A 23-year-old softball player is referred to you after falling on an outstretched right hand. He complains of wrist pain. On physical examination, there’s tenderness on the anatomic snuffbox and scaphoid proximal pole.
Which of the following is the most likely complication of this patient’s condition?
Correct Answer B: This patient fell on an outstretched hand and given the physical examination findings with tenderness at the anatomic snuffbox and scaphoid tubercle, the most likely diagnosis is scaphoid fracture. With this type of fall, the wrist is radially deviated, which results in extreme dorsiflexion at the wrist and compression to the radial side of the hand. Forces are transmitted from the hand proximally to the arm through the scaphoid.
Scaphoid fractures are quite common, and account between 70% and 85% of all carpal bone fractures. According to anatomic location, scaphoid fractures are grouped into tubercle fractures, distal-pole fractures, and proximal-pole fractures. 80% of the scaphoid bone consists of cartilage, leaving limited space for entrance of the supplying arteries. The main blood supply is through retrograde branches of the radial artery. The proximal pole largely depends from the distal pole on blood supply and in the case of a scaphoid fracture, blood supply is interrupted, making the healing process of proximal pole more difficult. This is why the proximal pole has greater risk of avascular necrosis (choice B).
→ Osteomyelitis (choice A) is more likely to occur in patients with traumatic penetrating injury, sickle cell disease, intravenous drug use, and chronic ulcers.
→ Compartment syndrome (choice C) is serious condition that involves increased pressure in a muscle compartment. It is more common in forearm and leg where fascia separate muscles with layers that create confined spaces. While it may occur with bone fracture, it is far less common than avascular necrosis in scaphoid bone fractures.
→ Carpal tunnel syndrome (choice D) occurs due to median nerve entrapment resulting in paresthesia, pain, and numbness in the distribution of the median nerve due to its compression at the wrist at the carpal tunnel. This tunnel has 9 flexor tendons that pass through it. This syndrome is not the most likely complication of a scaphoid fracture.
→ Radial nerve damage (choice E) is more likely to occur with humeral shaft injury.
Key point: Scaphoid bone fracture is the most common among all carpal bone fractures and frequently occurs in those who fall on an outstretched hand. The most common complication of scaphoid bone fracture is avascular necrosis.
A 32-year-old male presents to the ED having been rescued from a burning building. He is moaning in pain, and unable to answer any questions. The patient's blood pressure is 105/75 mmHg, heart rate is 110 bpm, respiratory rate 20 bpm, and co-oximetry is within normal limits. He is 1.8m, and weighs 80kg. Burns are noted on the entire anterior and posterior surfaces of his right arm, and the anterior of his right leg, chest, and abdomen. Two large bore IV lines are started, and fluids are about to be administered.
What is the estimated initial minimum amount of resuscitation fluid to be administered to this patient over the next 24 hours?
Correct Answer C: Fluid resuscitation is a crucial part in the management of burn victims. The minimum amount of fluid to be administered in the first 24 hours is determined by the Parkland formula:
Minimum fluid = 4ml x weight (kg) x percent of body surface area burned
Half of the volume is administered in the first 8 hours, and the other half is administered over the following 16 hours. The percent of body surface area (BSA) burned can be estimated using the 'rule of nines' (image below). Lactated ringer's solution (LR) is the preferred fluid used in burn victim resuscitation because the sodium content and pH are closer to physiologic levels than normal saline. In addition, the lactate would be advantageous in its capacity to buffer the metabolic acidosis present in burn victims. Applying these rules, we see that the patient has burns over 36% of his body, thus 11520ml or 11.5L (choice C) is the minimum amount of fluid required for this patient in the first 24 hours.
Rule of Nines (Adult)
→ 8.7 L (choice A) is incorrect. This corresponds to a burned BSA of 27%.
→ 10 L (choice B) is incorrect. This corresponds to a burned BSA of 31.5%.
→ 13 L (choice D) is incorrect. This corresponds to a burned BSA of 40.5%.
→ 14.5 L (choice E) is incorrect. This corresponds to a burned BSA of 45%.
Key point: The Parkland burn formula is used to determine the minimum amount of fluid required for the resuscitation of burn victims in the first 24 hours. Fluid required = 4ml * weight in kg * percent of BSA burned, with half that amount being given over the first 8 hours, and the other half given over the following 16 hours.
A 34-year-old woman underwent an uneventful subtotal thyroidectomy for Grave's disease. A few hours later, you are called by the nurse because the patient is complaining of difficulty breathing. When you see the patient you find her distressed and you can hear inspiratory stridor. There is a large, firm, tense, anterior swelling right under the surgical wound.
What is the most appropriate next step in the management?
Correct Answer D: The development of hematoma after a thyroidectomy is a rare complication of the surgical procedure. Typically, a cervical hematoma is large, tense, firm, immobile anterior cervical swelling under the incision, which can be accompanied by respiratory distress and stridor. This complication presents in as much as 1.2 percent of patients post thyroidectomy.
Once the diagnosis is suspected, the patient should be taken to the OR for exploration of the incision. There is no recommended diagnostic study or procedure prior to opening of the incision as it is an emergency. Also, the patient should be kept awake in order to allow airway protection. Once the incision is open, the blood can be evacuated, making intubation easier.
→ It would be inappropriate to waste time in obtaining an X-ray (choice A) or a CT scan (choice B).
→ Intubation (choice C) should not precede the exploration of the incision, nor should laryngoscopy (choice E).
Key point: Although rare, a hematoma after a thyroidectomy is a life threatening complication. It is vital to know that exploration of the wound should precede any other study or procedure.
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