<Severe right hip pain after running ! >

A senior high school student suffered a sudden right hip pain while running.

Right hip ROM was marked limited with severe pain. Palpable of the right hip also revealed a severe tender area.

Here was his pelvic radiography

Avulsion fracture of the Anterior Superior Iliac Spine (ASIS)  was identified.

Tendons are much more stronger than muscles for any cross-sectional area. When a sudden strain is applied to a muscle-tendon-bone unit, the muscle will rupture, or the tendon will avulse at its insertion, together with a fragment of bone to which it is attached.

The most common avulsion fractures of the pelvis and its related muslce attachement are  (Figure)
1. ASIS                    -- Sartorius muscle
2. AIIS                     -- Rectus femoris muscle
3. Ischial tuberosity -- Hamstring muscles
4. Lesser tuberosity -- iliopsoas muslce

 

References:
1. Fernbarch, Wilkonson RH. Avulsion injuries of the pelvis and proximal femur. Am J Roentgenol 1981; 137:581-4
2. M Naude, Lindeque, Rensburg. Avulsion fractures of the pelvis. Sports Medicine. June 2003.

A 23 y/o young man fall by direct impact on left shoulder. Here is his radiographys.

1. What is the injury ?

     Acromioclavicular joint seperation.

2. What is the mechanism for this type of injury ?

    Fall with direct impact on the superior aspect of acromion.

3. What type of injury in this patient ?

    Type V.

4. What is the treatment goal for an EP ?

    Type I~II is conservative.

    Type III optional/controversial

    Type IV~VI is surgical intervention.

Classification of AC joint seperation:

     Type I appear normal

     Type II 0~50% displacement at the AC joint but no increase in the coracoclavicular interval

     Type III clavicle displaced superiorly 50% to 100% when compared to normal side.

     Type IV distal clavicle displaced posteriorly into or through the trapezius

     Type V  displaced > 100~300%

     Type VI distal clavicel displace inferiorly

Here were the post-op view of this patient



Left ankle pain after MBA

29 year-old female complaint of left ankle pain after MBA.

Her ankle was shown below

 

Medial ankle showed mild swelling and ecchymosis; Lateral ankle appeared normal

Her ankle x-ray:

Her Foot X-ray:  

What is your diagnosis ?

Left foot pain after MBA

18 year-old man presented after MBA. He ambulatory on scene or at ED. Left mild medial midfoot pain was complaint but without any abrasion or echymosis on dorsal or plantar foot.

Here are his left foot x-ray (AP and oblique view)

1. What clinical decision rule could guide the utility of x-ray ?
     Ottawa Foot Rule

2. What are the radiographic abnormalities ?
     Widening of space between the 1st and 2nd MT base.  Diastasis > 2mm is diagnostic of Lisfranc injury.

3. What is your diagnosis ?
     Lisfranc Injury.

4. What is Lisfranc Joint ?
     The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790–1847), a field surgeon in Napoleon's army.

5. What is the clinical significant of this injury ?
    Lisfranc joint fracture–dislocations and sprains carry a high risk of chronic secondary disability.

6. What is the different between Lisfranc joint and Lisfranc joint complex ?
   
7. What clinical sign could be found on this kind of injury ?
    Plantar ecchymosis sign
    Palpable tender on medial aspect of midfoot   
    Patient unable to bear weight while standing on tiptoe
    Check for dorsal pedis pulse and distal capillary refilling tie

8. What is the radiographic pitfall when interpretating the film ?
   Weight-bearing radigraphy is necessary to reveal minor injury.
   Compared with the normal side
   "Fleck sign"-small avulsed fragments within the joint space

    Here is the patient unaffected side x-ray:

 

   
 

Urethral Injury

When to suspect  urethral injury

• blood at the urethral meatus
• perineal ecchymosis
• blood in the scrotum
• high riding or nonpalpable prostate
• pelvic fracture
• inability to void

Earler's sign
Detsot's sign

Retrograde urethrogram
Retrograde cystogram

ATLS Primary Survey

Primary Survey

1. Airway Maintenance with Cervical Spine Protection

• "Airway Obstruction"
• Airway Manipulation
• check for FB and related fractures
• repeated assessment
• cervical spine immobilization-manual in line stabilization (MILS)

  
Comparison of cervical spine stabilization

2. Breathing and ventilation

• "Tension Pneumothorax"
  "Massive Hemothorax"
  "Open Pneumothorax"
  "Fail Chest with Pulmonary Contusion"
• Needle decompression, tube thoracostomy

3. Circulation with hemorrhage control

• Cardiac Tamponade
• blood volume and cardiac output-level of consciousness, skin color, pulse
• bleeding- SCALPeR
• Two large-caliber IV catheters, rate of infusion related to the internal diameter of the catheter and inversely by its length (not by the size of the vein)

  "Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?"

• IV solutions warmed or storage in 37~40 degree Celcius; high-flow fluid warmer for crystalloid fluids to 39 degree Celcius but blood product should not be warmed in a microwave oven.

4. Disability (Neurologic evaluation)

• Level of consciousness
• pupillary size and reaction
• lateralizing signs
• spinal cord injury level
• cerebral oxygenation/perfusion VS direct cerebral injury

5. Exposure/environment control