What’s the diagnosis? #11

This gentlemen fell asleep on the toilet and fell off bumping his head. There was no LOC. There should be enough information in the first x-ray to guess at least one diagnosis which in this context should lead to the second.

https://gmep.org/media/12308

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The underlying diagnosis is ankylosing spondylitis. The c-spine x-ray shows  the bamboo spine appearance pretty well.

If someone has ankylosing spondlylitis then they’re incredibly high risk for spinal fractures in the context of even minor trauma like this.

Outcome

The inadequate nature of the plain film was recognised (I can only see to C6) and a CT was obtained.

https://gmep.org/media/12309

Hopefully that’s a fairly obvious fracure to most of us.

I’ve seen a few of these c-spine fractures in people with bamboo spines and they seem to do fairly poorly. The other thing is to be careful with immobilisation. If your neck is normally in a hyperflexed position then ramming it back into a neutral position with a collar seems a terrible idea. I tend to immobilise these guys in position of comfort – be that partially sitting up with a folded sheet to support the head and allow immobilisation with blocks or collar.

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What do these two x-rays have in common?

Simple question. What do these two chest x-rays have in common. No info I’m afraid.

https://gmep.org/media/12305

https://gmep.org/media/12306

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They are both x-rays of the same patient.

He had fallen through a roof and fractured his left humerus but was clinically quite well. The first x-ray was supine. After c-spine clearance and observation he remained very well and despite the official report of  CXR 1  suggesting to get a CT thorax, we sat him up and got CXR 2 and left things be.

This illustrates the impact of projection and position on CXR findings. We would all agree that the first x-ray as a massive and concerning mediastinum and the second looks fine.

It would be wise to get a CT on these people if the clinical situation demands it, which is  a slippery (but still accurate) way of saying that lots of info goes into deciding when to go looking for a mediastinal haematoma or aortic dissection.

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What’s the diagnosis 010


This is a pretty incidental finding so no history to give.

https://gmep.org/media/12303

1) Which bit is abnormal?

2) What is it?

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Hydatid Cyst

These also look pretty funky on plain films

Click for source

It is caused by Echinococci which is caused by a tape worm common in central and south america. The organ involved usually determines the presentation.

Add to your list of “things I like to have heard of but don’t need to remember in resus at 3am…” [/peekaboo_content]

 

 

What’s the diagnosis 009


Here’s an image sent to me by a good friend and mentor in EM from up North.

Any ideas what’s wrong with this image?

https://gmep.org/media/12299

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While it may look like this person has swallowed a baby it’s not actually the case.

There is calcification of the stylo-hyoid ligament. If this is associated with neck pain and dysphagia then it rejoices in the moniker “Eagle’s Syndrome.”

https://gmep.org/media/12297

As a quick anatomy reminder:

https://gmep.org/media/12301

The hyoid bone is held suspended between the floor of the mouth and the laryngeal skeleton. It’s mobility comes from the attached muscles and lack of any joint to the rest of the head and neck. The ligament lies parallel to the muscle of the same name.

https://gmep.org/media/12298

In Eagle’s syndrome it can be either calcification of the ligament or an elongated styloid process that causes the symptoms. Of note an elongated styloid is fairly common, Eagle’s syndrome is as rare as hen’s teeth as they say…

https://gmep.org/media/12300

The proximity of the styloid to the carotid sheath (and to CNvs 9-12) explains the symptoms that are sometimes present – dysphagia and very occasionally stroke.[/peekaboo_content]

Conclusion – What’s the diagnosis 008

A few days ago I posted this:

https://gmep.org/media/12291

And the answer is of course:

https://gmep.org/media/12292

What’s the deal with blow-out fractures then?

  • Typically from a blow to orbit and in particular the globe itself
  • Classically this is from a squash ball (which I’ve seen twice now) or in this case a fist

Why is the inferior orbital wall affected?

  • the orbit is pyrmidal in shape with the base of the pyramid facing you and the apex post in the skull. As the globe is forced backwards the walls of the orbit come under pressure

https://gmep.org/media/12294

  • Technically the thinnest walled part of the orbit is the medial wall and the ethmoid bone but the force in a blow to the globe tends to get redirected inferiorly rather than medially

What kind of problems can it cause?

  • First look at this guys CT and take a guess [UPDATE – I suspect the muscle labelled inf oblique is actually inf rectus but don’t worry too much about it]

https://gmep.org/media/12295

  • yes you’ve got it – opthalmoplegia
    • specifically difficulty in movements in the vertical plane. Even though sup rectus brings about superior gaze, the fact the inf rectus is trapped means that the eye is unable to be directed superiorly

Any other problems?

  • direct globe injury – this is a whole topic in itself but in brief think fixed or irregular pupil, severe pain, and reduced acuity.
  • orbital compartment syndrome – this is fairly interesting and worth a point or two
    • pressure can rapidly develop in the orbit either from oedema from the injury or a haematoma or build up of air in the orbital cavity from the opened maxillary sinus
    • the orbit it a fairly fixed compartment bounded by the bony walls and the globe and orbital septum
    • the pressure eventually will lead to an ischaemic and dead eye if not treated
    • treatment is surgical release, typically by a lateral canthotomy (that’s a fairly eye watering link by the way so be warned) – one of those procedures that Cliff Reid and Simon Carley suggested we should be thinking about in extreme situations.
  • big time vagal reactions
    • sometimes these people can brady and faint on you. They can vomit lots and look terrible too and that’s all thought to be down to vagal stimulation. Which brings me to my next point…
  • remember these patients have head injuries and ? brain injuries so that vomiting nd brady might not be down to vagal response but cushings reflex!
  • and remember too that if they have a head injury then they might have a neck injury. Not from a squash ball though…

And now that you’ve read all that can I strongly suggest that you go and read a similar and much better post on the same topic over on LITFL.