Detailed Treatment Process
Female, 14 years old, presented for medical attention due to left knee pain after a collision during a physical education class. The following is the discharge summary from Hospital A Department: Orthopedics 【Admission Date】: December 9, 13:20:20 【Discharge Date】: December 13, 13:30 【Length of Stay】: 4 days 【Outpatient Diagnosis】: Left patellar dislocation 【Admission Diagnosis】: Left patellar dislocation 【Discharge Diagnosis】: 1. Left patellar dislocation; 2. Left patellar avulsion fracture (?); 3. Left knee patellar ligament, medial and lateral collateral ligament injuries (?); 4. Left knee medial and lateral meniscus injuries (?) 【Main Symptoms and Signs on Admission】: Admitted due to "left knee pain and limited movement for more than 6 hours after sprain" Departmental examination: Obvious swelling of the left knee, floating patella test (+), slight lateral displacement of the left patella, peripatellar tenderness (+) around the left knee, obvious pain during movement so range of motion not measured, no obvious sensory deficit in the left lower limb, strong dorsal pedal artery pulsation, good distal blood supply to the toes, normal toe movement Auxiliary examinations: Left knee X-ray (December 9, from another hospital): No obvious fracture signs in the left knee joint 【Main Laboratory Results】: Routine blood, C-reactive protein (CRP) (December 10): White blood cell count: 9.47 * 10⁹/L, Neutrophil%: 68.4%, Lymphocyte%: 24.2%, Monocyte%: 6.7%, Eosinophil%: 0.5%, Basophil%: 0.2%, Red blood cells: 4.10 * 10¹²/L, Hemoglobin concentration: 122g/L, Mean red blood cell volume: 91.5fL, Mean HGB content: 29.8pg, Mean HGB concentration: 325.0g/L, Red blood cell distribution width CV: 13.6%, Platelet count: 198 * 10⁹/L, Mean platelet volume: 10.3fL, Platelet distribution width: 11.4%, Hematocrit: 37.5%, Plateletcrit: 0.20, C-reactive protein: <0.5mg/L; Urine routine + sediment (December 10): Color: light yellow, Turbidity: clear, Red blood cells (quantitative): 0/ul, White blood cells (quantitative): 1/ul, Epithelial cells (quantitative): 0/ul, Red blood cell casts (quantitative): 0/ul, White blood cell casts (quantitative): 0/ul, Hyaline casts (quantitative): 0/ul, Granular casts (quantitative): 0/ul, Waxy casts (quantitative): 0/ul, Crystals: 0/ul, Bacteria: 0/ul, Occult blood: -, Urobilinogen: -, Urobilin: -, Ketones: -, Urine protein: -mg/L, Nitrite: -, Urine glucose: -, PH: 6.5, Specific gravity: 1.020, White blood cells: -, Vitamin C: -mmol/L, Mucus threads: 13/LP; Coagulation (basic) (December 10): Prothrombin time: 9.2sec, PT international normalized ratio: 0.78, Fibrinogen: 2.13g/L, Activated partial thromboplastin time: 32.4sec, Thrombin time: 23.7sec; Liver function, kidney function, electrolytes (December 10): Prealbumin: 218mg/L, Total protein: 62.5g/L, Albumin: 39.7g/L, Globulin: 23g/L, Albumin/globulin ratio: 1.7, Total bilirubin: 14.5umol/L, Direct bilirubin: 3.6umol/L, Alanine aminotransferase: 10U/L, Aspartate aminotransferase: 11U/L, γ-glutamyl transpeptidase: 15U/L, Alkaline phosphatase: 78.1U/L, Lactate dehydrogenase: 146U/L, Urea: 3.9mmol/L, Creatinine: 65.1umol/L, Uric acid: 284umol/L, Glucose: 4.97mmol/L, Calcium: 2.31mmol/L, Phosphorus: 1.12mmol/L, Magnesium: 0.85mmol/L, Serum potassium: 3.8mmol/L, Serum sodium: 134mmol/L, Serum chloride: 107mmol/L, Carbon dioxide: 17.6mmol/L, Total bile acids: 3.4umol/L, Glycocholic acid: 0.7mg/L, Serum adenosine deaminase: 12.1U/L, Cystatin C: 1.02mg/L, Complement C1q: 176mg/L, Fibronectin: 194mg/L. 【Special Examinations and Important Consultations】: Electrocardiogram: Sinus rhythm, T-wave changes Chest X-ray: No obvious abnormalities in heart, lungs, or diaphragm Left knee joint CT: Possible avulsion fracture of the lower pole of the left patella, free bony density shadow in the left knee joint cavity, effusion in the left knee joint cavity, recommend MR examination Left knee joint MRI: Bone injuries at the lower pole of the left patella and lateral femoral condyle, please combine with thin-slice CT to rule out fracture; possible injuries to the upper segments of the patellar ligament and medial and lateral collateral ligaments; possible injuries to the posterior horns of the medial and lateral menisci; large amount of effusion in the joint cavity and suprapatellar bursa, please combine with clinical findings. Right knee joint CT: Slightly irregular cortical bone at the lower pole of the right patella 【Disease Course and Treatment Outcome】: After admission, relevant examinations were completed. The left lower limb was immobilized with a patellar brace. The original plan was elective left knee arthroscopy exploration + medial patellofemoral ligament reconstruction. The patient requested discharge against medical advice. With approval from the attending physician, she was discharged this afternoon. 【Complications】: None 【Main Symptoms and Signs at Discharge】: The patient was alert and in fair spirits, complaining of left knee pain. Physical examination: Vital signs stable, left knee immobilized with patellar brace, left knee swelling, tenderness (+), no sensory deficit in the left lower limb, strong dorsal pedal artery pulsation, good distal blood supply to the toes, normal toe movement. 【Post-Discharge Medications and Recommendations】: 1. Recommend further treatment at another hospital's orthopedics or sports medicine department; 2. Follow-up in orthopedic outpatient clinic. 【Treatment Outcome】: Discharge against medical advice Date: December 13
The above discharge summary from Hospital A clearly states, "The original plan was elective left knee arthroscopy exploration + medial patellofemoral ligament reconstruction. The patient requested discharge against medical advice." However, the girl's parents said they decided to leave because Hospital A recommended surgery on both legs. The following is the left knee joint X-ray report from Hospital B Department: Orthopedics and Traumatology Examination Date: January 7 of the following year, 08:29:04 Report Date: January 7 of the following year Clinical Diagnosis: Follow-up Examination Name: Left knee joint AP and lateral views Examination Method: DR Radiological Findings: Avulsion fracture of the intercondylar eminence of the left tibial plateau, with the fracture fragment now showing mild medial tilt. Mild soft tissue swelling at the lateral supracondylar region of the femur. No abnormalities in the remaining bones. Joint is in position with normal joint space. Radiological Diagnosis: Avulsion fracture of the intercondylar eminence of the left tibial plateau, with the fracture fragment now showing mild medial tilt. Mild soft tissue swelling at the lateral supracondylar region of the femur.
* The following is the knee joint CT plain scan + reconstruction report from Hospital C Department: Orthopedics, Arthroscopy Specialty Examination Category: CT examination Referring Physician's Request: Confirm diagnosis Clinical Diagnosis: Trauma Examination Site and Name: Left knee CT plain scan (3D) Examination Method: Left knee transverse CT plain scan + 3D reconstruction Imaging Findings: Small bone fragment shadow at the posterior margin of the left patella, strip-like high-density shadow in the joint cavity, small amount of effusion in the left knee joint, small depression in the lateral condyle of the left femur, shallow femoral trochlea on the left, no obvious bony abnormalities in the remaining bones of the left knee joint, joint in position, smooth articular surfaces, no obvious narrowing of the joint space. Imaging Diagnosis: Shallow left femoral trochlea, possible left patellar dislocation with post-reduction changes, small avulsion fracture of the left patella, small amount of effusion in the left knee joint. Please correlate with clinical findings and follow up. Examination Time: January 10 of the following year, 09:52:00 Report Time: January 10 of the following year, 10:03:51 Film Review Time: January 10 of the following year, 16:28:14
The girl, accompanied by her parents, visited the outpatient clinic at Hospital C four times. Three visits occurred on December 27 with one doctor, and on January 17 of the following year with two different doctors on the same day. One additional outpatient record did not specify the visit date. During the four outpatient visits at Hospital C, some doctors recommended conservative treatment, some suggested deciding on surgery based on the situation, and some advised immediate surgery. However, none of the four doctors mentioned the tibial intercondylar eminence fracture. They also did not clearly state whether the surgery would target the left knee or both legs. Some doctors did document in writing the congenital shallow femoral trochlea.