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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

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What do my lab test reports indicate?

Answered by
Dr.
Dr. Praveen Tayal

Orthopaedic Surgeon

Practicing since :1994

Answered : 12020 Questions

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Posted on Mon, 22 Aug 2016 in Back Pain
Question: I am a T12 incomplete paraplegic x30 years. I am now dealing with a broken femur that occurred three months ago, as well as a pressure sore (i was so proud that after 30 years I had never had a sore...damn).
I am attaching a pic of my sore, and will get a copy of my xrays and ct scan. When I went to the hospital and told them I had a broken femur, they were a bunch of asses and decided that a 20 year old break was the problem. NOT!

IMPRESSION:
1. Acute on chronic supracondylar distal femur fracture.
2. Severe osteopenia.

INDICATION: Right knee pain.

TECHNIQUE: A digital scout radiograph was obtained. Multiple thin
high resolution CT images were obtained through the lower extremity
of interest.

COMPARISON: None

FINDINGS:

Synovium: A small joint effusion is observed.

Soft tissues: Diffuse fatty muscle atrophy is noted most prominently
involving the posterior compartment musculature as well as the rectus
femoris.

Bones: Severe generalized osteopenia degrades assessment. There is a
transverse supracondylar distal femur fracture. Moderate smooth
periosteal reaction is noted about the lateral cortex of the distal
shaft compatible with an old fracture. A superimposed more sharply
marginated transverse fracture line through the supracondylar region
is noted suggesting an acute on chronic fracture. Mild callus
formation is evident about the fracture site.

The condylar fragment is laterally displaced 2 cm in relation to the
shaft. Additionally, the condylar fragment is posteriorly displaced
approximately 7 mm in relation to the shaft.
No intercondylar fracture line identified. No additional fracture
demonstrated.





Dictation Location: XXXXXXX OR 97477

DICTATED BY: Jerrell Ingalls, M.D. on 5/8/2016 14:35:38
SIGNED BY: Jerrell Ingalls, M.D. on 5/8/2016 2:42:25 PM

TR:
DT:

Narrative
LOCATION: SHRB


CT LOWER EXTREMITY RIGHT WO CONTRAST (CT-34) CT-34

Component Results
There is no component information for this result.

General Information
Collected:
05/08/2016 12:40 PM
Resulted:
05/08/2016 2:42 PM
Ordered By: XXXXXXX J Burt, MD
Result Status:
Final result
This test result has been released by an automatic process.
doctor
Answered by Dr. Praveen Tayal 57 minutes later
Brief Answer:
An old fracture with a superimposed new fracture.

Detailed Answer:
Hello,
Thanks for posting your query.
The CT scan findings are suggestive of an old fracture with partial healing with a new fracture in the lower end of femur. The bones and muscles are thinned out and weak due to immobilization.
The open sore that you have is a pressure sore and needs a regular debridement and dressing for it to heal. Oral broad spectrum antibiotics are also needed to prevent the infection in the area.
I hope this answers your query.
In case you have additional questions or doubts, you can forward them to me, and I shall be glad to help you out.
Wishing you good health.
Regards.
Dr. Praveen Tayal.
For future query, you can directly approach me through my profile URL http://bit.ly/Dr-Praveen-Tayal

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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