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Handcasestudy2chcecked

Handcasestudy2chcecked

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Published by: superhoofy7186 on Feb 03, 2009
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06/14/2009

 
Hand Case Study 2: Boxers Fracture
James Anderson is a 20 year old apprentice plumber who has been experiencing painin his right hand for 2 months since he sustained a fracture to the 5
th
Metatarsal shaftfollowing a punch injury. This was fixed internally with a plate and screws. He isnow noticing wasting of the muscles around the thenar and hypothenar eminence andhas decreased grip strength and limited MCP and IP movement of the 3
rd
and 4
th
digits. He is currently off work but needs to grip for prolonged periods but the painand lack of grip makes it difficult to return to work. He lives with his parents andteenage brother in a 3-bed house.
Anatomy & Pathology
Boxer’s fracture – punching something hard – end of metacarpal takes the brunt – usually breaks at narrower end near the endThe ulnar nerve is shared by 3/4/5/ digitsHypothenar area ->means around ulnaThenar area ->means around thumbTendons in extension and flexion are shared by digits – see insertion for extensor digitorum and extensor digitorum
Subjective Examination
Where\What:
Fracture at 5
th
metatarsal, pain & lacks grip - muscle wastage around3
rd
and 4
th
digits – ask where is pain – expect it to be around the fracture point
When
: 2 months ago – expect stiffness, muscle wastage from splint
How
: punching
0-10 rating
: decreasing
24-hour cycle
: expect no real change
Better for
: rest
Worse for
: picking things up
Type of pain
: deep pain relates to bone – sharp pain to OA of joint – ask what type of  pain they are experiencing – stiffness and weakness would be an uncomplicatedexpectation
Past Medical History/ General History
: nil, ask about osteoporosis, bone diseaseand previous fractures
 
Red Flags and general concerns
: nerve lesion – pins and needlesMalunion/non-union – joint not healedPost traumatic arthritis – crepitus 
SH
: parents and brothers in 3-bed house
DH
: nil ask ?
Patient’s main outcome
: grip and return to work?
Objective Examination
Working Hypothesis
: examine rule out nerve lesion, non/malunion &arthritis
Advice & Consent
: give and obtain
General Observations
: watch walking, how use hand if possible – canoffer to gently shake hand.
Acute Observations
:Skin colour – check for remaining bruisingSwelling – check PositiveMuscle bulk Deformity – broken bone or knuckle misaligned with affected finger – ask if at break the finger head had rotated to thumb – can be a permanent bend if knuckle badlyhealed => this can affect other tendons.
Active Tests
,
Passive Tests
&
Resisted Tests
:-All in sitting with hands and wrists across bedInferior Radioulnar – pronation supinationRadiocarpal – flex extension radial deviation ulnar deviationCarpometacarpal joint of thumb – flexion extension abduction adduction oppositionMetacarpal phalangeal Joint – flexion extension abduction adductionProximal & distal interpahlangeal joints – flexion extension

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