Case 2 Flashcards
(18 cards)
Case 2: Age and sex
19 yo female
Case 2: HPI
19yearold righthand dominant female presented
with a oneyear history of worsening left wrist pain that began insidiously.
More recently she noticed popping and increased pain. Her pain was rated as
7 out of 10. She had previously attempted conservative management,
including bracing and physical therapy, but noted no improvement in her
symptoms.
Case 2: PMhx
Anxiety. Depression. Obesity.
Case 2: Phys Exam
Examination of the left wrist revealed notable
acute tenderness dorsally over the lunate and radiolunate joint. Wrist motion
was markedly restricted secondary to pain, with extension limited to 30
degrees and flexion to 45 degrees. Pronation and supination were 90deg.
Neurovascular examination of the left upper extremity was normal.
Case 2: Lab and imaging
Preoperative imaging
included plain radiographs demonstrating Kienböck disease stage IIIa of the left wrist, with mild collapse of the lunate, minimal scaphoid rotation, and a 4mm ulnar negative variance. MRI confirmed mild collapse of the lunate with associated signal changes, while showing preservation of the lunate facet cartilage and maintenance of the lunatecapitate articular surfaces.
Case 2: Diagnosis
Stage IIIa Kienbock’s disease of the left
wrist.
Case 2: Treatment plan (operative and nonoperative options
Nonop: The patient
underwent an extended course of nonoperative management including
physical therapy and use of bracing for approximately one year, but continued
to experience persistent, worsening pain and loss of wrist range of motion.
Additional nonoperative options such as continued bracing or casting and
expectant management were considered, but clinical progression and
refractory symptoms made further conservative measures unlikely to provide
benefit. Operative: Surgery in the form of left wrist radial shortening
osteotomy with internal fixation was discussed, with the goal of offloading the
lunate and preventing further collapse. This was indicated by imagingconfirmed Kienböck’s disease stage IIIa with mild lunate collapse, ongoing
functional impairment, and the preservation of key articular cartilage. The
patient’s clinical course and imaging findings supported surgical intervention.
Case 2: Primary surgical indications:
: Surgery was indicated due to a yearlong history
of progressive, debilitating left wrist pain and restricted motion that had failed
to improve with physical therapy and bracing. Imaging demonstrated stage
IIIa Kienböck’s disease with lunate collapse but preserved carpal alignment
and cartilage, making radial shortening osteotomy a rational intervention to
preserve wrist function and halt further deterioration. The patient was young,
continued to have significant pain impacting daily function, and had shown
refractory symptoms despite appropriate conservative care.
Procedure(s) and date(s) of surgery:
4/12/2024: L wrist radial shortening
osteotomy.
Length of surgery:
1 hours 38 minutes.
Postoperative course:
POD 0: volar splint applied. POD 2 wk: incision healing
well, minimal tenderness, sutures removed, transitioned to removable carpal
tunnel brace full time except for washing and gentle ROM, instructed to keep
weightbearing 〈1 lb. POD 8 wk: scars wellhealed, no tenderness, continued
brace compliance, wrist stiff, full finger ROM, wrist extension/flexion limited,
PT ordered for ROM, WBAT allowed. POD 20 wk: wellhealed scar, no
tenderness, full finger ROM, wrist extension 45°/flexion 60°, WBAT, continued
PT, no pain, able to use wrist as tolerated. POD 18 wk: wellhealed scar, no
tenderness, wrist extension 45°/flexion 60°, plate and osteotomy site healed
on XR, WBAT, continued home exercises, no restriction. POD 65 wk: pt not
seen in clinic as scheduled, provider called pt to recommend return for repeat
eval and XR.
Date of most recent followup:
8/19/2024
Total length of followup:
17 weeks
Is the patient happy with the outcome?
Yes, the patient reported satisfaction
with her care, noted improvement in wrist pain compared to preoperative
status, and resumed daily activities without significant limitation.
Are you happy with the outcome?
Yes, the patient regained functional wrist
motion, improvement in pain, and was able to participate in activities of daily
living without notable restriction.
Were there complications?
No
What went well in this case?
The patient achieved consolidation of the
osteotomy, maintained stable alignment, and experienced improved functional
wrist motion sufficient to resume desired activities.
What might you do differently in future?
I would consider earlier initiation of
formal physical therapy to address postoperative stiffness and may monitor
lunate collapse more closely with advanced imaging if indicated by
symptoms.
