Left Tibial Plateau Fracture: Case Study

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CHIEF COMPLAINT: Left tibial plateau fracture, status post ORIF on August 23, 2015. HISTORY OF PRESENT ILLNESS: Dewayne is here for a three week recheck of his left medial tibial plateau fracture. He has been nonweightbearing as instructed and wearing a hinged knee brace, while working on his range of motion. He notes that he has some occasional achiness but overall has noted improvement in his overall pain control. He has been going to physical therapy twice a week and is tolerating these exercises well. [ 1:00 Even with therapy, Vicoprofen once or twice a day on days when he uses physical therapy.] He notes no other new problems or conditions and his happy with his progress thus far. PHYSICAL EXAM: The patient 's swelling is greatly reduced. Incision is well healed and shows no…show more content…
He has been maintained in nonweightbearing and we will continue this. Hinged knee brace is to be worn when he is up and about for extra protection but if he is at home, it is okay to remove the brace to work on range of motion in a nonweightbearing fashion. He is using crutches and is comfortable with these. He should contact us immediately if there is any other change in his condition. Once again, we have had a long conversation about his diagnosis, prognosis, and treatment alternatives. He is possibly going to need some soft tissue reconstruction type surgeries in the future, though at this time, he appears to be healing well and show more stability than expected. We will base this on his clinical results. Long-term outcome shows a high likelihood of traumatic osteoarthritis of the knee, for which he may need both nonoperative and possibly operative treatments in the future. He understands this as it was discussed with him and all questions were entertained to his satisfaction. We will see him back in two weeks ' time for repeat clinical and radiographic

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