Pediatric Orthopedic Conditions Block 5A January 6, 2010

Identifying data MA 6 years old, Female Filipino, Roman Catholic Right handed From Isabela c/c gross deformity of R leg

History of Present Illness DOI: Dec 2006 TOI: 10 AM POI: House, Isabela MOI: Fall

History of Present Illness 4 years PTA (Dec 2006) ◦Patient was then 2 years old, can already maintain balance in running and walking ◦Patient was running in their house when she slipped and fell on a one step approximately half a foot high in a kneeling position ◦Patient was then brought to a hospital in Isabela ◦X-ray of the R foot showed fracture of the Distal third of the Tibia ◦Casting was then done from ankle to above the knee and was maintained for 6 months ◦No traction done ◦Patient was not allowed to walk by parents at this time ◦Cast was then remove with a note of small mass at the site of the fracture

2 years PTA (May 2008)  Patient underwent Intramedullary nailing of the fracture  In the Interim  patient was able to walk, still with R leg shorter than L  Patient’s foot was progressively bending at the site of the fracture with noticeably increased leg length discrepancy  No consults were done due to financial constraints

Review of systems (-) DOB (-) chest pain (-) palpitation (+) occasional aspiration (-) cough, colds (-) fever, malaise, anorexia, (-) edema (-) abdominal pain (-) urinary changes (-) bowel changes

Past Medical History Chicken Pox (sept 2009) “combulsion” at 1 year old described as very high fever, which required hospital admission and was subsequently given unrecalled IV antibiotics (-) bronchial asthma, recurrent fever, coughs colds (-) food and drug allergy (-) PTB

Family Medical History (-) congenital anomaly (+) BA- Father (+) Pulmonary TB- grandfather, completed 6 months of medication Allergy to chicken- younger brother (-) HPN, DM, Ca, Kidney, liver diseases

Personal Social History Grade 1 Eldest of 2 Hobbies include playing with siblings and female playmates

Birth and Maternal History Born FT to a then24 year old mother G1P0 via Ceasarian Delivery secondary to fetopelvic disproportion, pelvimetry was inadequate Regular prenatal check –up c/o OB with no known comorbidities Denies smoking, alcohol intake, drug use Patient was already noticed with leg length discrepancy with no other gross deformities and congenital anomalies (-) FMC

Immunization Completed EPI given at the local health center Developmental History At par with age

Physical Examination Awake, alert, cooperative, ambulatory NICRD, comfortably sitted in bed with obvious gross deformity of the Distal third of the R leg BP 90/60 HR 96 RR 24 Temp afebrile

PHYSICAL EXAMINATION HEENT: no gross deformities, structural congenital anomalies on the head, face and neck, anicteric sclerae, pink palpabral conjunctivae, (-) tonsilopharyngeal congestion (-) cervical lymphadenopathies CHEST & LUNGS: (-) gross deformities, symmetric chest expansion, clear breath sounds (-) wheezes (-) crackles (-) rhonchi

PHYSICAL EXAMINATION CVS: adynamic precordium (-) heaves (-) thrills distinct heart sounds, normal rate, regular rhythm (-) murmurs Abdomen: flat abdomen, normoactive bowel sounds, soft to palpation (-) organomegaly (-) tenderness on deep and light palpation

EXAMINATION OF THE EXTREMITIES Lower extremity, right: ◦Full and equal popliteal, anterior and posterior dorsalis pedis pulses ◦No sensory deficits ◦Pink nail beds on all digits,(-) clubbing, cyanosis ◦(+) scar 5 inches x 1 cm at the site of the operation ◦Attitude of the foot: Distal third of leg is angulated approximately 45 degrees posteriorly

Gross Picture

Radiographs

EXAMINATION OF THE EXTREMITIES LEG LENGTH MEASUREMENT RIGHTLEFT TLL ALL

Assessment