Detailed Treatment Process
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A 14-year-old girl presented with left knee pain after a collision during 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. Possible avulsion fracture of the left patella (?); 3. Possible injury to the left patellar ligament, medial and lateral collateral ligaments (?); 4. Possible injury to the medial and lateral menisci of the left knee (?) [Main Symptoms and Signs on Admission]: Admitted with “left knee pain and limited movement for more than 6 hours after sprain” Physical examination: Obvious swelling of the left knee, positive floating patella test, slight lateral displacement of the left patella, positive tenderness around the patella, obvious pain on movement (range of motion not measured), no obvious sensory deficit in the left lower limb, strong dorsalis pedis pulse, good distal circulation, and 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]: Complete blood count and 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: 122 g/L, Mean corpuscular volume: 91.5 fL, Mean corpuscular hemoglobin: 29.8 pg, Mean corpuscular hemoglobin concentration: 325.0 g/L, Red cell distribution width CV: 13.6%, Platelet count: 198 × 10⁹/L, Mean platelet volume: 10.3 fL, Platelet distribution width: 11.4%, Hematocrit: 37.5%, Plateletcrit: 0.20, C-reactive protein: <0.5 mg/L; Urinalysis with sediment (December 10): Color: light yellow, Turbidity: clear, Red blood cells (quantitative): 0 /μL, White blood cells (quantitative): 1 /μL, Epithelial cells (quantitative): 0 /μL, Red cell casts: 0 /μL, White cell casts: 0 /μL, Hyaline casts: 0 /μL, Granular casts: 0 /μL, Waxy casts: 0 /μL, Crystals: 0 /μL, Bacteria: 0 /μL, Occult blood: -, Urobilinogen: -, Ketones: -, Protein: - mg/L, Nitrite: -, Glucose: -, pH: 6.5, Specific gravity: 1.020, Leukocytes: -, Vitamin C: - mmol/L, Mucus: 13/LP; Coagulation (basic) (December 10): Prothrombin time: 9.2 sec, PT INR: 0.78, Fibrinogen: 2.13 g/L, Activated partial thromboplastin time: 32.4 sec, Thrombin time: 23.7 sec; Liver function, renal function, electrolytes (December 10): Prealbumin: 218 mg/L, Total protein: 62.5 g/L, Albumin: 39.7 g/L, Globulin: 23 g/L, Albumin/globulin ratio: 1.7, Total bilirubin: 14.5 μmol/L, Direct bilirubin: 3.6 μmol/L, Alanine aminotransferase: 10 U/L, Aspartate aminotransferase: 11 U/L, Gamma-glutamyl transferase: 15 U/L, Alkaline phosphatase: 78.1 U/L, Lactate dehydrogenase: 146 U/L, Urea: 3.9 mmol/L, Creatinine: 65.1 μmol/L, Uric acid: 284 μmol/L, Glucose: 4.97 mmol/L, Calcium: 2.31 mmol/L, Phosphorus: 1.12 mmol/L, Magnesium: 0.85 mmol/L, Potassium: 3.8 mmol/L, Sodium: 134 mmol/L, Chloride: 107 mmol/L, Carbon dioxide: 17.6 mmol/L, Total bile acids: 3.4 μmol/L, Glycocholic acid: 0.7 mg/L, Adenosine deaminase: 12.1 U/L, Cystatin C: 1.02 mg/L, Complement C1q: 176 mg/L, Fibronectin: 194 mg/L. [Special Examinations and Important Consultations]: Electrocardiogram: Sinus rhythm with T-wave changes Chest X-ray: Heart, lungs, and diaphragm unremarkable Left knee CT: Possible avulsion fracture of the inferior margin of the left patella, free bone-density shadow in the left knee joint cavity, joint effusion; MRI recommended Left knee MRI: Bone injury at the inferior margin of the left patella and lateral femoral condyle; recommend thin-slice CT to rule out fracture. Possible injury to the upper portions of the patellar ligament and medial and lateral collateral ligaments. Possible injury to the posterior horns of the medial and lateral menisci. Large amount of effusion in the joint cavity and suprapatellar bursa; correlate with clinical findings. Right knee CT: Slightly irregular cortical bone at the inferior margin of the right patella. [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 with exploration and 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 good spirits but reported left knee pain. Physical examination: Vital signs stable, left knee immobilized in a patellar brace, swelling and tenderness present, no sensory deficit in the left lower limb, strong dorsalis pedis pulse, good distal circulation, and normal toe movement. [Post-Discharge Medications and Recommendations]: 1. Further evaluation recommended at another hospital’s orthopedics or sports medicine department; 2. Follow-up in the orthopedic outpatient clinic. [Treatment Outcome]: Discharge against medical advice Date: December 13
The discharge summary from Hospital A states: “The original plan was elective left knee arthroscopy with exploration and medial patellofemoral ligament reconstruction; the patient requested discharge against medical advice.” However, the girl’s parents said they chose to leave because Hospital A recommended surgery on both legs. The following is the left knee 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: Left knee joint, anteroposterior and lateral views Method: DR Radiographic Findings: Avulsion fracture of the intercondylar eminence of the left tibial plateau, with the fragment now showing mild medial tilting. Mild soft tissue swelling at the supracondylar region of the femur on the fibular side. No other bone abnormalities. Joint is in position with normal joint space. Radiographic Diagnosis: Avulsion fracture of the intercondylar eminence of the left tibial plateau with mild medial tilting of the fragment; mild soft tissue swelling at the supracondylar region of the femur on the fibular side.
* The following is the left knee CT plain scan and reconstruction report from Hospital C. Department: Orthopedic Arthroscopy Specialty Examination Category: CT Request: Clarify diagnosis Clinical Diagnosis: Trauma Examination Site and Name: Left knee CT plain scan (3D) Method: Left knee transverse CT plain scan + 3D reconstruction Imaging Findings: Small bone fragment at the posterior margin of the left patella, strip-like high-density shadow in the joint cavity, small amount of left knee joint effusion, small depression in the lateral condyle of the left femur, shallow trochlear groove of the left femur. No obvious bone abnormalities in the other bones of the left knee. Joint in position, smooth articular surfaces, no obvious joint space narrowing. Imaging Diagnosis: Shallow trochlear groove of the left femur, possible left patellar dislocation with post-reduction changes, small avulsion fracture of the left patella, small amount of left knee joint effusion. 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 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, others suggested deciding on surgery based on progress, and some advised immediate surgery. However, none of the four doctors mentioned the tibial plateau intercondylar eminence fracture. They also did not clearly state whether surgery would involve the left knee only or both legs. Several doctors did document in writing the congenital shallow trochlear groove.