Orthopedics Case Study

EMERGENCY ROOM REPORT

SUBJECTIVE

This patient sustained a laceration to his left index finger with an X-ACTO knife approximately 10 minutes prior to arrival in the emergency room.  The patient’s last tetanus immunization was greater than 5 years ago.  He noted no loss of sensation in the distal digit and noted that he is right-hand dominant.

OBJECTIVE

Findings reveal a 4-cm laceration in a V shape with the apex of the cut towards the distal digit on the radial aspect of the digit.  There was no loss of sensation in the distal digit.  There was heavy bleeding noted, and a Penrose drain tourniquet was applied.  Hemostasis was thence obtained, and the wound was irrigated with Betadine and saline followed by copious amounts of saline.  There was no evidence of tendinous involvement, and full flexion was observed as well as extension.  The wound was explored, and the digital nerve was identified and seemed to be intact, although it was very nicely exposed.  Several small digital rays were observed to have been severed.  The wound was closed.  The wound was dressed with Polysporin.  An aluminum splint was applied.

ASSESSMENT

A 4-cm V-shaped laceration, radial aspect of left index finger, sutured.

FOOTNOTE

Line 9.  The brand name X-ACTO is spelled in all capital letters on the packaging and product; however, it may be written with upper and lowercase letters, X-Acto.

Line 25.  Although the word ray can refer to a finger, it also is defined as “any of a system of parts radially arranged.”  Thus, the physician could be referring to nerves, tendons, vessels, or other radial structures in the hand when he states that several small digital rays were observed to have been severed.

Orthopedics Case Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Admitting diagnosis was a nonunion of a fracture of the right radius, status post gunshot wound to the right forearm.

Operative procedures performed included a bone graft to the right radius from the iliac crest.

Briefly reviewing the patient’s admitting history, physical, and hospital course, he was admitted to the hospital for a bone grafting of the right radius from the right iliac crest.  Patient was status post gunshot wound to the right forearm with a segmental bone loss.  Patient was taken to the operating room, underwent the operative procedure without any difficulty.  Postoperatively he had an uneventful postoperative course and was subsequently discharged home to be followed up as an outpatient in my office.

DISCHARGE DIAGNOSIS

Discharge diagnosis included nonunion of fracture of the right radius, status post gunshot wound to the right forearm.

FOOTNOTE

Lines 7, 8.  “Admitting diagnoses was” was edited to “admitting diagnosis was” for proper subject-verb agreement.

Line 26.  The final sentence regarding the operative procedures performed (previously dictated in line 11) was deleted.

Orthopedics Study

Her arm shows forward flexion of about 90 degrees, abduction
60 degrees, external rotation 20 degrees, internal rotation
50 degrees, a well-healed scar.  X-ray shows healing and good maintenance of the fracture.  She is to continue with the range of motion exercises.  She may need the Rush rod removed at some time.  I will see her back here in about 3 months.

CHART NOTE

Her shoulder is improving with PT (physical therapy).  However, she still seems to have restrictions.  She can forward flex about 70 degrees to 80 degrees.  Abduction is only 50 degrees.  She probably has an element of adhesive capsulitis at this time.  She is going to continue her therapy.  In the future she may be a candidate for decompressive acromioplasty if the pain continues.

CHART NOTE

Seen approximately 5 weeks after a fracture of left humerus.  He has been in medial and lateral plaster slabs.  Today there seems to be a slight prominence laterally at the humerus, but the arm seems to be moving as a unit and it is not particularly tender.  X-rays shows some lateral angulation to the humerus, but definitely some callus formation.  I think that even with the deformity, it is mild, and I think the function will be very good.  He is therefore willing to leave things alone at the present and let it heal, and I will see him again in approximately 6 weeks.  He does not need a splint as long as he is careful with the arm.

CHART NOTE

Doing better.  She had the ulnar collateral ligament of her thumb repaired.  She now has almost symmetrical range of motion, but it is still somewhat tight.  It is not particularly painful.  The repair seems solid.  I think she just needs to work on the mobility a little bit longer and that she will be okay.  She will call me in about 2 months to let me know how she is doing.

CHART NOTE

Having a little pain over the distal radial ulnar joint when she lifts something.  There was no popping or clicking.  She has good range of motion and no deformity.  I suggested she just get a small weight and do some strengthening exercises and obtain a splint for her wrist, and she will call and let me know how this is going in the near future.

FOOTNOTE

Lines 7-9 (Page 1).  The degree word was added for clarity.

Line 19 (Page 1).  Alternative:  70-80 degrees.  The degrees word was added to 50 for clarity.

Line 32 (Page 1).  The word callus in the context functions as a noun, not an adjective; the physician is referring to the information of callus.

Line 36 (Page 1).  So as long as was edited to as long as. 
Alternative:  So long as.

Line 44 (Page 1).  She was changed to it for clarity.

Orthopedics Case Study

CHIEF COMPLAINT

Chief complaints of pain, swelling, and slight discoloration of the right ulnar hand.

HISTORY OF THE PRESENT ILLNESS

This 23-year-old laborer was working, moving 2 large tubs, one of which was empty and one full of cooked spinach, when he apparently swung one of the tubs to the side around the corner, resulting in his right hand becoming crushed between the tub he was moving and another stationary tub.  He had immediate pain at the ulnar portion of the right hand, and 20 minutes later he went to the aid station, and apparently the hand was iced and he then went home.  Within an hour, he indicated, the area swelled, and eventually he was aware of some slight discoloration at the site.  He apparently returned to work the next day, but he noted gripping with the right hand intensified his discomfort.  He went to the emergency room.  The ER (emergency room) physician on duty examined him and obtained x-rays of the right hand, applied a splint to the hand, and prescribed Vicodin for pain and referred the patient to my office for orthopedic consultation.

The patient indicated he possibly may have fractured the same hand in the past; however, he did not seek treatment at that time and was not sure if it was fractured or not.  Apparently this earlier injury occurred when he hit someone in a fight, and apparently the hand swelled for a day or so and then the swelling went down, so he never went to a doctor.

PAST MEDICAL HISTORY

The past medical history revealed the patient to be a smoker.  He had no regular family physician.  He had had no major operations in the past.  He denied any serious illnesses or injuries in the past.

CURRENT MEDICATION

Current medications included Vicodin p.r.n. for pain.

ORTHOPEDIC EXAMINATION

The orthopedic examination revealed a well-developed,
well-nourished, alert, 23-year-old Caucasian male in apparent good general health and in no obvious severe acute pain, but who did complain of discomfort as noted below.  The skin of his right hand was intact.  There was an old scar, 2.0 x 1.5 cm, at the radial aspect of the right forearm 2-3/4 inches proximal to the radial styloid.  There was a crust at the center of the old scar where the patient said he “scratched it at work”.  There was slight swelling of the ulnar portion of the right hand at the fifth metacarpal area.  There was moderate tenderness along the ulnar aspect of the right wrist and at the right fifth metacarpal area and, to a lesser extent, the right fourth metacarpal area.  There was a bump at the ulnar portion of the right hand at the mid fifth metacarpal bone area.  The patient made a full fist with both hands, right equals left.  He had full digital extension except for a 10-degree flexion contracture of the PIP joint of the right little finger.  Grip strength was normal and equal bilaterally using the digital grasp method, although the patient did not grip with the right little finger.  The circumferences of the forearms at the level of maximum girth, right over left, were 11-3/4 inches over 11-1/2 inches.  The circumferences of the wrists at the radiocarpal joint line, right over left, were 7-1/4 inches over 7-1/4 inches, and the circumferences of the hands at the second through fifth metacarpal heads, right over left, were 9-1/4 inches over
9 inches, reflecting a swelling at the right ulnar distal hand.  The deep tendon reflexes in the upper extremities were brisk and equal bilaterally.  Pinprick in the upper limbs was normal and equal bilaterally, including the areas of the hands supplied by the median, radial, and ulnar nerves.  Peripheral circulation in the upper limbs was normal and equal bilaterally.  There was no unilateral muscle atrophy, weakness, or incoordination of the upper limbs, comparing contralateral sides.

ROENTGENOGRAMS

AP, lateral, and oblique x-rays of the patient’s right hand were examined by me and revealed what appeared to be residuals of a well-healed (?) fracture with a large ball of mature callus and residual moderate angulation at the midshaft of the right fifth metacarpal bone.  One could see evidence of a fracture line through a portion of the original fracture site, though the fracture line appeared partially obliterated elsewhere.  There was a question of a hairline re-fracture through an old healed or partially healed prior fracture.

DIAGNOSIS

Contusion, ulnar right hand and wrist.  (Rule out hairline
re-fracture through old right midshaft fifth metacarpal fracture.)

RECOMMENDATIONS AND/OR TREATMENT

I advised the patient that it appeared as though he had sustained a fracture through his right fifth metacarpal that had healed or had at least partially healed, and that he possibly had sustained a re-fracture through the same area of the fifth metacarpal.  I recommended application of a cast to immobilize the right hand fracture area, and the patient was agreeable, and therefore a 3M short arm fiberglass cast was applied, including the basal portions of the ring and little fingers.  The patient was to work with the cast on and was to be rechecked by me in 2 weeks, and at that time the plan is to remove the cast and re-x-ray the right hand out of the cast to determine whether or not there was a refracture on an industrial basis.

FOOTNOTE

Lines 15-19 (Page 2).  Over was written out for clarity, rather than using the slash mark.

Orthopedics Case Studies

Comes to clinic today with problems with recurrent bursitis.  He states that he did make an appointment to see me several weeks ago because of 1 episode of bright red bleeding per rectum.  He states he had never had this occur before, and it has not occurred since.  I discussed the different possibilities of this condition.  He has definitely decided not to pursue the matter.  He is asymptomatic at this time.

What is troubling him at this time is recurrent tendinitis to the left arm (this has been injected successfully with cortisone on multiple occasions), as well as intermittent problems of left hip pain, which also seems to be tendinitis/bursitis in nature.  Smokes 2 packs of cigarettes per day and continues to do so despite a rather severe episode of bronchitis earlier this year.

On examination, he is in no acute distress.  Blood pressure 120/74.  HEENT clear.  Chest clear.  Cardiac examination reveals regular rate and rhythm without murmur.  Patient has marked trigger point on the lateral epicondyle.  He is asymptomatic to his hip at this time, and examination is benign.

After discussing the different possibilities, elected to try conservative therapy.  Tennis elbow armband is placed to the left arm.  He is begun on Anaprox DS on a trial basis.  If this gives adequate relief, I would just have him use it on a p.r.n. basis.  If, however, he continues to have significant pain, would recommend return to clinic for trigger point injection.

FOOTNOTE

Line 19.  Has continues was edited to continues.