A lot going on

[Farisshd]

For this patient reflection post, I am choosing a motor vehicle accident case. It is the only recent upper extremity evaluation that has come onto my caseload, but it is absolutely relevant and the patient had a lot to consider. My patient is a 45 year old female that works as a crafter and sells her products at different events in the state. She was involved in an accident in which an elderly woman had been drinking and looked to be stopping the car at an intersection and then sped up in front of my patient’s oncoming vehicle, leading her to T-bone the elderly driver’s vehicle, and both vehicles to lock together and spin across the road.

This accident occurred about 8 weeks prior to the patient being seen by me for her evaluation. My patient suffered multiple fractures in her left elbow, wrist, and hand, as well as a T2 compression fracture. She has spent 6 weeks in a C-collar forearm/wrist splint, and arm sling, and had just been released by her physician to slowly resume activities as her symptoms allowed, and was referred to PT. The patient had two referrals from her doctor, one for the compression fracture with no restrictions and listed as “mild”, and one for her L UE injuries listing a nondisplaced fracture of the distal L radius, a closed displaced fracture of the proximal head of the L radius with routine healing, and a nondisplaced fracture of the third metacarpal, as well as a mention of a L elbow contracture. There was no surgical intervention, and the script indicated normal healing, listing strength and motion as the reason for referral.

I could immediately see that the patient was very protective of her L arm, walking with it flexed to ~100 degrees and internally rotated across her belly as if she was still in a loose fitting sling. She was very cautious to move it and initially concerned for physical therapy being intense and painful. However, her initial pain ratings were low and she indicated moderated irritability related to use of the arm, and positioning during the night, but that she could find relief with rest, repositioning and Tylenol + NSAIDs. I took the time to set her mind at ease, and let her know that we are careful to keep discomfort to an “acceptable level” and explaining that she and I would work together to keep her pain level with in 1-2 points/10 from baseline. She expressed relief and her demeanor changed very quickly. She expressed that the limited strength and range of motion were her main concern, and that her thoracic pain was mild and less concerning. The patient denied numbness and tingling, denied shooting pain, had no lower extremity or balance concerns, and indicated no sensation deficits. Other screening for red flags was unremarkable.

I was initially concerned for where to focus the evaluation and initial intervention, but the subjective interview and initial presentation led me to my answer naturally. After clearing the cervical spine, I focused my exam on her Shoulder, elbow, and wrist. I noted -40 degrees AROM elbow extension, and a 35 degree initial deficit for elbow extension PROM with a firm end feel and pain in the distal biceps, though no indication of bony block. Pronation and supination were mildly limitted, and flexion was limited to 130 degrees due to pain. Wrist flexion and extension were moderately limited, and the shoulder was mildly limited in all planes. Strength impairments were mild to moderate (in available range) and most limited in the wrist by pain. Light touch sensation was present bilaterally but slightly diminished throughout the L UE, which was not exactly what I expected so I took note, but this did not follow any dermatomal distribution. Palpation was most painful over the olecranon and proximal radial head, and minimally uncomfortable over the scaphoid and base of the third metacarpal. Pain free grip strength was limited to 10 pounds on the L and the baseline was 60 pounds on the R. The patient was unable to close her fist more than halfway sue to swelling, but was able to individually oppose her fingers to her thumb.

Due to the complexity of the situation and the patient’s initial concern over intensity, I kept the initial HEP light with a focus on decreased swelling and gaining ROM in the wrist, elbow, and forearm and talked the patient through beginning to use her arm and hand cautiously, but to let her symptoms guide her. After educating the patient on the role of PT, her prognosis, and the plan of care, I instructed her in some tendon glides, wrist AROM, elbow ROM before discussing sleeping positions, and use of elevation and ice throughout the day to bring down her inflammation. I answered any questions the patient had and ensured she was up to speed.

Both the patient and I seemed to be reassured at the session completion. I was initially concerned for patient buy in, but felt that she was engaged and excited to participate by the end of the session. I think a lot went well with this patient experience, though there is always something to improve upon. In this case I might have delved a little deeper into the slightly diminished sensation into the L UE in this first encounter, and I realized I did not check UE reflexes after the fact. Though the difference is likely explained by inflammation, these would have helped me to rule out any tricky upper motor neuron involvement right away. With her specific presentation, I think I could have done so effectively. In a future encounter of this sort, I would check reflexes. I think I was caught up in the multiple complaints and dialed in on the chief complaint at the time.

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