clinical reasoning tutorial – martin

8/6/2019 Clinical Reasoning Tutorial Martin

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Clinical Reasoning Tutorial TOM

CUES INFERENCES

Social Social

21 years

Male

Rides motorbikes

Possibly likes to ride a motorbike

Possibly lives at home with family

Possibly works full time

Possibly studys

Possibly has to support another person

or persons

Injury Injury

Accident occurred yesterday morning

Transverse fracture - Right Tibia and

Fibula

Lesion of left brachial plexus

Could be a learner on the motorbike

Maybe inexperienced doesnt know how

to handle the roads

Possibly riding on paddocks

Might not have been concentrating when

riding

Could have been a slippery road

Might have hit something

Possible muscle damage

Possibly all cords of plexus damaged oronly one of the three (Lateral, Posterial

or Median)

Limited ROM right leg

Limited ROM right foot

Limited ROM upper body

Possible swelling upper and lower limps

Possibly very painful

Possibly quite a serious injury

Possibly has good bone density due to

age

Event/Management Event/Management

Fell off motorbike

Had surgery yesterday afternoon

Surgeon advised he can walk using a

partial weight bearing gait

Complete flaccidity in all muscles

Serious injury had surgery straight

away

Possibly a lot of sutures

Possibly very painful

Possibly could have a lot of rehabilitation


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supplied by brachial plexus

Intramedullary nail was inserted into his

tibia

Unsure what scale of damage to brachial

plexus

May need walking aids

Possibly bandaged heavily

Possibly scared of prognosis

Possibly may have permanent damage to

brachial plexus

Possibly may be just bruised

Swelling

Pain

Possibly highly motivated to get out of

hospital

Possibly highly motivated to get

rehabilitated

Client Summary Statement:

21 year old male after having a motorbike accident yesterday morning has fractured

his right Tibia and Fibula and sustained a lesion to the left Brachial plexus, leaving all

muscles from there flaccid. He had surgery yesterday afternoon to place an

intramedullary nail into his tibia.

HYPOTHESES

Pathophysiology Impairment/Source

Swelling

Muscle damage dorsiflexors,

plantarflexes, inverters and everters of

the foot

Ligament damage to the foot

Superficial soft tissue damage

Pain

Numbness in upper left body

Limited ROM dorsiflexion due to

fracture R tibia fibula

Limited ROM plantar flexion due to

fracture R tibia fibula

Limited ROM inversion due to fracture

R tibia fibula

Limited ROM eversion due to fracture

R tibia fibula

Limited ROM upper body muscles due

to brachial plexus damage

Problems sleeping due to pain R lower

leg and upper body

Activity/Participation Environmental/Personal

Problems using left arm so therefore

might not be able to do some self-care,

showeringetc.

Also trouble working,driving, using a

Could have been riding on winding

streets with sharp corners and could

have been inexperienced with the

conditions


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computer due to no muscle contraction

in upper left limb

Problems walking and using upper limb,

transfers

Problems standing and walking therefore

difficulty in working or driving a vehicle

Difficulty standing and using left upper

limb might not be able to socialize

Possibly could have been riding in busy

traffic

Management Contributing Factors

Walking and mobility aids

Rehabilitation for lower limb and

possibly damage to the brachial plexus

Support at home and work

Medication for pain

Time off work to recover- Workcover?

Time off Study

Raining slippery roads

Might have been a rock or item on road

Rider might not have clear vision

Might be inexperienced

Contraindications/Precautions Prognosis

Need to take rehabilitation slow dont

want to rush as unknown possibilities

with Brachial plexus

Rehabilitation could be too strenuous

and possible re injure slower recovery

Possibly a long recovery

Serious injury

Patient highly motived

Young and fit

Questions for Tom:How did you land?

How did it happen?

Where did it happen?

Do you feel any pain?

Where do you feel the pain?

What movements are you able to do with you left arm?

Learning goals:

Why do you not put in an intramedullary pin into the fibula?

What swelling can occur from transverse fractures of the tibia and fibula?

What is the rehabilitation time for this injury?

What options do you have for a Partial Wei ght Bearing Gait?

How do you damage your Brachial Plexus?


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Can all three cords be damaged at once and what is the effect?

What are the treatment options for this?

What are the signs and symptoms of this injury?

What does swelling look like in this injury?

What is the rehabilitation time for this injury?

clinical reasoning tutorial – martin

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