A 36 year old male presents through your sub-acute area with increasing facial pain & swelling. He reports a simple trip and fall 18 hours earlier (no alcohol on board, recalls all events), where his right cheek struck a concrete step. He had no LOC at the time, and has no historical features concerning for intracranial injury.
He is worried today as the swelling ‘just keeps getting worse’.
On examination he has obvious marked right zygomatic/maxillary swelling and ecchymoses. His cranial nerves are ok (particularly extra-occular movements and facial sensation). When you palpate his facial bones, for find something unexpected which leads you to expediting his CT scan….
What has happened here ?
What other injuries may have been sustained ??
What do you do next ???
A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.
No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.
Here are his initial xrays….
As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….
This patient has been in your ED for over 24 hours waiting for a CCU bed. He presented with vomiting and syncope, but acquired left sided rib fractures during his collapse. He has been comfortable for most of the day on nasal-prong oxygen and a morphine PCA.
You are asked to see him as he has sudden worsening of his left-sided chest pain. He has become clammy and hypoxic.
This is what you see….
What’s going on ?
What are you going to do now ??
A few days ago I was looking after a 31/40 gestation restrained passenger from low-speed MVA with a slight seatbelt abrasion in her RIF & mild suprapubic pain. She looked well, HR 70 with BP 108 systolic and no features of peritonism.
As I placed the US-probe on for her FAST, this was the first image I acquired…..
A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!
You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.
This is his supine CXR…
EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….
… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.
Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).
These are two of his original xrays.
I thought this case gave me the perfect excuse to share one of my favourite orthopaedic papers that I discovered earlier in the year.
by Yu JS, Cody ME in Emerg Radiol. 2009 Jul;16(4):309-18.