Medical Note
DOI - MM/DD/2009
Patient was 40-year-old in 2009 when he stepped out into the path of a forklift. The forklift ran over both of his feet. He sustained the following injuries;
1) Severe degloving injuries to his left foot
2) Open fractures and lacerations to his right foot and ankle
3) Laceration to his right forearm.
4) Right knee injury.
In the immediate post-injury period, he underwent an emergent left below knee amputation, debridement and ORIF of a right bimalleolar ankle fracture, and repair of a right forearm laceration. He also underwent fluid resuscitation and treatment for a previously undiagnosed diabetes mellitus (blood glucose 250 in the ER).
There is no record of injuries to the C-spine, L-S spine, shoulders, chest wall, or his umbilicus.
He required multiple debridement procedures and eventually a skin graft to his right foot to obtain a clean, dry wound. In the near immediate post-injury phase, he developed Post traumatic stress syndrome and depression and he has required ongoing therapy for these.
He was non-weight bearing for several months, and, at about 5 weeks out he began to complain of low back pain, bilateral shoulder pain, and persistent right knee pain. MRI’s were done.
1) Shoulders revealed bilateral DJD of the A-C joints, supraspinatus tendinosis, and partial thickness tearing of the supraspinatus tendons bilaterally.
2) The L-S spine revealed degenerative changes with mild stenosis at the L2-3, and L3-4 levels (all chronic, no acute findings).
3) The right knee study revealed partial tear of the lateral meniscus and a marked strain of the medial collateral ligament, and fairly severe chondromalacia patellae. The meniscal tear and strain of the MCL most likely do relate to this accident, coming from a severe valgus strain of the right knee.
I get the sense that this patient is not particularly athletic or trim (it’s not stated anywhere in this record). I feel that his low back pain and bilateral shoulder pain are due only secondarily to the injury of MM/DD/2009.
They are due to a dramatic change in his level of activity and the necessity to do transfers from bed to chair and back with his shoulders because of his non-weight bearing status. I suspect that this 40yo laborer had the usual amount of wear and tear to his shoulders that most of us have, and they probably had their share of damage before this accident.
The weakness in his right upper extremity is accident related. The laceration was said to have extended down to muscle (and possibly into the muscle) resulting, to some extent, in the weakness and contractures noted chronically. The normal EMG and NCV ruled out cervical radiculopathy/carpal tunnel.
The osteopenia noted on later x-rays is due to his prolonged immobilization.
His bowel problems, reflux esophagitis, most likely relate to his earlier medical history (which is apparently unknown to us).
I definitely believe that his “painful” chest wall lipoma and umbilical hernia, both of which “showed up” quite late, have nothing to do with the injury of MM/DD/2009.
His post traumatic stress syndrome and depression most likely do relate to this injury.
This patient suffered a terrible trauma and should be disabled from any manual type labor as per Dr. XXX Anderson’s report. As this young man is most likely bilingual, and if he wants to continue working, he might be an excellent candidate for vocational rehabilitation; He should consider becoming a translator for the state or legal field, I understand there’s decent money in that area for a good translator.
Medical Note
2 of 2