Ortho Consult

Orthopaedic Surgeon Consultation Note Consultation: London, Rooms Patient: Mrs. Eleanor Vance File number: EV-2024-001 Referred by: Dr. David Chen Cc: Dr. Emily White (GP), Hand Clinic Administration Co-morbidities: Mild hypertension (controlled with medication) Diagnosis: Left Scaphoid Fracture, suspected non-union Date of injury: 1 November 2023 Summary of healthcare encounter: The patient, Mrs. Eleanor Vance, attended a consultation in clinic regarding ongoing left wrist pain following a fall a year prior, with suspicion of scaphoid non-union. Subjective: - 48-year-old, right-hand dominant, office manager. - Chief complaint: Persistent left wrist pain, dull ache, 7/10 at worst, exacerbated by gripping and lifting, present since a fall one year ago. Pain is localised to the anatomical snuffbox and radial aspect of the wrist. - Injury event: Fall onto an outstretched left hand whilst walking down stairs. Heard a 'pop' at the time, immediate swelling and pain. Attended A&E, x-rays initially reported as normal, treated conservatively with a splint for 3 weeks. - Pain severity: Currently averaging 5/10, intermittent sharp pains with movement, constant dull ache. No significant improvement since injury, occasional worsening with increased activity. - Injury circumstances: Work-related, occurred during office hours while descending internal stairs. - Current work status: Currently on light duties, struggling with typing and lifting files. Discussed options for modified work duties and potential sick leave if surgery is required. - General practitioner: Dr. Emily White, "The Family Practice" clinic. - Current medications: Amlodipine 5mg OD, Paracetamol 1g QDS PRN, Ibuprofen 400mg TDS PRN. No other supplements. - Allergies: Penicillin (rash), no known food or environmental allergies. No history of adverse reactions to anaesthesia. Objective: - Physical examination reveals localised tenderness over the anatomical snuffbox and volar aspect of the left wrist. Mild swelling noted. Reduced range of motion in flexion/extension compared to the contralateral side. Finkelstein's test negative. No obvious deformity. - Assessment of muscle strength: Pain with resisted wrist extension and radial deviation. Grip strength reduced on the left (25kg) compared to the right (40kg). - Diagnostic imaging results: Previous X-rays from one year ago showed no acute fracture. Recent MRI scan (10/10/2024) revealed a transverse fracture line through the waist of the left scaphoid with surrounding oedema, highly suggestive of scaphoid non-union. No avascular necrosis noted. - Physiotherapy: Attended 6 sessions of physiotherapy 6 months post-injury, with minimal improvement in pain or function. Assessment & Plan: 1. Left Scaphoid Fracture, suspected non-union - Suspected nature of injury: Traumatic scaphoid fracture with delayed union/non-union, likely due to initial missed diagnosis and inadequate immobilisation. - Recommended further investigations: CT scan of the left wrist to further characterise the fracture morphology and assess for union, including 3D reconstruction if necessary. - Potential future interventions: If non-union confirmed on CT, surgical fixation with bone grafting will be considered. Discussion regarding risk of avascular necrosis and potential for further surgery. - Management strategy if specific findings are identified on further imaging: If CT confirms non-union, will schedule for open reduction and internal fixation with cancellous bone graft. Pain management with NSAIDs and paracetamol, referral to pain clinic if conservative measures fail. - Counselling provided: Discussed potential prolonged recovery time post-surgery (3-6 months immobilisation), and implications for returning to full duties at work. Emphasised importance of strict post-operative rehabilitation. - Explanation given: Explained the nature of a scaphoid non-union, the challenges in healing due to its tenuous blood supply, and why initial x-rays might have missed the fracture. Rationale for CT scan to guide surgical planning. Limitations of conservative treatment for established non-unions. Additional Notes: Clinical Examination: Detailed examination of the left wrist revealed tenderness maximal in the anatomical snuffbox and over the scaphoid tubercle. Mild swelling, no warmth or erythema. Range of motion: Flexion 50 degrees (Right 75 degrees), Extension 40 degrees (Right 60 degrees). Radial deviation 10 degrees, ulnar deviation 20 degrees. Pronation/Supination full and painless. Grip strength reduced as above. Sensation intact. No neurovascular deficits. Diagnostic Imaging Findings: Initial X-rays (1/11/2023) reported as normal. Recent MRI Left Wrist (10/10/2024) demonstrated a scaphoid waist fracture, non-union with evidence of fibrous tissue at the fracture site. No significant cystic changes or avascular necrosis noted at this time. Treatment Plan: - Specific diagnostic procedures: Arrange urgent CT scan of the left wrist with fine cuts and 3D reconstruction. - Next steps in patient management: Following CT results, re-evaluate with the patient. If non-union confirmed, discuss surgical options (open reduction and internal fixation with bone grafting). Post-operative immobilisation and physiotherapy to follow. - Discussion regarding return to work: Patient advised to continue modified duties. Following potential surgery, extended sick leave of 2-3 months is anticipated, with gradual return to work, potentially starting with partial duties and ergonomic assessment.