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 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

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

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

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

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

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

Case Presentation Physical Exam

Physical Exam General Survey Vital Signs 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

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

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

Physical Exam Neck no cervical lymphadonapathy supple Chest adynamic precordium 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

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

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

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

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 posteriorly deformed distal forearm bluish discoloration on the anterior wrist (–) external lesions noted

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

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

Post-Operative diagnosis Fracture, closed, complete, transverse, displaced, ulnar styloid, Right Distal radius and ulna styloid fracture, Right