Detailed Treatment Process
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Female, 65 years old The following is the discharge summary from the first hospitalization Department: Trauma Admission date: June 12 Discharge date: June 22 Discharge diagnosis: Left lateral condyle fracture of the humerus Major symptoms and signs on admission: The patient was admitted with a three-day history of swelling and pain in the left elbow following trauma. Physical examination: Swelling of the left elbow with localized tenderness and positive axial percussion tenderness of the left upper limb. Limited range of motion in the left elbow. X-ray showed a left lateral condyle fracture of the humerus. Major examination results during hospitalization: Routine blood work: WBC: 6.0 × 10⁹/L, RBC: 4.12 × 10¹²/L, Hb: 121 g/L, HCT: 36.3%, MCH: 29.4 pg, MCHC: 33.3 g/L. Liver function, kidney function, and electrolytes were normal. Hepatitis B markers: HBsAg(-), HBsAb(+), HBeAg(-), HBeAb(-), HBcAb(+); anti-HCV(-), HIV(-), TPPA(-). Coagulation profile: normal. Fasting blood glucose: 5.3 mmol/L. Special examinations during hospitalization X-ray: Fracture of the left elbow joint. Electrocardiogram: Sinus rhythm, low T waves, atrial premature beats. Hospital course and discussion: After admission, preoperative evaluation was completed. On June 13, open reduction and internal fixation of the left humeral fracture was performed under brachial plexus block anesthesia. The procedure went smoothly, and postoperative recovery was good. Condition at discharge (symptoms and signs) General condition was stable, temperature normal. The wound showed no redness, swelling, or exudation; the dressing was dry. Swelling of the affected limb had decreased significantly, with no other specific discomfort. Post-discharge medications and recommendations Rest and outpatient follow-up. Date: June 22
The following is the discharge summary from the second hospitalization Department: General Orthopedics Ward: General Orthopedics Admission date: January 2 Discharge date: January 7 Admission diagnosis: Postoperative left lateral condyle fracture of the humerus; ulnar nerve entrapment; tenosynovitis of the left thumb Discharge diagnosis: Postoperative left lateral condyle fracture of the humerus; ulnar nerve entrapment; tenosynovitis of the left thumb Major symptoms, signs, and key examination findings on admission: The patient was admitted with a six-month history of left elbow trauma surgery, reduced sensation on the medial aspect of the left forearm, and impaired left hand function. Physical examination: Old surgical scar on the left elbow, claw deformity of the left hand, reduced sensation on the ulnar side of the left hand, positive paper-pulling test, limited extension of the left thumb with triggering on passive movement. Major examination results during hospitalization: Coagulation profile normal. Blood glucose normal. Hepatitis B surface antibody positive. Core antibody positive. Anti-HCV negative. HIV and TPPA negative. Special examinations during hospitalization: EKG: Sinus rhythm, normal electrocardiogram. Hospital course and treatment results: After admission, preoperative evaluation was completed. On January 4, exploration and decompression of the left ulnar nerve plus removal of Kirschner wires was performed under brachial plexus anesthesia. Postoperative anti-inflammatory and anti-swelling treatment was given, and recovery was uneventful. Condition at discharge: General condition stable, wound dry with no exudation. Post-discharge medications and recommendations: 1. Outpatient follow-up with dressing changes every other day and suture removal in two weeks; 2. Functional exercises. Treatment outcome: 1. Cured January 7
The following is the first electromyography report after the second hospitalization I. Electromyography: Relaxation: (omitted) II. Nerve conduction velocity measurement: (omitted) Diagnostic impression: EMG: Partial denervation potentials observed in some examined muscles. NCV: Left ulnar nerve SCV and MCV not elicited. Impression: Partial injury to the left ulnar nerve (complete involvement of abductor digiti minimi and flexor carpi ulnaris). Examination date: January 30
The following is the second electromyography report after the second hospitalization I. Electromyography: Relaxation: (omitted) II. Nerve conduction velocity measurement: (omitted) Diagnostic impression: EMG: Denervation potentials observed in all examined muscles. NCV: Left ulnar nerve SCV not elicited; MCV slowed with prolonged latency and reduced amplitude. Impression: Partial injury to the left median and ulnar nerves. Examination date: April 23
The following is a description of the patient’s left palm in maximum extension (photograph) The palm cannot be fully flattened: the fingers remain in a partially open, partially flexed position and cannot achieve the normal fully extended “flat palm” appearance with even spacing between the fingers. The wrist is in a neutral position (no obvious dorsiflexion or palmar flexion), but the entire hand appears stiff with limited range of motion. Specific findings for each finger (from thumb to little finger): Thumb: markedly adducted and flexed, unable to abduct fully to align with the other fingers. Both the interphalangeal and metacarpophalangeal joints show obvious flexion, directed toward the palm, with clearly reduced mobility. Index finger: relatively the straightest, with interphalangeal joints nearly fully extended; the most “open” of the four fingers. Middle finger: good extension but still mildly flexed; the metacarpophalangeal joint (finger base) not fully straightened. Ring finger: most markedly flexed, with a large flexion angle at the metacarpophalangeal joint, unable to straighten fully, and reduced spacing with the middle finger. Little finger: also markedly flexed (both metacarpophalangeal and proximal interphalangeal joints), with the fingertip pointing downward, making it difficult to align with the other fingers in one plane.