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.
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.)
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.
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