Detailed Treatment Process
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Male, 44 years old Discharge Summary Department: Orthopedics Admission date: September 15 of the previous year Discharge date: January 14 Admission status The patient presented with pain, bleeding, and limited movement in the left lower limb for 2 hours after a traffic accident injury. Physical examination: A skin avulsion wound approximately 20 cm long was found in the middle to lower segment of the left lower leg, with active bleeding. The wound had irregular edges, extended deeply to the muscle layer, and showed partial rupture of the left Achilles tendon with exposed tendon ends. Two 3 cm wounds on the anterior left tibia had exposed bone. There was mild local swelling and deformity of the left lower leg, with tenderness, percussion pain, bone crepitus, and a palpable crepitus sensation. Swelling, tenderness, and deformity were noted in the middle segment of the left thigh. The left dorsalis pedis artery pulse was palpable. Sensation was numb. Both lower limbs were essentially equal in length, with no abnormalities in the other limbs. X-ray revealed an open comminuted and displaced fracture of the mid-tibia and a left femoral shaft fracture. Admission diagnosis 1. Open fracture of the left tibia; 2. Skin avulsion injury of the left lower leg with partial rupture of the left Achilles tendon; 3. Left femoral shaft fracture Main examinations and special examinations (with dates and examination numbers noted) Routine blood tests, blood glucose, coagulation profile, liver and kidney function, electrocardiogram, chest X-ray, and electrolytes showed no significant abnormalities. Hepatitis B serology: negative. Treatment course After admission, the patient underwent emergency surgery under general anesthesia: open reduction and internal fixation of the right (as per original record) femoral shaft fracture, combined with debridement and internal fixation of the open tibial fracture and repair of the Achilles tendon rupture. The procedure went smoothly. Postoperatively, the patient received blood transfusion and anti-inflammatory treatment. The thigh incision healed by primary intention (Grade I/A). The lower leg wound healed poorly. On October 18, debridement of the lower leg was performed under EPA. The anterior tibial and Achilles tendon wounds continued to heal poorly. On October 25 and November 16, left lower leg flap transfer and cross-flap skin grafting were performed, respectively. Blood counts were normal at discharge. Sutures had been removed from the wounds, leaving only a 0.8 × 0.8 cm unhealed wound on the anterior tibia. The patient was discharged for outpatient dressing changes and follow-up. Discharge diagnosis 1. Open fracture of the left tibia; 2. Skin avulsion injury of the left lower leg with partial rupture of the left Achilles tendon; 3. Left femoral shaft fracture Discharge status General condition was good, with no subjective discomfort. Physical examination: The patient was alert and in good spirits. Incisions showed good skin healing. The thigh incision had healed by primary intention (Grade I/A). The lower leg had healed by secondary intention (Grade II/B). A 0.8 × 0.8 cm wound remained unhealed on the anterior tibia. The skin graft area showed no redness, induration, bleeding, or exudate. Distal limb circulation was good, with normal dorsalis pedis artery pulsation and symmetric sensation without impairment. No abnormalities in other limbs. Discharge instructions 1. Return for outpatient dressing changes every other day and specialist clinic review on Monday mornings. Plan for future adjustment of internal fixation. 2. Remain on bed rest with immobilization. Timing for weight-bearing activity to be determined at outpatient follow-up. Medications: Gentamicin × 20 ampoules for dressing changes. Cefuroxime axetil × 8 boxes. Levofloxacin × 6 boxes. Treatment outcome: Cured
Partial hospitalization costs totaled $41890, with self-paid portion $7319. Additional records indicate internal fixation plate implant costs of approximately $30000. Imaging review on October 13 showed severe osteomyelitis changes in the left tibial medullary cavity with obvious bone destruction. Subsequent years of continuous treatment ultimately failed, leading to amputation of the left lower limb. The patient’s sister, a nurse at the same hospital, was told by the orthopedic surgeon that the osteomyelitis resulted from the patient’s constitutional allergy to the internal fixation plate.