21. Post-Operative diagnosis • Fracture, closed, complete, transverse, displaced, ulnarstyloid, Right • Distal radius and ulna styloid fracture, Right

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