Case 3 Flashcards
(19 cards)
Patient age and gender:
69 yearold Female
Patient age and gender: 69 yearold Female
History of present illness:
The patient was a 69yearold righthand dominant
female who presented after sustaining a laceration to her left thumb near the
MP crease while cutting an ice cream box. She experienced immediate
significant bleeding, followed by decreased sensation in the thumb and
inability to flex the interphalangeal (IP) joint. She was evaluated in the
emergency department, where the thumb was found to be well perfused, but
she was still unable to actively flex at the IP joint and had diminished
sensation over the volar pad. A tetanus booster was given in ED, skin closed,
prescribed amoxicillin, and was referred to my office for evaluation and
definitive treatment.
Relevant past medical history:
Allergic rhinitis, GERD without esophagitis,
lipidosis, hearing loss, irritable bowel syndrome
Relevant physical findings:
: Examination of the left thumb demonstrated a 1
cm laceration on the volar radial aspect at the MP flexion crease. There was
markedly diminished sensation on the ulnar volar pad of the thumb with twopoint discrimination of 2 cm, and reduced discrimination on the radial aspect
with 2PD between 10–15 mm. The patient was unable to actively flex at the IP
joint but maintained active MCP flexion, and the IP joint rested in
hyperextension. The remainder of the hand exam was unremarkable. The
thumb was wellperfused with no evidence of vascular compromise.
Interpretation of laboratory and imaging studies:
2 view radiographs of the left
thumb taken preoperatively demonstrated no fracture or significant bony
injury, but did reveal soft tissue disruption at the volar aspect of the thumb.
Diagnoses (differential diagnoses):
Laceration of left thumb flexor pollicis
longus and laceration of ulnar digital nerve of the left thumb. Differential
diagnosis included partial tendon or nerve injury (including radial digital nerve) but was considered unlikely on clinical examination.
Treatment plan (operative and nonoperative options:
Nonop: Nonoperative
management options for full thickness laceration to the left thumb flexor
tendon and digital nerves included wound care, observation, splinting, and
expectant management. Potential outcomes of these strategies would involve
limited ability to actively flex at the interphalangeal (IP) joint and ongoing
sensory deficits, with notable risk of persistent functional impairment.
Operative: Surgical intervention with left thumb irrigation and debridement,
repair of the flexor pollicis longus (FPL) tendon, and digital nerve repair was
discussed. The goal was restoration of thumb flexion and improvement of
digital sensation. These options were chosen due to the likelihood of
complete FPL and digital nerve laceration, and the patient’s high functional
demands as an artist.
Primary surgical indications:
The patient had a complete loss of active flexion
at the thumb IP joint and decreased sensation following a laceration,
indicating likely complete laceration of the FPL tendon and ulnar digital nerve.
Functional deficits were expected to persist and severely impact hand use
without timely surgical intervention. Restoration of tendon and nerve
continuity offered the greatest potential for meaningful return of thumb flexion
and improved sensation, aligning with the patient’s occupational needs and
desire for optimal recovery.
Procedure(s) and date(s) of surgery:
02/29/2024 Left thumb flexor pollicis
longus repair and left thumb ulnar digital nerve repair
Length of surgery:
1 hours 42 minutes.
Estimated blood Loss:
30 cc
Postoperative course:
POD 0: dorsal blocking and thumb spica splint
applied, NWB through thumb, referral sent for PT to begin early active ROM,
custom molded extension block splint to be made, instructed to avoid
extension 〉30° at IP/MCP, avoid resisted flexion, gentle active motion
encouraged. PO 2 wk: sutures removed, transitioned to custom molded
extension blocking splint, PT initiated for early active ROM, instructed to keep
WB 〈1 lb, plan to wean narcotics to Tylenol/ibuprofen. PO 6 wk: volar scars
healing well, using custom molded brace, PT con’t, brace to be worn when
risk of impact, avoid forceful gripping and extension. PO 3 mo: PT con’t to
maximize ROM, may use thumb as tolerated, mild swelling present. PO 8 mo:
normal active flexion, residual tingling on ulnar aspect, sensation partially
returned. PO 13 mo: patient active as potter, minor thumb swelling by end of day, 2PD 10mm ulnar aspect of thumb persists but no major limitations, flexor
tendon intact, with active flex/ex 45-0 deg.
Date of most recent followup:
4/8/2025
Total length of followup:
58 weeks
Is the patient happy with the outcome?
Yes. The patient reported satisfaction
with the result, noted functional use of her left thumb, and was able to
resume her work as a potter and daily activities, though she described some
persistent but improving numbness and some endofday swelling.
Are you happy with the outcome?
Yes. The patient regained functional range
of motion, resumed her desired activities including pottery and art, and
demonstrated tendon healing with gradual sensory return on the ulnar aspect
of the thumb.
Were there complications?
No
What went well in this case?
The patient achieved functional range of motion
at the thumb, maintained tendon integrity, and resumed her occupational and
recreational activities. Sensation improved over time and did not preclude
return to desired hand use.
What might you do differently in future?
I could provide better anticipatory
guidance on the slow pace of tendon and nerve healing and the prolonged
course of recovery.
