Case 1 Flashcards
(19 cards)
Case 1: What is it?
Right pertrochanteric and Right olecranon
Case 1: Age and Sex
82 yo female
Case 1: HPI
Ground level fall (getting out of her truck)
Pain in R elbow and R hip
Transferred from peripheral hospital by EMS
Case 1: Relevant PMHx
Osteoperosis, depression, stroke
Case 1: Physical Exam
- Elbow: ecchymosis, tenderness, step off
- Hip: pain with movement of hip, leg shortened and externally rotated
Case 1 : Imaging/Labs
Preoperative imaging
included xrays of the right elbow demonstrating an acute, displaced fracture
of the olecranon, and xrays of the right hip revealing a comminuted,
displaced intertrochanteric femur fracture. A CT head was negative for acute
pathology.
Case 1: Dx
Right olecranon fracture, Right
intertrochanteric femur fracture
Case 1: Treatment Plan
Nonop: Treatment
options included prolonged immobilization and bedrest for her right intertrochanteric femur fracture, with pain management and nursing care. However, prolonged nonweight bearing in an elderly patient risks
complications such as decubitus ulcers, pneumonia, and thromboembolism,
and is associated with poor functional outcomes. Non operative treatment of
the olecranon fracture can lead to reasonable outcomes for pain relief, but is generally associated with loss of extension strength.
Operative: Early surgical
fixation with an intramedullary rod to stabilize the femur fracture was
recommended, with the goal of enabling early mobilization, reducing systemic complications of immobility, and promoting prompt restoration of function. In addition, ORIF of the olecranon was recommended to restore maximum elbow
strength in an otherwise healthy and active patient.
Case 1: Surgical indications
The patient sustained an acute comminuted intertrochanteric femur fracture and olecranon fracture following a ground level fall, resulting in inability to ambulate and significant pain. In the setting of advanced age and osteoporosis, nonoperative management could have
led to rapid functional decline and systemic complications from immobility.
Operative fixation was indicated to restore skeletal stability, allow early
mobilization, minimize the risk of lifethreatening complications, and maximize the chance of returning to her baseline independence.
Case 1: Procedure and date
01/06/2024: ORIF R olecranon and IMN
fixation of R hip 02/01/2024: Fragment excision and tricep advancement R
elbow
Case 1: Lenth
2h 54min
Case 1: EBL
100 ml
Case 1: Post op course
POD 0 (Op01): posterior slab splint R elbow, pt WBAT
R hip, R UE to keep weightbearing 〈1 lb, ASA started for DVT ppx. PO 3 wk
(Op01): splints removed, sutures removed, planned for revision surgery, as
xray showed escape of posterior fragment. POD 0 (Op02): posterior slab
splint R elbow, WB 〈1 lb, ASA con’t. PO 2 wk (Op02): splint off, incision
healing well, gentle ROM 135° flex/60° ext, PT referral for elbow started, WB
〈5 lb, ASA con’t. PO 7 wk (Op02): incision healing well, elbow ROM to 30°
ext/135° flex, cane for gait, PT ongoing, methocarbamol started for spasm,
use elbow as tolerated except avoid extension force 〉10 lb. PO 16 wk (Op02):
incision healed, elbow ROM 25–145°, strong extension, PT con’t for terminal
ROM. PO 30 wk (Op02): incision wellhealed, elbow ROM 10–135°, good
triceps strength, mild plate prominence noted, but not bothersome,
ambulating independently, with no aids.
Case 1: Length of Follow up
34 weeks (7 months)
Case 1: Is the patient happy with the outcome
Yes, the patient reported satisfaction
with the progression of her recovery. She returned to independent
ambulation, denied significant pain at the elbow or hip, and did not express
any major functional limitations in her daily activities.
Case 1: Are you happy with the outcome
Yes, the patient regained functional elbow range of motion, did not experience ongoing pain, and returned to her baseline ambulation status following both the right elbow revision surgery and concurrent right hip fracture fixation.
Case 1: Complication and response
Following the initial open reduction and internal fixation (ORIF) of the right olecranon fracture, the patient experienced proximal fragment escape two weeks postoperatively. In
response, revision surgery was performed with excision of the olecranon fragment and triceps advancement, with subsequent improvement in stability
and function.
Case 1: What went well in the case?
The patient achieved a functional range of elbow motion sufficient for daily activities and regained independent ambulation after both the elbow revision and hip fracture surgeries. She reported no ongoing pain and expressed satisfaction with the treatment course.
Case 1: What might you do differently in the future
Better fixation of proximal olecranon
fragment, likely with nonreabsorbable sutures in triceps tendon tied through
plate. I will also consider proceeding directly with fragment excision and
triceps advancement in highly comminuted olecranon fractures with
osteoperotic bone and a stable elbow.
