case of the week sept13th (Full Version)

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Dr.Wagner -> case of the week sept13th (September 13, 2007 1:08:04 PM)

Motorcycle wrecks seem to be “in vogue” this year for the trauma service. This fellow was riding his  Harley out on the street, and was side-swiped by a car.

Here is his xray:




[image]local://2287/382040DAD54C4C878EAEF3A83DB8CBCD.jpg[/image]



ehanso -> RE: case of the week sept13th (September 13, 2007 1:59:35 PM)

The AC joint looks a bit unusual.



jma -> RE: case of the week sept13th (September 13, 2007 2:11:44 PM)

Agree with the above. AC joint definitely looks displaced. I don't think I would want to play around with that shoulder unless it was reduced somehow.



Dr.Wagner -> RE: case of the week sept13th (September 13, 2007 3:25:00 PM)

because this is late in the week...diagnose from this xray only.  No clues, no exam.  Radiograph only.

Give your best answer.
Answer on Sunday/Monday



ehanso -> RE: case of the week sept13th (September 13, 2007 4:01:04 PM)

I"ll upgrade my view to a distal clavicular fracture. The whole shoulder complex looks depressed. This could be the angle of the x-ray. If it is depressed as much as it appears, must consider some brachial plexus involvement.



bonez -> RE: case of the week sept13th (September 13, 2007 9:07:43 PM)

Well where I come from medico legal issues require two views of the injured area from 90 degree angles. I suspect that the real problem will appear in the part of the ap that we don't see. The presence of the soft tissue striations of the pectoralis fibers suggest air empyhsema to me. Most likely cause is a high rib# that has a fragment that entered the pleural space. This has allowed air to escape into the surrounding soft tissues resulting in the striations. Additional causes could be #'s of other structures on the chest.
The AC has been burned through on this single view not allowing a call on the status of the joint. he distal clavicle seems to have normal alignment as well.
If it is a rib # and all else is stable and the lung stays inflated then time will result in resorbtion of the air and manage as any other rib #. This can be a sign of oter potential serious trauma so be vigilent.



Shill -> RE: case of the week sept13th (September 14, 2007 8:23:12 AM)

That is interesting bonez, that the air in (or is it out of ?) the pleural space makes the striations of the pec visible. I dont see chest films on a regular basis, but that is the first time it was easy to pick out the pec.  Thankfully I didnt have to pick a pec of pickled pectorals.  Sorry, I am losing it.  Anyway, very astute observation.  I cant see anything obvious to me with the bony structures on the microscopic picture of the film.



Dr.Wagner -> RE: case of the week sept13th (September 16, 2007 12:16:19 PM)

The answer is Subcutaneous Emphysema from pneumothorax.  It is true that this xray does not show the pneumothorax, but those that are less than 15% of lung volume can be difficult to see.  In this case, this was due to a high rib fracture allowing the air to escape into the pectoralis.




[image]local://2287/3E108839A6754143AD4D4E3414A5ED23.jpg[/image]



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