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October case #1
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October case #1 - October 11, 2007 2:20:59 PM
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Dr.Wagner
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A 35-year-old man presents to the emergency department (ED) complaining of sacral pain and right hip pain. The pain is associated with increasing swelling in these regions that began 3 days before presentation. The patient otherwise denies having any systemic symptoms, such as fevers, chills, nausea, or vomiting. His past medical history is significant for a recent admission to the hospital after being on the losing end MMA contest during an open weight tournament. The man, a welterweight, lost to the eventual champion, a light heavyweight. The patient suffered several facial lacerations, rib fractures, and multiple soft tissue contusions that follow fights. He alos suffered a concussion at "knock out". He was discharged to home from the hospital 10 days before presentation and has been doing relatively well, with adequate pain control for his rib fractures.
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RE: October case #1 - October 11, 2007 3:27:21 PM
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Tom Reeves DPT ATC
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Xrays? to rule out sacral fracture. He looks like he has a Left lateral shift so rule out disk rupture as well. Any neurological symptoms? does it hurt more to walk or sit? Does coughing provoke increased pain? How about deep breaths since the sacrum moves when you breathe. I understand he will have rib pain but does his sacrum hurt more when he takes a deep breath?
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RE: October case #1 - October 11, 2007 8:53:09 PM
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bonez
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Was there post match swelling in these areas? Did he walk in or is he walking without obvious gait deviations? What was he doing in the past 4-5 days? Is there pain on pelvic ring compression? Is he voiding normally?
In light of the symptoms I suspect thet the good Doc has some imaging for us but are there some labs as well say maybe urinalysis and posssibly markers for muscle damage?
< Message edited by bonez -- October 12, 2007 9:05:21 PM >
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RE: October case #1 - October 12, 2007 9:23:08 AM
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orthotherapist
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freudian slip withthe typing bonez - calling the doc god
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RE: October case #1 - October 12, 2007 4:25:03 PM
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Shill
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From: Madison WI USA
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At anytime during his time in the womb, was there a twin that seemed to disappear? If an arm pops out of that bulge, I am running for the hills!
Butt seriously folks....this seems a bit bizarre, and I cant think of anything beyond the previously mentioned posts.
The sacrum moves when someone breathes? Tom, explain please.
And finally, is SJ in front of this man checking the testicles?
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RE: October case #1 - October 13, 2007 1:41:55 AM
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Tom Reeves DPT ATC
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extension or counter nutation with inspiration (the top of the sacrum moves backward) the reverse with expiration. fractured sacrum might hurt with big breathing.
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RE: October case #1 - October 13, 2007 11:43:26 AM
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Dr.Wagner
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On physical examination, the patient’s temperature is 98.96°F(37.20°C), with a blood pressure of 129/67 mm Hg and a heart rate of 89 bpm. His respiratory rate is 20 breaths/min, and his O2 saturation is 95% while breathing room air. The patient is not in acute distress. The head, eyes, ears, nose, and throat (HEENT) examination shows well-healing facial lacerations with intact sutures. His chest is clear to auscultation on both sides, with normal cardiovascular and abdominal findings. The lower extremities have normal sensation and 5/5 strength
A visible fluid collection is observed in the proximal lateral aspect of his right thigh. The fluid seems to track up around the gluteus maximus muscle to the lumbosacral region, with slight crossing of the midline to the left (see patient photograph). The fluid appears to be a free-flowing, low-viscosity collection without evidence of erythema or ecchymosis. No loculation is noted on palpation, and the patient has no thickening or induration of the skin in the overlying and surrounding areas.
UA: 0-5 WBC, 5rbc, no bacteria, no nitrites, small blood, small protein, normal specific gravity
CBC: hgb 12, hct 35, wbc 10, platelets 230
bmp: na 135, k 4, cl 105, co2 25, BUN 18, cr 1.1, glucose 110
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Dr. Wagner DO
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RE: October case #1 - October 14, 2007 3:29:54 AM
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bonez
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Once again was there pain on pelvic ring compression? Was there difficulty to bear weight on one leg?
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RE: October case #1 - October 14, 2007 8:49:07 AM
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jma
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Has the fluid itself been analyzed to see what it is? Small blood in the UA does not sound right to me.
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RE: October case #1 - October 15, 2007 8:05:11 AM
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Tom Reeves DPT ATC
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a ruptured Glut max?!
This why I am not a radiologist.
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RE: October case #1 - October 15, 2007 8:38:01 PM
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bonez
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The fluid is outside of the edge of the gluteal tissue and there is even gluteal tissue from side to side.
There has to be some fluid source maybe free fluid from deep tissue hematoma which has now surfaced. There were no signs from infection was there?
If I recall Jaromir Jager had to have one of these drained in the playoffs several years ago and it was free fluid from a muscular structure. This guy likely got ground and pounded with multiple knees to the gluts as the source?
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RE: October case #1 - October 15, 2007 9:27:32 PM
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Dr.Wagner
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A closed, internal degloving injury is a clinically significant soft-tissue injury that is associated with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, which creates a potential space that can fill with serous fluid and/or a hematoma caused by the disruption of the arteries that perforate through the fascia mixed with viable and necrotic fat. The condition commonly occurs over the greater trochanter, but it can occur anywhere over the trunk, buttock, or thighs. When a closed, internal degloving injury occurs over the greater trochanter, the condition is known as a Morel-Lavallee lesion. As mentioned, this condition usually occurs in association with pelvic and acetabular fractures, but it can also occur in the absence of fractures. Direct crush injury to the pelvis or a high-speed motor vehicle crash are the most common mechanisms of injury. The importance of this soft-tissue injury may not be initially apparent; some patients present months after the initial event, complaining of soft-tissue swelling or contour abnormalities that are not resolving.
The diagnosis of a closed, internal degloving injury is usually based on physical findings (ie, a soft, fluctuant area over the lesion and a loss of local sensation). Diagnostic aids may include ultrasonography and CT imaging. Various methods or combinations of techniques for treating degloved areas have been suggested, including the application of compression dressings, fluid aspiration or liposuction, injection of sclerosing agents, deep fascial fenestration, prolonged closed surgical drainage, and open surgical debridement (ie, leaving the degloved area open for closure by secondary intention). A review of the available literature, while failing to reveal prospective comparisons, did demonstrate variable outcomes with different therapeutic approaches, ranging from complete resolution to the development of various complications, including infections and skin necrosis or breakdown. The complications associated with closed, internal degloving injuries often require extensive therapy and surgical management.
< Message edited by Dr.Wagner -- October 15, 2007 9:30:57 PM >
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Dr. Wagner DO
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RE: October case #1 - October 16, 2007 8:22:18 AM
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Tom Reeves DPT ATC
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wow, trauma must keep you on your toes. I have never heard of an internal degloving injury. thanks for the case.
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RE: October case #1 - October 16, 2007 7:44:09 PM
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trudytheot
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Dr. Wagner, Heard about this website from my new boss, Shane. First time on it. How nice to have your time and interest in sharing cases and challenges!! When I saw the photo of the "bump" my first thought was fascial. As an OT, I find myself less technically inclined than many PTs and more intuitive when first assessing a problem. Nice to know I was on the right track. Would not have touched this patient without your diagnosis, though! Too weird. Did just have an elderly woman this summer who fell out of bed and months later had a lump over her spine that was the size of a tennis ball. It had been evaluated out the wazoo with no diagnosis. Ultrasound did not reduce it. It caused her no pain but it bugged her. I got rid of it in 3 weeks with hands on tissue massage. Thanks again for your time.
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RE: October case #1 - October 18, 2007 7:35:54 PM
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Dr.Wagner
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From: Indianapolis
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Thank you...I find it fun...I would love to turn it into a formal course.
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Dr. Wagner DO
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RE: October case #1 - October 22, 2007 10:12:48 AM
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jma
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This was an interesting case. Definitely won't forget something like that if I ever saw it agan.
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Always check testicles! 