ORTHO FILES

ORTHO_1

CONSULTATION

This 30-year-old male has been followed by me.  He is a right BK amputee.  He has been having pain in the right side of his knee on the lateral aspect.  He did have resection of his peroneal nerve approximately 6 weeks ago.  The wound has healed, all but 1 small area.  It was felt that he may have some bursitis or tendinitis on the lateral aspect of the femoral condyle.  A few injections have been done which have helped somewhat, but he still has an area of persistent discomfort.  X-ray was obtained which is negative.

The lateral and posterior aspect of the knee was again injected with Xylocaine and Depo-Medrol.  If this does not help completely, we should start him back on some physical therapy.

ORTHO_2

HOSPITAL PROGRESS NOTE

He has chronic osteomyelitis of the right ankle from an old attempted ankle fusion.  Had obtained a gallium scan; it was found to be hot, and he also has an elevated sed rate.  This is all compatible with his x-rays, which do indeed show evidence of an underlying chronic osteomyelitis with cystic formation and poor union of the old attempted ankle fusion.  Otherwise he has a normal neurovascular examination.

On physical exam he has a chronically swollen, tender ankle.

States that the ankle wakes him at night.  He has difficulty ambulating about and has many problems with the ankle.

At this point it is felt that he is going to need to have some type of operative intervention to try to get the infection cleared up as well as to try to get the ankle fusion to heal.  At the present time this is an extremely complex problem.  With the underlying x-rays, he would need to have the old attempted ankle fusion completely taken down, resect all the dead bone, and at this present time it is felt probably he is a candidate for a new procedure in orthopedics called Ilizarov apparatus application with a corticotomy of the proximal tibia.  We could remove all the infected bone about the ankle fusion, cut the proximal tibia proximally, then pull the proximal portion of the tibia down to the ankle fusion where all the dead bone had been removed, and then try to get good bone on good bone to go ahead and heal.  He would need to be the hospital for probably 4 to 6 weeks with I.V. antibiotics as well as having the surgery done.

ORTHO_3

HISTORY AND PHYSICAL EXAMINATION

This patient works as a carpenter and was working on stairs when he fell through a stair and fell 6 feet.

The patient claims that he had a broken rib over the right rib cage and an injury to the right hip and right shoulder.

The patient was then referred to an orthopedic surgeon who, because of continuing complaints to the right shoulder, had an arthrogram done.  The patient states he then underwent surgery for the right shoulder.

Following surgery, he underwent physical therapy for 4-1/2 months and then returned to work.  The patient has been working since that time and has had no further treatment.

The patient states he does note occasional aching involving the right shoulder area.  He has no complaints for the right hip.

PHYSICAL EXAMINATION:  Weight 200 pounds, height 6 feet.

Patient walks without difficulty.  The gait is stable.  He is in no acute distress.

SHOULDER GIRDLE EXAMINATION:  Scapulothoracic motion is smooth and intact.  There is no percussion tenderness or spasm over the scapulovertebral borders.  He is able to forward flex his neck to 60 degrees, extend to 40 degrees.  Rotation 80 degrees/80 degrees, tilting 30 degrees/30 degrees.  The right shoulder shows a well-healed 4-inch scar over the anterior aspect of the right shoulder.

The shoulder girdle muscles reveal no atrophy or asymmetry.  The patient is able to abduct the right shoulder to 160 degrees, forward flex to 170 degrees.  External rotation is 50 degrees, internal rotation 60 degrees.  Shoulder abductors for flexors and extensors show a grade 4 strength against resistance.

There is a mild amount of crepitus on the passive range of motion of the right shoulder with minimal discomfort.  There is no catch or hangup of the right shoulder.  The biceps, triceps, and forearm muscles show no atrophy or asymmetry.  The deep tendon reflexes are 2+ and equal for the biceps, triceps, and the brachioradialis.

RIGHT HIP EXAMINATION:  The right hip shows full excursion.  He is able to forward flex to 130 degrees, extend through zero degree.  Internal rotation 50 degrees, external rotation 60 degrees.  The right hip abducts to 40 degrees and adducts to 40 degrees.  The range of motion at the right hip level is full with no crepitus.  The hip flexors, extensors, and abductors show excellent strength against resistance.

Patient is able to forward flex his back fully to 90 degrees, extend to 30 degrees, tilting 30 degrees/30 degrees, rotation 30 degrees/30 degrees.  Squatting ability is full.  The gluteus maximus tensing test is strong and symmetric.  Trendelenburg test is negative.  He is able to perform supine straight leg raises to 90 degrees bilaterally, and the deep tendon reflexes are 2+ and equal for the patellar and ankle jerks.  The extensors, flexors, invertors, and evertors are strong and symmetric against resistance.

DIAGNOSES

1.  Rotator cuff tear, per history, right shoulder.

2.  Right rib contusion.

3.  Right hip contusion.