DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left tibial plateau fracture.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant, community ambulatory Hispanic female with a past medical history significant for osteoporosis, hyperlipidemia, and rosacea, who sustained a twisting injury while shopping today. She awkwardly twisted her knee and hyperextended it. The patient had immediate right knee pain, particularly over the anterior aspect of the knee. She had difficulty bearing weight. She denies any prior knee trauma or surgery. She was taken to the hospital where clinical and radiographic evaluation revealed a nondisplaced closed left proximal tibial fracture. She denies any other orthopedic symptoms.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: Denies.
ALLERGIES: No known drug allergies.
MEDICATIONS: Please see the emergency room records for the list.
SOCIAL HISTORY: The patient denies alcohol, tobacco, or illicit drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Significant for left knee pain.
PHYSICAL EXAMINATION: Vital Signs: Stable, afebrile. General: She is awake, alert, and oriented x3. On examination of the left lower extremity, the skin is circumferentially intact. There is mild soft tissue swelling over the anterior aspect of the knee. There is no ecchymosis. The foot is warm and well perfused with brisk capillary refill. Dorsalis pedis pulse is palpable and strong. Sensation is intact to light touch distally in the distribution of the sural, saphenous, superficial, peroneal, deep peroneal, and tibial nerves. She is able to actively dorsiflex and plantar flex the foot and toes against gravity. There is no calf pain, swelling, or tenderness to palpation. There is no tenderness to palpation about the forefoot, midfoot, hindfoot, ankle or lower leg. There is point tenderness to palpation over the proximal tibia. There is a small knee effusion. There is no warmth or erythema. From a flexed position, she is able to fully extend; however, this is uncomfortable for her. The patellar and quadriceps tendons are intact. There is tenderness to palpation over the proximal lateral tibia. There is no tenderness to palpation over the distal femur. The knee is stable to varus motor stress testing at 0 and 30 degrees of knee flexion. Passive range of motion is from full extension to approximately 65 degrees of flexion. Further flexion is limited by patient discomfort.
Radiographs of the left knee demonstrate a nondisplaced tibial plateau fracture in the anterior aspect of the joint just proximal to the tibial tubercle.
ASSESSMENT AND PLAN: Closed minimally displaced left tibial plateau fracture. The diagnosis was reviewed in detail with the patient and her husband. Treatment options were discussed in detail, including nonoperative versus operative. Based on the nondisplaced nature of the fracture and the intact extensor mechanism, our recommendation is for closed nonoperative treatment. Today, she was placed into a soft compressive dressing as well as a knee immobilizer, which is to be locked in extension. She may remove the brace for hygiene purposes. She may be touchdown weightbearing on the left lower extremity. She will be crutch trained in the ER. We will arrange for office followup in two weeks’ time for repeat clinical and re-evaluation with AP and lateral radiographs of the left knee to be taken with the brace removed. If there are problems prior to the next appointment, she will give us a call. She understands the treatment plan as above.
