AMA Guides 4 th Edition: Sample Case Review CASE #1 Ms. Parker is a 26 year old woman who sustained a fracture of the tuft of the distal phalynx of the right little finger, which was treated with a splint. Three weeks later she complained of constant, severe burning pain of her entire right hand and forearm, with associated swelling, red discolouration, sensitivity to touch and decreased grip strength. Cases Source: The Guides Casebook, Third Edition 1
CASE #1 Examination of the right arm revealed edema, erythema and decreased passive range of motion of the DIP, PIP and MP joints of the ring and little fingers. Three phase bone scan revealed hypervascularity of the right fingers, hand and forearm on the early images followed by a diffusely increased uptake in a periarticular distribution on the delayed images. Diagnosis? CASE #1 Diagnosis confirmed by pain specialist treatment included NSAID s and physical therapy A comprehensive medical and psychological evaluation did not reveal alternative explanations. The patient had significant improvement over the subsequent 2 years. 2
CASE #1 Currently, Ms. Parker reported resolution of he right forearm and hand pain, swelling discoloration, and hypersensitivity but reported persistent stiffness of her ring finger, diminished grip strength and difficulty with tasks requiring digital dexterity. She was able to use her right upper extremity for self care, holding objects and daily activities including her occupational duties as a material handler. CASE #1 On examination, there was no edema, erythema or dyshydrosis in the right upper extremity. Active range of motion was normal except in the right little finger. The MP joint had extension to 0 and flexion to 80, the PIP had extension to 0 and flexion to 80 and the DIP joint had extension to 10 (10 extension lag) and flexion to 50. There was no discrepancy between active and passive range of motion. 3
CASE #1 The Purdue Pegboard Test for fingertip dexterity was scored at the 45th percentile, consistent with mildly diminished fingertip dexterity. Bilateral grip strength assessment using a Jamar dynamometer showed a bell shaped curve, good correlation between static exchange and rapidexchange grip, and a coefficient of variation on repeated trials of 10%. The position 2 maximum grip strength was 10 pounds greater for the left hand than for the right. 4
Mr. Martin is a 54 y.o. man who experienced the onset of low back pain and bilateral lower extremity numbness while lifting at work. He had no prior episodes, had no difficulty on initiating urination and had no urinary or fecal incontinence. Shortly after the injury, physical exam showed muscle guarding and dysmetria of the spine. Neurologic exam demonstrated moderate weakness of his quadriceps femoris bilaterally; mild weakness of his gastrocnemius, extensor halluces longus and anterior tibialis muscles bilaterally; diminished sensation of his perineum, thighs and proximal anterior calves bilaterally; absent patellar tendon and Achilles tendon reflexes; and normal anal sphincter tone. Ankle clonus was noted bilaterally. Wadell signs and nonorganic physical signs were absent. 5
An MRI of the lumbar spine showed a large postcentral herniated nucleus pulposus at L3 4with a free disc fragment, resulting in multilevel nerve root compression. Surgical treatment included decompressive laminectomy at L3 4 with excision of the herniated disc material and free fragment One year after surgery, at MMI, Mr. Marten reported mild residual low back pain, but no leg pain. He had considerable difficulty with stair climbing; he required use of his arms to ascend a 1 ft step with either leg (quadriceps weakness). He denied difficulty with bowel or bladder control. 6
On examination, Mr. Martin reported diminished sensation over his left anterolateral thigh, anterior knee and medial leg and foot. Right leg sensation was normal. Patellar DTR s were absent on the left and trace present on the right. Muscle strength of his quadriceps femoris, anterior tibial and gastrocnemius was mildly diminished bilaterally (4/5), although clearly improved from his preoperative status. The remainder of his neurological examination was normal. Straight leg raise was negative bilaterally and Waddell signs were absent. Preoperative MRI of the lumbar spine showed a large posterocentral herniated nucleus pulposis at L3 4 with a free disc fragment, resulting in multilevel nerve root compression consistent with a cauda equine like syndrome. Lumbar plain films were unremarkable for any structural changes. 7
Mr. Macdonald is a 75 year old man who was involved in a motor vehicle accident when he was travelling at 130 km/hr. As a result, he sustained a displaced femoral neck fracture of the left hip. Surgical intervention at the time included insertion of a dynamic hip screw (DHS). Unfortunately, Mr. Macdonald went on to develop avascular necrosis of the hip with loss of joint space. Despite conservative management, his ongoing pain was significantly limiting his activities and sleep. 8
One year later, Mr. Macdonald underwent total hip arthroplasty. Unfortunately, during the procedure one of the light handles fell into the wound causing an interoperative infection of the surgical site. Despite ongoing antibiotic treatment, Mr. Macdonald suffered worsening hip pain and fever over the next several months. Ultimately, his orthopaedic surgeon recommended further surgery to remove the entire femoral head and prosthetic acetabulum. At that time, positive cultures were obtained and Mr. Macdonald was treated with further antibiotics and prolonged traction. Two years after his original injury, Mr. Macdonald was readmitted to the hospital for extensive debridement. His surgeon noted massive scarring and chronic infection. Postoperatively, he developed an acute abdomen as a part of his bowel herniated through an eroded defect in the acetabulum. Following a bowel resection with loop ileostomy, further debridement and antibiotics were provided. 9
By three years post injury, Mr. Macdonald was ambulating with full weight bearing without crutches, although he did have a 3 cm leg length discrepancy. In addition, he suffered from short gut syndrome once his loop ileostomy was reversed. Six months later, Mr. Macdonald was offered a revision hip arthroplasty (uncemented) which was followed by extensive physiotherapy. Over the subsequent months, he continued to suffer chronic burning and stabbing pain and complained that his leg would collapse intermittently. Mr. Macdonald was increasingly limited in his ADL s and IADL s and was no longer able to climb stairs or sit in a chair longer than one hour. On examination, Mr. Macdonald was an overweight gentleman with hypertrophic scarring of the right thigh and buttock as a result of his multiple surgeries. There remained a 3 cm leg length discrepancy. Mr. Macdonald ambulated with two long crutches which allowed him to walk short distances and used his axillary weight bearing to substitute for partial left lower extremity weightbearing. The left knee was stiff with a relative loss of the knee component of gait He leaned to the left with each left step in a compensated Trendelenburg gait pattern. 10
Mr. Macdonald was suffering from a lateral femoral cutaneous neuropathy, chronic diarrhea and chronic pain for which he was taking opiods. As a result of the bowel surgery and chronic infections, he had also developed multiple upper urinary tract infections and decrease kidney function. Mr. Macdonald was suffering from a lateral femoral cutaneous neuropathy, chronic diarrhea and chronic pain for which he was taking opiods. As a result of the bowel surgery and chronic infections, he had also developed multiple upper urinary tract infections and decrease kidney function. 11
MSK examination revealed the following: Intermittent hip subluxation with a palpable click 3 cm leg length discrepancy Abnormal right lower extremity range of motion with flexion to 0 to 90, extension to 0 to 10, abduction was from 0 to 45 and adduction 0 to 20. External rotation was 0 to 65 and internal rotation was 0 to 70. The left knee demonstrated flexion at 110 and extension at 0. Neurological examination demonstrated weakness of most hip muscles from 2 3/5 12