Case Presentation for the Orthopedic Department Rotation in the Philippine Orthopedic Center.

1. Katrina C. Morales
MD 10-0045
May 25, 2013
ORTHO ROTATION CASE PRESENTATION

2. IDENTIFYING DATA
• JD is a 7 year old male, Filipino, Catholic, from North Fairview Quezon City who went to
the Philippine Orthopedic Center – Emergency Room last May 23, 2013.
• The source of information is CD, the patient’s mother, with good reliability.
SOURCE AND RELIABILITY

3. CHIEF COMPLAINT
• Patient came in for pain in the forearm, right
• Two hours prior to consult, patient was attempting to climb up the slide in the playground
when he was pushed and he fell on his right forearm. The height at which he fell and the
positioning of the arm (whether it was angulated or not) were unrecalled. The pain as well
as the observed gross deformity of the patient’s right forearm prompted the consult.
HISTORY OF PRESENT ILLNESS

4. REVIEW OF SYSTEMS
• Nothing pertinent
• No previous illnesses, such as asthma, allergic rhinitis, known allergies to food and
medicines, as well as previous forms of similar injuries
• No prior hospitalizations and surgeries done
• No medications used for maintenance and the like
• Patient is the youngest of 2 siblings
• No known illnesses in the family, as well as in the paternal and maternal side
PAST MEDICAL HISTORY
FAMILY HISTORY

5. IMMUNIZATION HISTORY
• It was claimed that the patient had complete immunizations from the barangay health
center
• Patient was exclusively breastfed at the early months from birth and was then mixed-fed
• Developmentally at par with age.
• Currently, patient is more involved in doing physical activities (playing on the slides is his
favorite)
NUTRITIONAL HISTORY
DEVELOPMENTAL HISTORY

6. PHYSICAL EXAMINATION
• (+) open wound (~1.5cm), proximal third of the forearm, right
• (+) gross deformity, proximal third of the forearm, right
• (+) tenderness, shoulder and elbow, right
• (+) difficulty in movement of the shoulder and elbow, right
• (+) movement of all digits, right
• *Wrist, right not moved due to pain

7. ASSESSMENT
• Problem list:
• Possible open fracture of the forearm, right  gross deformity and open wound
• Possible fracture of the shoulder, elbow and wrist, right tenderness, difficulty in
movement
• Diagnostic Procedures:
• Right, shoulder AP
• Right, elbow APL
• Right, forearm with wrist APL
• Laboratory:
• Wound gram staining, right forearm

13. X-RAY FINDINGS
• Fracture, complete, oblique, displaced shortened, proximal 3rd of the ulna, right
• Radial head displaced
• Fracture, open (GustiloType 2), complete, oblique, displaced shortned, proximal 3rd of the
ulna, right with radial head displacement  Montaggia Fracture Dislocation
COMPLETE CLINICAL ASSESSMENT

14. DIFFERENTIAL DIAGNOSIS
Rule In Rule Out
Galeazzi Fracture
Dislocation
Pain and swelling of the forearm
Forearm rotation is painful
Wrist has pain but no swelling
No fracture on the radial shaft in
x-ray
Ulnar Shaft Fracture Generally obvious gross deformity
Minimal soft tissue involvement
X-ray shows cortical breaks on the
ulnar shaft
Caused by direct blows to the
ulna
Radius and Ulnar Shaft
Fracture
Common in pediatrics
Often have open fractures
-/+ nerve involvement
No cortical breaks on the radius
on x-ray

15. MONTEGGIA FRACTURE DISLOCATION TYPE 1
• It is a fracture of the middle or proximal third of the ulna with anterior dislocation of the
radial head and characteristic apex anterior angulation of the ulna
• It is the most common of all types, occurring about 60% of the time
• Monteggia fractures are primarily associated with falls on an outstretched hand with
forced pronation.
ADDITIONAL EXAMINATION:
• Attempt to palpate radial head (anterior, posterior, or lateral)
• Posterior Interosseous Nerve palsy is most common in Type I fracture and may occur in a
delayed fashion if the radial head is not promptly reduced

16. Interosseous Membrane 
STRESS CAUSING
ULNAR FRACTURE!!!
Capitulum ------------------------------------

17. Interosseous Membrane 
STRESS CAUSING
ULNAR FRACTURE!!!
Capitulum --------------------------

18. MANAGEMENT
• For children, immobilization in flexion and supination are needed. The elbow should be
flexed more than 90 degrees to relax the biceps.
• Internal fixation (use of plates and screws) of the ulnar fracture and reduction of the radial
head are needed.
REDUCTION
• The radial head dislocation should be reduced emergently. Closed reduction under
sedation should be performed within 6-8 hours of the injury.
• Delay in reduction of the radius may lead to permanent articular damage, further nerve
injury, or both.
An open fracture requires emergent operative intervention. In closed injuries, once the radial
head is reduced, the forearm is splinted and operative fixation of the ulna fracture may be
carried out in an elective fashion.

19. MEDICAL MANAGEMENT
• Antibiotics should be given since there is an open wound
• Co-amoxiclav 31.25mg/5ml (oral suspension), 10ml three times a day for 7 days
• Ibuprofen should also be given to manage the pain
• Ibuprofen 200mg, three times a day as needed
CONSIDERATIONS FOR PATIENTS
• Neurovascular examination is important
• Nerve injury, involving the Posterior Interosseous Nerve is not uncommon
• Watch for compartment syndrome

20. POSSIBLE COMPLICATIONS
• Non union of fracture of ulnar shaft
• Radiohumeral ankylosis
• Radioulnar synostosis
• Recurrent radial head dislocation
• Myositis ossificans
PREVENTION
• Advise the parents to monitor the child in terms of the activities that he would be
doing, especially those involving heights (patient loves playing on the slide)
• The situation should be explained to the child, specifically the part about how it happened
so that he would be able to avoid unnecessary activities that might lead him to the same
dangers
• Wearing of protective gear when playing is advised

21. CLINICAL COURSE/ PROGNOSIS
• The patient arrived in good condition and was responsive to all the initial examinations
conducted.
• It is possible to have difficulty in movement after treatment and so rehabilitation is
recommended.
• Overall, it is expected that the patient has good prognosis.
CONTEXTUAL ANALYSIS
• Important to note that the patient’s condition would cost a lot to the family, and therefore
the proper financial adjustments should be made by the family, particularly the father who
is the breadwinner of the family. The caregiver, which is the mother, would need to be
supported because of the additional tasks she must do.
• The patient is a child and would be concerned with playing, which would be temporarily
limited due to his condition. Adjustments in terms of this should be done. Also, school is
about to begin, so the child must be able to get used to the initial limitations that he would
have and continue on with the rehabilitative activities that he must do to regain them
back.