1. Cecilia Lim Hipolito Neil Illescas CASE OF CHRONIC HIP DISLOCATION

2. PATIENT PROFILE Patient is K. R 8 years old male Right handed male Roman Catholic Grade 2 109 Luta Sur, Malvar, Batangas CC: Right hip deformity/ limping

3. HISTORY OF PRESENT ILLNESS Patient has no known co-morbids and with full and in good functioning capacity until... DOI: Oct, 2009 (3 rd week) TOI: 2 pm POI: School in Batangas

4. MOI: While the grade 6 students were playing volleyball, patient tried to get to the ball. Unfortunately, a 40 kg player, also trying to get the ball, collided into him, hitting him at the right side while on all fours; accidentally toppling him. There was noted to have deformity after the accident accompanied by limp and leg shortening. (-) LOC, (-) nausea, vomiting. (-) bleeding. (+) pain ~4/10, nonradiating, dull (pain on movement).

5. Patient was then carried home where he was brought to a local albularyo, with no relief of symptoms. There were no medications taken, and no consult at a medical institution. Patient’s pain gradually dissappeared (2-3 weeks). During this time, patient was able to walk in a limp,able to do all his ADLs without assistance.

6. 1 ½ months PTA, a free medical mission conducted by a private clinic was conducted at their hometown. Xray showed: hip dislocation of the R. No other lab tests done, no medications taken. He was then refered to PGH for further management. 1 month PTA, patient consulted at the ER, and was subsequently admitted.

7. REVIEW OF SYSTEMS (-) Headache (-) nausea, vomiting (-) fever (-) weakness, malaise (-) chest pain (-) abdominal pain (-) change in bowel and urinary habits (+) mild hip pain of R while in traction.

8. PAST MEDICAL HISTORY No known illnesses No known allergy to food and medications No previous surgeries and hospitalizations

9. FAMILY MEDICAL HISTORY (+) DM – grandfather (+) goiter – grandmother (-) HTN, PTB, Asthma, Cancer

10. PERSONAL/SOCIAL HISTORY Patient is born FT to a then G2P1(0100) mother via SVD in a house c/o midwife. No fetomaternal complications. Patient’s development is at par with age. Patient started schooling at age 6, and is currently in grade 2 at age 8. Patient is an active child, with hobbies including playing and watching TV.

11. Patient lives in a 1 storey, ~ 40 sqm house in Batangas with his parents and 2 siblings (3 and 1 yr old). The restroom is located around 2 m away from the bedroom; transportation arpund 5 m away from the house; and school around ___m away from house. Patients mother is a housewife, and his father is a bus driver.Family income is about 500-3000/month. Currently, patient’s medical bills were paid from money borrowed from relatives.

12. Immunization Complete EPI from the local health center.

13. Nutrition Patient likes to eat fruits, meat, and junkfood.

14. FUNCTIONAL HISTORY Self-care Pre- morbidity Post- morbidity At Present Eating777 Grooming777 Bathing777 Dressing – Upper Body777 Dressing – Lower Body777 Toileting777

15. Sphincter Control Pre- Morbidity Post- morbidity At Present Bladder Management777 Bowel Management777 Transfers Bed/Chair/Wheelchair767 Toilet777 Tub/Shower777

16. Locomotion Pre- Morbidity Post- morbidity At Present Walk/Wheelchair767 Stairs767 Communication Comprehension777 Expression777 Social Social Interaction777 Cognitive Function Problem Solving777 Memory777

17. GENERAL SURVEY Patient was received awake, conversant and speaking in sentences, Not in cardio-respiratory distress, oriented to 3 spheres, GCS 15 VITAL SIGNS BP:100/80 HR: 98 RR: 20 T: Afebrile to touch

18. HEENT Anicteric sclerae, pale palpebral conjunctivae, (-) nasal or aural discharges, pale buccal mucosa and tongue, pale lips, (-) tonsillopharyngeal congestion (-) anterior neck mass (-) neck vein engorgement. CHEST /LUNGS (-) gross deformities symmetric chest expansion, clear breath sounds (-) crackles (-) wheezes (-) ronchi

19. CVS (-) heaves, (-) thrills, distinct heart sounds, normal rate, regular rhythm ABDOMEN Flabby abdomen, normactive bowel sounds, soft to palpation, (-) masses (-) tenderness (-) organomegaly

20. SKIN and EXTREMITIES Full and equal pulses, pale nail beds, good capillary refill (-) edema (-) cyanosis (-) clubbing. PE on admission: R lower extermity attitude internal rotation; shortened ~ 4 cm, no sensory deficits Limitation motion of the R hip due to pain (minimal) Palpable bony deformity of R hip Galleazi sign

21. Currently Patient’s R leg on Pin traction, L leg on foam traction. Leg length of L, ___, of R ____.

22. NEUROLOGIC EXAMINATION Patient is awake, coherent, oriented to three spheres, and follows commands. CN I: intact smell II: pupils 3-3mm EBRTL, (+) visual threat; (-) visual field cuts III, IV, VI: full intact EOMs V: brisk corneals, V1 V2 and V3 sensation intact on both sides. Good masseter tone and temporalis. VII: (-) facial asymmetry VIII: intact gross hearing IX, X: Good gag reflex. XI: good shoulder shrug XII: tongue midline Cerebellars: No nystagmus, dysmetria and dysdiadochokinesia; Meningeal Examination: (-) Brudzinski’s, (-) kernig’s

23. Deep Tendon Reflexes DEEP TENDON REFLEXES RightLeft C5, C6Biceps2+ C5, C6Brachioradialis2+ C7, C8Triceps2+ L3, L4 Quadriceps (knee jerk) NT SI, S2Triceps SuraeNT Babinski(-) ClonusNT

24. MANUAL MOTOR TESTING RightLeft C5Elbow flexors55 C6Wrist extensors55 C7Elbow extensors55 C8Finger flexors 55 T1Finger abductors 55 L2Hip flexorsNT L3Knee extensorsNT L4Ankle dorsiflexorsNT L5Long toe extensorsNT S1 Ankle plantar flexors NT Total

25. RANGE OF MOTION ROMACTIVEPASSIVE Neck RLRL Extension (0-45) 0-45 Lateral Rotation (0-60) 0-60 Lateral Bending (0-45) 0-45

26. Shoulder Flexion (0-180) 0-180 Extension (0-60) 0-60 Abduction (0-180) 0-1100-120 Internal Rotation (0-90) 0-90 External Rotation (0-90) 0-90

27. Elbow Flexion (0-150) 0-150 Extension (150-0) 150-0 Forear m Pronation (0-90) 0-90 Supination (0-90) 0-90

28. Wrist Flexion (0-80) 0-80 Extension (0-70) 0-70 Radial Deviation (0-20) 0-20 Ulnar Deviation (0-30) 0-30

29. PIPFlexion good Good DIPFlexion Goodgood FingersAbduction (0-20)0-20 Adduction (0-20)0-20 Flexion (0-150)0-150 Extension (0-45) 0-45

30. SENSORY:Pain & light touch RIGHTLEFT C2-C622 C7-T3 22 T4-T12 22 L1-L5 2 NT S1-S5 2 NT

31. XRAY RESULTS Superiorly and posteriorly dislocated, R hips. No acetabular change.

32. LABORATORY RESULTS DATETESTRESULT/INTERPRETAT ION Dec 16, 2009ESR25 Dec 16, 2009CRP< 6 : same as reference value Dec 18, 2009GS of pus PMN 0-1, no org seen Dec 15, 2009PT13.1/12.3/1.0/1.18

33. LABORATORY RESULTS DATETESTRESULT/INTERPRETAT ION Dec 15, 2009PTT33.6/40 Dec 14, 2009BUN2.65 Crea48 (low) Na140 K4.1 Cl103 Dec 15, 2009BTO+

34. LABORATORY RESULTS DATETESTRESULT/INTERPRETAT ION Dec 14, 2009UrinalysisYellow, slightly hazy, sp g 1.030, CHO (-), CHON (- ). Rbc, wbc, epi cells, bact, mt, cast, crystals = negative.

35. ASSESSMENT Chronic Hip Dislocation, R secondary to trauma

36. PLAN OF ORTHO DEPARTMENT Skeletal traction, increase in weight for 2 weeks. If failed after maximum weight ~10 kg, would consider OR, possible fixation hip spica?

37. COURSE IN THE WARDS DATEWhat was done Dec 14, 09Patient admitted. Xrays requested: B hips AP, XTL B. Labs requested: CBC, BT, Pt/PTT, UA, BUN, crea, Na, K, Cl, CXR PAL,ESR, CRP. planned to start traction Dec 18, 09 Ketorolac (18-22) Cloxacillim (18-22) s/p application of skeletal traction of R femur/GA. Started onkg on Dec 20. Dec 26, 096 kg weight applied

38. COURSE IN THE WARDS DATEWhat was done Dec 28, 2009 Ibuprofen 200 mg/5 ml, 5 ml q 8. Repeat Xray: femoral head hinging on superior shoulder of acetabulum. 9 kg weight applied; abduct R LE. Dec 30, 2009Traction maintained Jan 07, 2009For repeat xray