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Lumbar Spine Collapse: A Case Study

935 Words4 Pages

DOI: 4/25/2014. The patient is a 37-year-old male laborer who sustained a work-related injury to his wrist, left elbow, ribs, and head when the ladder he was on collapsed.
MRI of the right knee obtained on 01/26/16 revealed the following: medial meniscus: Grade 2 mucinous change, posterior horn; discoid lateral meniscus; anterior cruciate ligament (ACL) partial tear; medial cruciate ligament (MCL) thickening due to sprain or stress change; 1.5 cm osteochondral lesion at the medial femoral condyle with differential diagnosis that includes osteochondritis dissecans versus old osteochondral impaction fracture; medial femorotibial joint space narrowing; and Patella chondromalacia grade 1/2.
Urine drug screen result dated 06/28/2016 …show more content…

Palpation of the lumbar spine revealed hypertonic spasms along the lumbar paraspinal muscles bilaterally. Sensation is decreased to sharp at the thigh, foot at L4, L5, and S1 on the right. Lumbar spine range of motion is restricted due pain and stiffness on flexion, extension and left lateral bending. Straight leg raise is positive on the right. Range of motion of the left wrist is restricted on flexion and extension due to pain. Palpation reveals + 3 tenderness at the distal radioulnar joint of the wrist right, and the triangular fibrocartilage complex. Tinel's sign is positive and Phalen's sign is positive at the carpal tunnel. Patient has a positive EMG/NCV dated 12/17/14 for moderate to severe damage to the median nerve at the left wrist, consistent with right carpal tunnel syndrome.
Patient walks with a gait, favoring the left leg. Right knee swelling is seen at the patellar area. Range of motion was decreased due to swelling and pain. There is popping and snapping with flexion and extension. McMurray's test is positive on the right.
There is medial joint line tenderness on the right MCL and ACL tests. Chondromalacia patellar compression test is positive right with a grating sensation. Left knee range of motion is decreased. There is tenderness to the medial joint

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