SGD: HANDBlock Y

July 26, 2009

Tiuseco, Torno, Trocio, Tuliao, Uy C., Uy G., Valencia, Verde, Villanueva

TORIO, Arren

12 yo/ male

General Data:

• A.T., 12 y.o., male, right-handed, filipino, catholic, 1st year h.s. student, born on August 21, 1996 in Las Pinas City, presently residing at 406 Cosme Compound, Talon I, Las Pinas City, admitted for the first time at PGH on July 16, 2008.

• Chief complaint: Left finger deformity

• DOI: May 15, 2009

• TOI: 5 P.M.

• POI: at home

• MOI: 3 weeks prior to consult, Patient was playing basketball when he lost his balance and hit his left 5th finger on the ground. The patient then felt pain on his left 5th finger, associated with swelling, limitation of movement and mild numbness. There was no open wound, paresthesia nor pallor. He was brought to a “hilot” who tried to manipulate his finger by extending it but afforded no relief. Patient then applied menthol oil (omega painkiller) but also afforded no relief.

• 1 day prior to consult, the patient was brought to Alabang Hospital where x-ray was done and revealed presence of fracture, closed, complete, comminuted, displaced, base of proximal phalanx, 5th finger, left. They were then referred to our institution for management.

• Review of Systems:

• Constitutional: (-) weight loss, (-) loss of appetite, (-) weakness, (-) fever, (-) chills

• Hematologic: (-) abnormal bleeding, (-) easy fatigability, (-) easy bruisability

• CNS: (-) headache, (-) seizures, (-) loss of consciousness• Endocrine: (-) polydipsia, (-) polyuria, (-) polyphagia, (-) heat or cold

intolerance• HEENT: (-) headache, (-) lacrimation, (-) tinnitus, (-) blurring of

vision• Respiratory: (-) cough, (-) sputum production, (-) colds, (-) difficulty

of breathing• CVS: (-) chest pain, (-) orthopnea, (-) easy fatigability, (-)

palpitations, (-) cyanosis• GIT: (-) constipation, (-) nausea, (-) diarrhea, (-) melena, (-) vomiting• GUT: (-) dysuria, (-) urgency, (-) frequency, (-) polyuria, (-)

hematuria• Extremities: (-) edema, (-) weakness, (-) pain• NMS: (-) arthralgia, (-) myalgia, (-) stiffness of joints• Skin: (-) pallor, (-) jaundice, (-) erythema, (-) pruritus

Past Medical History: unremarkable

FAMILY HISTORY:• Father: B.R., 43 years old, construction worker• Mother: A.R., 39 years old, Housewife• Children:

1st: A.R., 15 year-old male, student

2nd: A.T., index patient

3rd: J.R., 8 year-old female, student

The parents and all the other siblings are apparently healthy. Denies any heredofamilial diseases such as hypertension, diabetes, asthma, malignancy, heart, liver, or kidney diseases. Denies any exposure to pulmonary tuberculosis.

PERSONAL and SOCIAL HISTORY:

• The patient is the 2nd child among 3 siblings living together with his mother and father in a bungalow type house, well lit and well ventilated. Drinking water is boiled tap water for 3-5mins. The mother is the primary caregiver. The patient has no vices.

BIRTH AND MATERNAL HISTORY

• Born FT via SVD to G2P1(1001) at lying in clinic

• Breastfed for 1 to 2 mos and bottle fed thereafter

IMMUNIZATION HISTORY

• Complete EPI

DEVELOPMENTAL HISTORY

• At par with age.

• 1st year highschool student with satisfactory grades

NUTRITIONAL HISTORY • No Food Preference

PHYSICAL EXAMINATION• GENERAL SURVEY: awake, coherent, afebrile, not in

cardiorespiratory distress with the ff. vital signs BP: 90/60 mmHg CR: 95 bpm RR: 21 cpm T: 36.5 C

• HEENT: Pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no lymphadenopathy

• LUNGS: Symmetrical chest expansion, clear breath sounds, no crackles, no wheezes

• HEART: Adynamic precordium, normal rate and rhythm, no murmur

• ABDOMEN: Flat, soft, non-tender, normoactive bowel sounds

NEUROLOGIC EXAM:

• Cerebrum: Awake, coherent• Cerebellum: No nystagmus• Cranial Nerves: CN I – not assessed• CN II – 2-3 mm equally reactive to light• CN III, IV, VI – intact extraocular muscles• CN V – (+) corneal reflex• CN VII – no facial asymmetry• CN VIII – not assessed• CN IX, X – can swallow• CN XI – not assessed• CN XII – not assessed

• Motor: 5/5 5/5 sensory: 100% 100% DTRs: ++ ++• 5/5 5/5 100% 100% ++ +

+

• EXTREMITIES:

Inspection Left 5th digit: (+) gross deformity; PIP in flexion(-) swelling, erythema

Palpation FEP, PNB, Left 5th digit: (-)warmth, tenderness

Sensation (-) sensory deficits

Range of Motion

Movement Left

Finger adduction & flexion (+)

Finger abduction and extension

(+), limited extension of left 5th digit

Opposition with thumb (+)

Ulnar Deviation (+)

Radial Deviation (+)

Full range of Motion except extension of the left 5th digit (10 degrees)

Muscle StrengthMuscle Strength (Bilateral)

Wrist flexors 5/5

Wrist Extensors 5/5

Elbow Flexors 5/5

Elbow Extensors 5/5

Shoulder Extensors 5/5

Shoulder Flexors 5/5

Shoulder abductors 5/5

Shoulder adductors 5/5

Assessment

• Hand: Fracture, closed, complete, comminuted, displaced, base of proximal phalanx, 5th finger, left, in malunion

Hand Injuries

• are very common in all sports, especially in ball-playing athletes.

• Most athletic hand injuries are closed hand injuries and include ligamentous injuries, fractures and fracture-dislocations, tendon injuries, and neurovascular problems.

• There is increasing recognition that fractures and dislocations of the hand can result in long-term pain and disability if they are not recognized and treated early.

Proximal Phalanx Fracture

• The mechanism of action usually results from a direct perpendicular force, a rotary force, or hyperextension of the finger.

• Fractures of the proximal phalanx are more common than fractures of the middle phalanges.

• Dorsal or palmar angulation may occur with these fractures, depending on their location.

• Nondisplaced fractures are usually stable and are treated with closed reduction and fixation.

• If significant comminution or segmental bone loss is present, these unstable fractures may require either internal or external fixation.

Proximal Phalanx Fracture

Malunion

• defined as healing of a fracture in an abnormal (nonanatomic) position.

• presents a combined functional and aesthetic problem.

• may result from inadequate treatment or failure of treatment.

• Malunion is the most common bony complication of phalangeal fractures.

Patterns of Malunion Four patterns of deformity are recognized: malrotation, volar angulation, lateral angulation, and shortening.

•Malrotation usually is seen after oblique or spiral fractures of the proximal and middle phalanges. The best method to assess malrotation is to ask the patient to make a fist and look for digital overlap.

•In adults with proximal phalangeal fractures, volar angulation >25-30° may result in pseudoclawing. This deformity makes using the hand awkward and can result in a fixed flexion contracture of the proximal interphalangeal joint. The appearance may be aesthetically unacceptable.

•Lateral angulation and malrotation often occur concomitantly.

•Shortening may occur after a comminuted fracture is allowed to heal in a collapsed fashion or after a long spiral fracture.

Surgical Therapy

The goals of treatment are to restore disordered function and, occasionally, to correct cosmetic deformity.

• The malunion should be studied carefully to understand the original deforming forces.

• A carefully planned osteotomy is necessary and must be executed with the least possible further damage to soft tissues. Techniques of osteotomy must be tailored to the biomechanical requirements for proper realignment of the malunited fracture.

Surgical TherapyImportant principles in the management of malunions are as follows:• Rotational deformities are most disabling yet frequently not appreciated. A

10° rotational malunion results in a 2-cm overlap at the fingertip. Alignment should always be checked with the fingers flexed in the palm.

• An appropriate form of osteotomy and subsequent fixation must be tailored to each individual deformity. Familiarity with osteotomy techniques and alternative forms of fixation affords flexibility in treating deformities.

• The soft tissues must be inspected carefully for scarring, adhesions, and contractures. Careful protection of delicate structures by judicious tenolysis and arthrolysis may be needed at the time of osteotomy.

• Appropriate, functional, postoperative rehabilitation is a must for good results; otherwise, even the best surgery produces suboptimal results.

• Phalangeal osteotomy offers the advantage of correcting the malunion at its site of origin, allows simultaneous correction of angular deformities, and permits concomitant soft-tissue procedures such as tenolysis or capsulotomy.

• Phalangeal osteotomies can be either step-cut or transverse, which are performed with a power saw.

• Step-cut osteotomies are fixed with either small AO (Arbeitsgemeinschaft für Osteosynthese or Association for the Study of Osteosynthesis) screws or K-wires, whereas transverse osteotomies can be held with a plate or with K-wires.

• Volar angulation of 25-35° results in fixed flexion deformity of the proximal interphalangeal joint.

- This requires correction by means of either closed- or open-wedge osteotomy and fixation with K-pins. The open wedge requires a bone graft to fill the gap, whereas the closed wedge may result in shortening of the finger.

• Lateral angulation of phalangeal fractures is corrected in the same manner as volar angulation, by performing osteotomies with a power saw.

•  

• Shortening due to a comminuted fracture that is allowed to heal in a collapsed fashion or that occurs after a long spiral fracture can be corrected with an appropriately fashioned intercalary graft insertion. When a spiral fracture of the phalanx heals in a shortened position with a distal spike on the proximal fragment, blocking flexion of the digit, careful removal of the spike may be all that is required.

• Unreduced condylar fractures extending into the joint require corrective osteotomy, arthrodesis, or arthroplasty.

Outcome

• most phalangeal and metacarpal malunions heal without clinically significant complications.

• Some patients may develop stiffness and decreased mobility.

• Most poor results are documented in elderly patients (>65 y) and in patients with crush injuries or extensive soft-tissue contractures. A combination of these factors increases the risk of compromised results. Proper selection of implants and quick rehabilitation may improve the prognosis.

Plan

• For OSTEOTOMY