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ORTHOPAEDICS CASE STUDY (CLOSED DISPLACED FRACTURE OF RADIUS )

CLOSED DISPLACED FRACTURE OF RADIUS

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ORTHOPAEDICS CASE STUDY (CLOSED DISPLACED FRACTURE OF RADIUS )

  1. 1. AZIMAH BINTI HASSAN 940507-02-5320 DIPLOMA IN OCCUPATIONAL THERAPY
  2. 2. A bone has closed displaced fracture when it breaks in two or more pieces and is no longer correctly aligned but no open wound in the skin. Typically the cause of the fracture is falling on the outstretched hand or force of impact against the hand Ulna and radius located in the forearm, which in most cases of adult forearm fracture, both bones are broken It can happen near wrist which is at distal end of the bone, middle of forearm or near the elbow which is at proximal of end of bone When radius or ulnar joint fracture occur, it will result in pain, decreased strength, limited range of motion, and loss of forearm function (Americans Academy of Orthopedic Surgeons,2011)
  3. 3. Weeks Goals Early phase: Week 0 - 6 • Reduce swelling - elevation of hand above level of heart - frequent active motion - compressive wrapping/ sleeves of digits • Minimize stiffness - active and passive digit ROM • Support reduced fracture - removable splint to support stable fracture or fracture with internal fixation • Promote ROM - wrist ROM (plate fixation) Middle phase : Week 6 - 8 • Increase motion - ROM (wrist flexion and extension) (radial-ulnar deviation) (forearm pronation-supination) Late phase : Week 8 -12 • Maximize motion • Promote strength - digit and grip - wrist and forearm - elbow, shoulder and scapula ( Brotzman, 2007 ) DISTAL RADIAL FRACTURE MANAGEMENT FOR THE FIRST TWELVE WEEKS
  4. 4. DEMOGRAPHIC DATA Name : Mr A. R Address : Banting, Selangor Age : 23 Years Old Sex : Male Race : Malay Religion : Islam Marital Status : Single Job : General Customer Service at KLIA Date of Onset : 29/04/2014 @ 8.30pm Date of Admission : 29/04/2014 @ 9.17pm Date of referral : 07/05/2014 @ 4.25 pm Dominant Hand : Right Hand Affected Hand : Right Hand Diagnosis : Closed displaced fracture of distal 1/3 of right radius with ulnar styloid process and DRUJ disruption Open comminuted fracture of left midshaft ulna with DRUJ disruption
  5. 5. Alleged MVA at Dengkil on 29/04/2014 @ 8.30pm Patient was riding a motorbike, helmet fastened Claimed was going at a moderate speed when all of a sudden a tractor crossed in front of him Unable to brake, hit the tractor and was thrown off the bike Landed on the left side of the body
  6. 6. No underlying medical problem
  7. 7. Works as a general customer service in KLIA Has worked for 5 years Shift work from 6.30am to 2.30pm and 1.00pm to 9.00pm. 2 days off on weekend Go to the workplace by motorcycle
  8. 8. Social smoker Enjoys spending time playing futsal with his friends during free time Always go to the gym during weekend (lifting dumbbells and bars)
  9. 9. FAMILY HISTORY  +  57 y/o 47 y/o          26 y/o 25 y/o (pt 23y/o ) 22y/o 20y/o 18y/o 14y/o 9y/o 7y/o Patient is single He is the third son of 9 siblings 4 of his siblings has worked meanwhile the others still study His father is a government officer while his mother is a housewife No other medical illness
  10. 10. ASSESSMENT Subjective and objective assessment are based on observation and interview that was done through observation on 7 May 2014 at OT department. SUBJECTIVE ASSESSMENT (7 May 2014) Patient wore hospital’s cloth Patient looked neat and tidy His right hand was bandaged Patient can co-operate during the session and answer all question asked Patient had edema at fingers of both hands Patient complained of pain at right forearm during supination.
  11. 11. Occupational Performance Area Assessments ADL Modified Barthel Index Work Role Checklist Leisure Interest Checklist Occupational Performance Component Assessments Sensory • Light touch • 2 - point discrimination • Pain Semmes-Weinstein Monofilaments Test 2 – Point Discriminator Visual Analog Scale (VAS) Neuromuscular • Range of Motion (ROM) • Muscle strength Upper Extremity Hand ROM and Wrist Chart Manual Muscle Testing (MMT) Psychological Depression Anxiety Stress Scales (DASS) Psychosocial Interview and observation OBJECTIVE ASSESSMENT (7 May 2014)
  12. 12. Activity Criteria Initial assessment Personal hygiene Unable to perform the task (0) Substantial help required (1) Moderate help required (3) Minimal help required (4) Fully independent (5) 4 Bathing 4 Feeding Unable to perform the task (0) Substantial help required (2) Moderate help required (5) Minimal help required (8) Fully independent (10) 10 Toilet 10 Stair climbing 10 Dressing 10 Bowel control 10 Bladder control 10 Chair/bed transfer Unable to perform the task (0) Substantial help required (3) Moderate help required (8) Minimal help required (12) Fully independent (15) 15 Ambulation 15 Total 98/100 Activity of Daily Living (ADL) by using MBI (Modified Barthel Index) on 7 May 2014
  13. 13. Minimal dependency level Total hours of help required per week is less than 10 hours In personal hygiene (clipping nails), patient has difficulty to clip and takes a long time to finish it due to poor pinch strength of right fingers In bathing, patient has difficulty to rub his back during soaping due to limited supination of right forearm
  14. 14. ii) . Work (through observation and Role Checklist on 7 May 2014) Before injury patient works as a general customer service His jobs are answering call and inserting data entry in which speed typing is necessary According to Role Checklist, patient still want continue to work after getting accident Role Past Present Future Student √ Worker √ √ √ Volunteer √ Caregiver √ Home maintainer Friend √ √ √ Family member √ √ √ Religious participant √ Hobbyist √ √ √ Participant in organization √ √
  15. 15. iii) . Leisure (through interview and Interest Checklist on 7 May 2014) According to Interest Checklist, patient still interested to involve in: carrying out exercise at gym; he always perform workout by lifting dumbbells and bars playing futsal with his friends during free time
  16. 16. Color Monofilament size Force in grams (g) Cutaneous Sensory Perception Green 2.83 0.07 Normal light touch Blue 3.61 0.2 Diminished light touch Purple / pink 4.31 2.0 Diminished protective sensation Red 4.56 4.0 Loss of protective sensation Orange 6.65 200 Untestable OCCUPATIONAL PERFORMANCE COMPONENT (OPC)
  17. 17. I. SENSORY (7 May 2014) Light Touch (Assessed by using Semmes-Weinstein Monofilaments Test) 2-Point Discrimination (Assessed by using 2-Point Discriminator Disc) Right hand : 2 – 6 mm (normal) Left hand : 2 – 6 mm (normal) Pain (Assessed by using Visual Analog Numerical Scale (VAS) - patient marks score 5/10 during rest at right forearm - patient marks score 8/10 during supination at right forearm Ulnar nerve Median nerve Radial nerve Right hand • Palmar • Dorsal 2.83 2.83 2.83 3.61 2.83 3.61 Left hand • Palmar • Dorsal) 2.83 2.83 2.83 2.83 2.83 2.83
  18. 18. NEUROMUSCULOSKELETAL (7 May 2014) Range of Motion Assess by using Upper Extremity Hand ROM and Wrist Chart Wrist Normal ( 0) Right ( 0) Left ( 0) Right ( 0) Left ( 0) Flexion 0 – 80 0 – 70 0 - 75 FROM FROM Extension 0 – 70 0 – 70 0 - 70 FROM FROM Ulnar deviation 0 – 30 5 - 25 0 - 25 FROM FROM Radial deviation 0 – 20 0 – 20 0 - 20 FROM FROM Elbow Normal (0) Right ( 0) Left ( 0) Right ( 0) Left ( 0) Flexion 0 – 150 0 – 140 0 – 145 FROM FROM AROM PROM AROM PROM
  19. 19. Finger Normal (0 ) Right ( 0 ) Left ( 0 ) Right ( 0 ) Left ( 0 ) Thumb MCP 0-50 0-40 0-45 FROM FROM DIP 0-90 0-60 0-90 FROM FROM Index MCP 0-90 0-60 0-75 FROM FROM PIP 0-110 0-95 0-110 FROM FROM DIP 0-80 0-50 0-70 FROM FROM Middle MCP 0-90 0-35 0-80 FROM FROM PIP 0-110 0-90 0-100 FROM FROM DIP 0-80 0-60 0-70 FROM FROM Ring MCP 0-90 0-30 0-80 FROM FROM PIP 0-110 0-90 0-105 FROM FROM DIP 0-80 0-55 0-65 FROM FROM Little MCP 0-90 0-70 0-80 FROM FROM PIP 0-110 0-90 0-100 FROM FROM DIP 0-80 0-60 0-65 FROM FROM AROM PROM
  20. 20. Has limited supination (35 degrees) at forearm of right UL due to immobilization and pain. Has slight ulnar deviation (5 degrees) at wrist of right UL . Has limited flexion of right fingers.
  21. 21. RIGHT HAND (cm) LEFT HAND (cm) Palmar crease 20.5 19.5 Thumb MCP 6.5 5.8 Thumb DIP 6.0 5.5 Index MCP 6.2 5.6 Index PIP 5.2 4.5 Middle MCP 6.2 5.4 Middle PIP 5.0 4.7 Ring MCP 6.0 5.2 Ring PIP 4.8 4.5 Little MCP 4.8 4.7 Little PIP 4.0 3.8
  22. 22. Location Flexion Extension Upper limb Score Score Elbow 5/5 5/5 Wrist 5/5 4/5 Fingers 4/5 4 /5
  23. 23. PSYCHOLOGICAL FUNCTION (through interview and DASS assessment) on 7 May 2014 INTRA – PERSONAL Patient is motivated Patient able to accept his condition and follow all the treatment given for full recovery. Patient has initiative to continue the treatment. Patient able to cope with pain. INTER – PERSONAL Patient is cooperative. Patient is able to follow the instruction well. Marks Interpretation Stress 1 Normal Anxiety 0 Normal Depression 2 Normal
  24. 24. PSYCHOSOCIAL FUNCTION (through interview on 7 May 2014) Patient has good relationship with family members. Patient has many friends and always spend time together during weekend. Patient can cooperate well with colleagues. Patient able to socialize in the community well.
  25. 25. Patient has good moral support from his family Patient is compliance and motivated to treatment Patient does not has financial problem Patient can follow the instruction well Patient has good communication skill with others
  26. 26. a) Occupational performance area (OPA) 1. Has difficulty to perform in ADL In personal hygiene (cutting nails), patient has difficulty to cut nails and takes a long time to finish it due to poor strength of right fingers In bathing, patient has difficulty to wash his back during soaping due to limited supination of right forearm 2. Has difficulty to perform in major work tasks (takes time for typing) due to poor pinch strength and dexterity of right fingers 3. Unable to perform in previous leisure activity (lifting dumbbells and bars ) b) Occupational performance component(OPC) 1) Has edema at both hand 2) Has pain at right forearm 3) Has deformity at right hand (slight ulnar deviation) 4) Has limited ROM at all fingers of right hand
  27. 27. Short term goal To reduce edema at both hand To reduce pain at right forearm To improve ROM, strength, dexterity at all fingers of right hand To correct deformities (ulnar deviation at right hand) Long term goal To enable patient to return in ADL independently (personal hygiene, bathing) To enable patient to return to work independently (fully participate in company administration and tasks) To enable patient to return in leisure activity (lifting dumbbells and bars )
  28. 28. Biomechanical FOR • The approach is focused on addressing basic client factor to improve occupational performance. Intervention is in the form of exercises, splinting or orthopedic approach in which the outcome must reflect engagement in occupation. (Pedretti, 2006) In this case, biomechanical approach is use to ensure patient get maximum level of functioning of right upper limb in order to enable patient performing activity daily living as usual. Rehabilitation FOR • The approach is focused on client ability to return the fullest physical, mental, social, vocational and economic functioning as is possible. (Pedretti , 2006) • Treatment are focused on avoiding and reducing impairment of the effected hand by using adaptation and give purposeful, meaningful activity to the patient.
  29. 29. Problem 1 Edema at both hands Aim To reduce edema at both hands Intervention Technique / Modalities Elevation technique Method 1. Putting the affected hand above level of heart so gravity help move interstitial fluid back toward heart. 2. Resting the hand on pillows while sitting or lying down Duration • Elevate the injured site for 10 – 15 minutes and perform it 3 – 4 times per day • Elevation performs during sleep and daytime for recovery and rehabilitation process. (Griffith, 2006) Grading Continuously until the edema has subsided Precaution • Prevent sleeping on injured site . • If sling is used, try not to use for long periods of time to prevent shoulder stiffness.
  30. 30. Problem 2 Pain at right forearm Aim To reduce pain at right forearm Intervention Technique / Modalities Pain management through deep breathing and physical agent modality (PAM) Method - Deep breathing 1. This treatment must be in a quiet and patient must be in comfortable position. 2. Ask patient to slowly inhale through nose while counting to 4 seconds. 3. Patient required to hold their breath while counting to 4 seconds. 4. Exhale through mouth while counting to 7 seconds. 5. Repeat the steps until patient feel relax and easy. - Physical agent modality (Cold therapy) 1. Apply ice at the effected side 10 to 20 minutes, several times per day. 2. Check skin frequently for sensation to prevent tissue damage 3. Stop apply if lose feeling in the skin where you are applying it Rationale Deep breathing reduces pain by having a direct effect on the sympathetic nervous system - fibres in the central nervous system which help to control blood flow and skin temperature. (Downey and Zun, 2009) Cold therapy has strong short – term analgesic effect in many painful condition, particularly those related to the musculoskeletal system. (Ernst and Fialka, 1994)
  31. 31. Problem 3 Deformity at right hand (slight ulnar deviation at 5 degrees) Aim To correct deformity at right hand (slight ulnar deviation) Intervention Technique / Modalities Splinting Method 1. Fabricate a resting splint followed by active use. 2. Educate wearing regime and splint care. 3. Splint review for every appointment. 4. Wear it during daytime rest periods and overnight. 5. Put splint for 2 hours then remove it and check the skin for reddened pressure area Precaution • Do not leave splint where it is exposed to temperature above 60 degrees as this will alter its shape • Remove splint when it causes any problems: - An area of pressure such as sores, swelling, excessive stiffness, pain, blisters Rationale Resting splints help prevent a hand deformity which are needed until the bone is healed, typically around 4 weeks. (Aubrey, 2014) Grading Continuously wear until the deformity has corrected
  32. 32. Problem 4 Has limited ROM, poor strength and endurance of all fingers of right hand Aim To improve ROM, strength and endurance of all fingers of right hand Intervention Technique / Modalities 1) Passive stretching 2) Strengthening activity (theraputty) Method • Passive stretching - Each stretch should be held 15 - 30 seconds and repeated 2 to 4 times (Wilson ,Hornbuckle and Kim et al. , 2010) • Strengthening activity (theraputty) Flexion - Place the putty at the base of the fingers - Squeeze with fingertips while keeping the palm of the hand open - After the fingers have pressed into the putty, fold over and repeat Extension - Roll putty back and forth, being sure to use all fingertips ( Killingworth and Pedretti , 2006) Rationale In order to improve ROM and strength, forceful exercise is necessary to use which is there has some type of force that was used to body part when soft tissue is either near on the available length (Pendelton & Schultz-Krohn,2006) Grading Theraputty (from soft to hard texture)
  33. 33. Problem 5 Has difficulty to perform in ADL • Difficulty in personal hygiene (cutting nails), takes a long time to finish it due to poor pinch strength of right fingers • Difficulty in bathing (brushing back of body) during soaping due to limited supination of right forearm Aim To enable patient to return in ADL independently • personal hygiene (enable to clip nails, maintain hygiene independently) • bathing (brushing back of body) Intervention Technique / Modalities Compensatory technique by using adaptive equipment Method • Use long – handled sponge as adaptive bathing aids to brush back of body during soaping • Use large grip nail clippers for comfortable handling Precaution Ensure the equipment is safe to use
  34. 34. Problem 6 Has difficulty to perform in work (major task; takes time for typing) Aim To enable patient to return to work independently (fully participate in company administration and tasks) Intervention Technique / Modalities Functional activity (computer typing) Method Sitting with good posture to stay comfortable and focus on better typing and speed Ensure the keyboard is at a comfortable height Keep the wrist elevated to ensure equal height with the keyboard Typing with both hands Precaution Avoid prolonged typing to prevent additional stress on shoulder and neck Use arm rest while typing to prevent compression at wrist Grading Increase total number of words and characters per minute Increase time
  35. 35. Subjective Assessment Done on 23 May 2014 Patient come to the department alone with properly attired and neat Looks more energetic than previous appointment
  36. 36. Activity Criteria Initial assessment Personal hygiene Unable to perform the task (0) Substantial help required (1) Moderate help required (3) Minimal help required (4) Fully independent (5) 5 Bathing 5 Feeding Unable to perform the task (0) Substantial help required (2) Moderate help required (5) Minimal help required (8) Fully independent (10) 10 Toilet 10 Stair climbing 10 Dressing 10 Bowel control 10 Bladder control 10 Chair/bed transfer Unable to perform the task (0) Substantial help required (3) Moderate help required (8) Minimal help required (12) Fully independent (15) 15 Ambulation 15 Total 100/100 Activity of Daily Living (ADL) by using MBI (Modified Barthel Index) on 23 May 2014
  37. 37. OCCUPATIONAL PERFORMANCE COMPONENT (OPC) I. SENSORY (23 May 2014) Light Touch (Reassessed by using Semmes-Weinstein Monofilaments Test) 2-Point Discrimination (Reassessed by using 2-Point Discriminator Disc) Right hand : 2 – 6 mm (normal) Left hand : 2 – 6 mm (normal) Pain (Reassessed by using Visual Analog Numerical Scale (VAS) - patient marks score 1/10 during rest at right forearm - patient marks score 4/10 during supination at right forearm Ulnar nerve Median nerve Radial nerve Right hand • Palmar • Dorsal 2.83 2.83 2.83 2.83 2.83 2.83 Left hand • Palmar • Dorsal) 2.83 2.83 2.83 2.83 2.83 2.83
  38. 38. NEUROMUSCULOSKELETAL (23 May 2014) Range of Motion Assess by using Upper Extremity Hand ROM and Wrist Chart Wrist Normal ( 0) Right ( 0) Left ( 0) Right ( 0) Left ( 0) Flexion 0 – 80 0 - 75 0 - 75 FROM FROM Extension 0 – 70 0 – 70 0 - 70 FROM FROM Ulnar deviation 0 – 30 0 - 30 0 - 25 FROM FROM Radial deviation 0 – 20 0 - 20 0 - 20 FROM FROM Elbow Normal (0) Right ( 0) Left ( 0) Right ( 0) Left ( 0) Flexion 0 – 150 0 - 140 0 - 140 FROM FROM AROM PROM AROM PROM
  39. 39. Finger Normal (0 ) Right ( 0 ) Left ( 0 ) Right ( 0 ) Left ( 0 ) Thumb MCP 0-50 0-50 0-50 FROM FROM DIP 0-90 0-70 0-90 FROM FROM Index MCP 0-90 0-70 0-85 FROM FROM PIP 0-110 0-105 0-110 FROM FROM DIP 0-80 0-70 0-70 FROM FROM Middle MCP 0-90 0-85 0-80 FROM FROM PIP 0-110 0-110 0-110 FROM FROM DIP 0-80 0-80 0-80 FROM FROM Ring MCP 0-90 0-90 0-80 FROM FROM PIP 0-110 0-105 0-105 FROM FROM DIP 0-80 0-75 0-80 FROM FROM Little MCP 0-90 0-90 0-85 FROM FROM PIP 0-110 0-110 0-105 FROM FROM DIP 0-80 0-80 0-80 FROM FROM AROM PROM
  40. 40. RIGHT HAND (cm) LEFT HAND (cm) Palm 19.6 19.3 Thumb MCP 5.9 5.6 Thumb DIP 4.9 5.5 Index MCP 5.5 5.3 Index PIP 4.9 4.5 Middle MCP 5.6 5.2 Middle PIP 5.0 4.6 Ring MCP 5.3 5.2 Ring PIP 4.5 4.5 Little MCP 4.8 4.5 Little PIP 4.0 3.8
  41. 41. Strengthening activity for upper extremity at right hand (wrist and forearm) Hand function training Work training (computer typing)
  42. 42. Medical Base on doctor review, patient prognosis is good where patient condition is not degenerate Rehabilitation Base on Occupational Therapy (OT) aspect, patient prognosis is good where:  Patient shows improvement in ROM and strength at right hand.  Patient is compliance with the appointment of treatment.  Patient is motivated to perform passive and active exercise at home.
  43. 43. Downey, L.V. , Zun, L. S. The effects of deep breathing training on pain management in the emergency department. South Med J. 2009 Jul;102(7):688-92. Ernst , E. & Fialka, V. (1994). J Pain Symptom Manage, Jan; 9(1): 56 – 9 . Griffith, H.W. , MD “Complete Guide to Symptoms, Illness & Surgery ” (The Berkeley Publishing Group, 2006)8 Killingworth, A.D. & Pedretti, L.W. (2006) Chapter 21. Evaluation of muscle strength. In. H.M. Pendleton & W. Schultz-Krohn (eds). Pedretti’s Occupational therapy: Practice skills for physical dysfunction (6th ed. pp. 469-512). St. Louis: Mosby, Inc Manual Muscle Testing (MMT). (2010) PST Exercise in SMA. Retrieved from October 24, 2013 from https://crcjs.med.utah.edu/sma_fitness/pdfs/manualmuslce_tests_upper_lower_PST.pdf Pendleton H. M., and Schultz-Krohn W. (2005) Pedreeti’s Occupational Therapy Practice Skills For Physical Dysfunction 6th Edition. Mosby Elsevier.
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