Trauma Thursdays: Under the Knife

Trauma Thursdays: Under the Knife

Excerpts from my medical record, concerning my second surgery and the surrounding circumstances:

Pediatrician: R.M.
Operation Date: 02/17/00
Surgeon: W.C.
Assistant: J.M.
Pre-op Diagnosis: Left Abductor Contracture
Post-op Diagnosis: Same
OPERATION: Left Abductor Lengthening
EBL (estimated blood loss): Negligible
INDICATIONS: 11 year old female who had sustained a left thigh injury. Patient developed an abduction contracture and had limited flexion as well as adduction of her left hip. The patient has been treated with physical therapy and other conservative modalities, however, she failed to improve with them. The patient was now brought to the OR for release of her abductor contracture.
PROCEDURE: The patient was brought to the OR and was mask ventilated. The left thigh and hips were prepped and then draped. Incision was made posterior to the ASIS and extending in a proximal and posterior direction. The incision was carried through the skin and subcutaneous tissues. The tensor fascia lata was palpated and the fat above it was cleared. The tensor fascia lata was then isolated, and using electrocautery, was released. Care was taken to insure that only the tensor fascia lata was isolated and that the lateral femoral cutaneous nerve was not also similarly released. The wound was then copiously irrigated and subcutaneous tissues closed using 2-0 vicryl and the skin was closed using monocular sutures. Attention was then turned distally. Insertion of the iliotibial band above the knee was palpated and a small transverse incision was made above the palpated band. The incision was carried down through skin and subcutaneous tissues. Any bleeding encountered was ligated using electrocautery. Bands were similarly isolated using a hemostat and then brought up and exposed so that they could be released with electrocautery as well. Palpation of the wound was then performed to insure that there were no remaining bands. The hip was then taken through a range of motion. There was significant improvement of her hip flexion, as well as her adduction. Sterile dressing was then applied in the OR. The patient was then given injections of Lidocaine and Marcaine, at both sites. The patient tolerated the procedure well. The patient was awake in the recovery room and able to transfer herself to the stretcher and she was stable on transfer to the recovery room.

Oh, by the way, this surgery took place at University Hospital at the Health Sciences Center at SUNY Stony Brook.

Now…what led up to this ordeal? Here goes it.

DATE: July 26, 1999
DIAGNOSIS: Bone contusion vs. AVN (avascular necrosis) of the femoral head
NOTES: Brianna is a 11yo female who sustained an injury to her hip when she was skating. She took a fall and subsequently had significant pain in the leg. (That is somewhat incorrect. I fell off the rings at a playground and “landed funny.” Subsequently (as in a week or two later) I had pain so intolerable I had to limp home crying uncontrollably.) This has been ongoing for a fairly significant period of time. Subsequently she was seen by Dr. Carter an orthopaedist on the South Shore, had an MRI of the hip obtained. The MRI was read as osteonecrosis, versus possible bone contusion. She was sent along for further care.
PAST MEDICAL HISTORY: Unremarkable with the exception of the use of growth hormone and hyperthyroidism (Incorrect. HYPOthyroidism). She was the product of a normal pregnancy, gestational diabetes is noted in mom. Child was delivered at 6 pounds 9 ounces, walked independently at 19 months of age (Yeah I was lazy…so kill me.) She has been hospitalized for tonsillectomy, lymphoma which was ruled out.  (Wait WHAT?! Hold on. Did the author of this record mean to say that I was hospitalized for lymphoma, which was ruled out or did he mean to say that I was hospitalized for tonsillitis, in which during that time the doctor/ lab tech ruled out lymphoma? I was seven y/o. Note to self: ask Mother later.) She has no known drug allergies. Benign past medical history except as noted.
Family History: Benign.
SOCIAL HISTORY: She lives at home with her parents, is in the 6th grade and will be in a resource room for a diagnosis of some ADD(Haha!). She is active in dance.
PHYSICAL EXAMINATION: Reveals a marked limitation in motion of her hip on the left as a result of severe pain. She sits in a wildly abducted position, is unable to adduct to neutral to internally or externally rotate. The patient has intact sensation to the toes, brisk capillary refill, good motor power to the ankle, knee. The right lower extremity is unaffected and both upper extremities are unaffected. The child’s spine is straight, no sacral dimples. The child has an appropriate affect. The MRI is reviewed as well as the plain films. This looks like either a bone contusion versus an early AVN. I think treatment at this point in time should be focused on the possibility that it is a bone contusion. Start with ROM(range of motion) activities, edema(swelling) control, strengthening for the muscles. In addition a bone scan would be appropriate because I am concerned whether there may be some sacral iliac joint involvement. We will obtain this, she has an aversion to needles (This author’s avoidance of the usage of “and” is worrying).
PLAN: FU (follow up) in 4-6 weeks time after we have given PT a chance and also give her a call regarding the bone scan.

DATE: October 13, 1999
DIAGNOSIS 1: Femoral Head Contusion (notice change in diagnosis)
NOTE: Brianna presents today for a FU appointment. A discussion was held with her PT. She presents today with her dad. On examination today she does have a gait disturbance with a limb length discrepancy, left being longer than the right. Severe pelvic obliquity. Measurements of her limb lengths reveals the left is approx. greater than 1 centimeter shorter then the right, appears to be coming from the femur. (So which is shorter–the left or the right?)
PLAN: We will order a CT scanogramof her limbs to evaluate this appropriately. She denies any discomfort or pain and will like to participate in sports. I told her there is no reason why she cannot participate in sports at this time. Her neurologic exam is still normal, she has good motor power, reflexes, sensation are all normal. She does appear to have a slight curve of her spine, but does not appear to have a rotational component, I think this is from the pelvic obliquity. FU in 1 months’ time to reevaluate the CT scanogram and wrist for bone age.

DATE: November 22, 1999
DIAGNOSIS 1: Hip Contusion (another change)
NOTE: Brianna is seen in FU Evaluation. She is doing pretty well. The overall picture is satisfactory. Her CT scan and bone age are consistent. The big issue for her is that we have a concern as to continuing limitation in ROM of the hip. We will get her started with further exercise program, but if this really does not produce the results we would like, our next step is going to go with an epidural and ROM activities of the hip under anesthesia and then CPM(continuous passive motion machine) post operatively.
PLAN: FU in 6 weeks’ time seeing what progress is. If necessary we will add more aggressive interventions.

DATE: January 24, 2000
DIAGNOSIS: Abduction contracture of the hip (yet another change)
NOTE: Brianna has equal leg lengths. She has an abduction contracture which is giving her a limb length inequality. She reports she has no pain at this stage. I have discussed with Dr. Yland the possibly of an epidural. What I would like to try, under anesthesia, have full ROM of the hip without abduction contracture then I think an ambitory epidural would be the next appropriate step. If she does not have adequate range and indeed has fixed abduction contracture then I would plan a procedure. I have discussed this in gross detail with the father. We will set up the appropriate intervention.

DATE: February 14, 2000
PROCEDURE: H&P (history and physical)
NOTE: Brianna is seen for a H&P. She recently had a otis media (otitis media is a middle ear infection…very painful), finished her antibiotics approx. 1 week ago. We will have her checked to make sure she has no difficulties. We will bring her to the OR for examination under anesthesia of her left hip. The risks and benefits of the intended surgical procedure have been described to the patient nd family who wish to proceed, all questions have been answered.

DATE: February 28, 2000
DIAGNOSIS: Abduction contracture ilio tibial band SP rel
NOTE: Brianna is seen in FUr for an ilio tibial band status post release. The wound is clean, closed, dry. No evidence of infection, steri strips and absorbable sutures are in place. She has minimal complaints of pain, discomfort. She is given a prescription for NSAID and to begin PT for gait training and ITB(iliotibial band) stretching.
PLAN: FU in 1 month.

DATE: March 27, 2000
DIAGNOSIS: Ilio tibial band contracture
NOTE: Brianna is seen in FU for her ilio tibial band contracture, she has undergone a surgical release, has been undergoing PT and is doing beautifully. She runs now, which is a new thing that she has not been able to accomplish in quite some period of time. She walks with a near normal gait, there is still a minor limp present, but she is working on this. The wounds are healed per primum. The overall picture is satisfactory.
PLAN: FU in approx. 3-4 months.

I chose to log this because for MORE THAN A DECADE I was left in the dark about a painful experience in my life and now that I have received the information, I never want to lose it. Up to about a week ago, I have been thinking I’ve had a “tibial lengthening” as per word of my parents. It is also comforting to know the reason why I have to hold onto handrails and look at the steps when I am going down stairs, or why I have a slight struggle walking in a straight line and keeping my balance. It especially helps to know there is a cause to why my left leg tenses when the weather changes. Thank you, medical release form.


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