Orthopaedic Progress Note

Progress Note 1 November 2024 Date of Surgery: 06/15/24: right femoral osteotomy Date of Injury: 06/14/24: right femoral shaft fracture Subjective: - Patient, a 7-year-old male, presents with ongoing pain and limited mobility in his right leg following a recent femoral osteotomy. Mother reports difficulty with weight-bearing and discomfort, particularly during physiotherapy sessions. - The patient sustained a right femoral shaft fracture in June, which was subsequently treated with an open reduction and internal fixation, complicated by malunion necessitating the osteotomy. Pain is described as a dull ache, 4/10 at rest, increasing to 7/10 with movement. Aggravated by weight-bearing and relieved slightly by rest and paracetamol. No previous orthopaedic issues or family history of bone disorders. - Physiotherapy is progressing slowly. Mother reports patient is reluctant to engage due to pain, which is hindering progress on range of motion and strengthening exercises. - Since the last visit two weeks ago, symptoms have remained largely consistent. There has been no significant improvement in pain levels or functional ability. Mother expresses concern about the slow recovery and impact on the child's daily activities. Objective: - Vitals: BP 100/60 mmHg, HR 85 bpm, Temp 36.8°C, RR 18 breaths/min. - Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc.: Right Hip: | Examination | Right Value | Left Value | |---|---|---| | Flexion | 80° (painful) | 120° | | Extension | 0° (painful) | 10° | | Abduction | 15° (painful) | 40° | | Adduction | 10° (painful) | 20° | | Internal Rotation | 5° (painful) | 45° | | External Rotation | 10° (painful) | 45° | Right Knee: | Examination | Right Value | Left Value | |---|---|---| | Flexion | 70° (painful) | 140° | | Extension | -10° (painful) | 0° | Inspection reveals mild swelling and erythema around the right mid-femur. Palpation elicits tenderness over the osteotomy site. No obvious deformity noted. Strength testing in the right hip and knee is limited by pain (3/5 against resistance). Left lower extremity examination is unremarkable. - Appearance of the surgical wound: Surgical wound on the right mid-thigh is well-approximated, dry, and clean, with no signs of erythema or discharge. Staples remain intact. - Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant: Lower extremity neurovascularly intact: Motor exam intact for femoral, sciatic, SPN, DPN, and tibial nerves. Sensation is intact to light touch in all distributions. The capillary refill is less than two seconds. Imaging: - For x-rays obtained in the office today, include the following statement and findings: "I ordered and independently reviewed x-rays in office of the right femur today (final radiologist read is pending at the time of the note). The findings are: The right femoral osteotomy site shows early callus formation with good alignment. No signs of hardware loosening or infection." - Prior X-rays of the right femur acquired on 06/15/24 at Saint Jude's Children's Hospital revealed a malunited femoral shaft fracture. Dr. Smith interpreted these as requiring corrective osteotomy. Assessment & Plan: 1. Post-operative right femoral osteotomy for malunion of femoral shaft fracture - Assessment, including the likely diagnosis and rationale based on subjective and objective findings: 7-year-old male with persistent pain and limited range of motion following a right femoral osteotomy. Clinical presentation, including pain with movement, limited ROM, and tenderness at the osteotomy site, is consistent with normal post-operative recovery, albeit slower than anticipated, possibly exacerbated by pain management and physiotherapy compliance issues. - Investigations planned: Discussed with mother the possibility of a bone scan if pain persists or worsens despite conservative management, to rule out stress reaction or subtle infection. - Non-surgical treatment options: Continue current physiotherapy regimen with increased emphasis on pain management strategies prior to sessions. Adjust pain medication to include scheduled ibuprofen in addition to paracetamol for better pain control. Referral to a paediatric pain specialist for further assessment and management strategies. - Post-operative care plan: Continue non-weight bearing for another 2 weeks, then partial weight bearing as tolerated with crutches for 4 weeks. Strict adherence to physiotherapy exercises at home. Follow-up in 4 weeks with repeat X-rays. - Relevant referrals: Referral to Paediatric Pain Management Clinic and to Paediatric Physiotherapy for reassessment of therapy plan. Additional Notes: - Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care: Educated mother and patient on the importance of consistent physiotherapy and adherence to pain medication schedule to improve rehabilitation outcomes. Discussed potential complications such as delayed union, non-union, or infection, and signs to watch for. - Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for: Instructed mother on wound care and to monitor for increased redness, swelling, drainage, or fever. Advised strict non-weight bearing for the next two weeks. Emphasised restricted activities, avoiding running, jumping, and contact sports until cleared by the surgeon. - Any specific patient or family concerns addressed during the consultation: Mother expressed concerns about the patient's refusal to participate in physiotherapy due to pain. We discussed strategies to make physiotherapy more tolerable, including timing pain medication before sessions and using distraction techniques. The importance of balancing pain relief with functional recovery was stressed.