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Original Question

What would be the rationale for inclusion for the Lab findings of the CT on the right knee for the patient? Patient data: Patient is a male in their 30s with a fracture of tibia and fibula, right closed, initial encounter, on regular diet, and at normal weight. Peripheral Vascular: no cyanosis, Left lower extremities – non-pitting, right upper extremities- none, right lower extremities edema- +1. Lower extremities are well perfused. Palpable pulses. Capillary refill less than 3 seconds. Neuro: Alert and oriented to person, place, time and orientation. Pupils are equal, round, reactive to light and accommodated. Gag reflex is intact and speech is appropriate. Purposeful motor function, strength, and sensation in all extremities. Absence of confusion, mental status changes, posturing, seizures, headaches, or coma. Absence of spinal precautions, drains, or monitoring devices. Absence of facial droop, slurred speech, unilateral weakness or numbness. CT Knee right findings: There is comminuted fracture of the proximal tibia with major fracture line along the lateral plateau w/10mm lateral distraction. There is an oblique/transverse fracture across the proximal tibial metadiaphysis with mildly displaced fracture fragment. Additionally, there is a fracture lucency involving the tibial spine with superior displacement of the fracture fragment by almost 9-10 mm. There is no tibial plateau central depression. There is partially visualized external fixation hardware within the distal femoral shaft. There is a comminuted fracture of the fibular head as well with multiple destructive fracture fragments. There is a small, displaced fracture fragments along the superomedial margin of the medial femoral condyle with donor site likely along the medial margin of the medial central femoral condyle. There is moderate sized lipohemarthrosis. There is a non-specific fat stranding left knee.

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