Open depressed skull fracture missed on computed tomography: a case report

A case of an open depressed skull fracture that was missed on standard computed tomographic (CT) scan is presented. The fracture was seen on a CT generated lateral scout film, and after repositioning the gantry, further CT images clearly showed the fracture and underlying brain injury. The authors recommend that all patients with head trauma undergoing head CT have either a CT generated lateral scout film or a lateral skull radiograph to assess the vertex of the skull, an area poorly visualized on standard axial images.     

A case report of an unusual sternal fracture

Most sternal fractures are transverse, and a lateral chest radiograph is diagnostic. We report a case of vertical sternal fracture that was not seen on plain radiographs but was revealed using computed tomography (CT). Thoracic CT with coronal reformatted images can also demonstrate sternal fracture lines, supernumerary synchondrosis, and costosternal joint abnormalities.     

An unusual case of an airplane headache

A 28-year-old man developed severe headache associated with changes in altitude during ascent and descent while flying in an airplane. Jabbing pain over the forehead and between the eyes began within minutes of ascent. It resolved once a cruising altitude was reached, but then returned at the start of descent.     

Golf club related basal skull fracture: a case study

Basal skull fractures, although rare, do occur and a high index of suspicion for high velocity injuries, should be at the forefront of the clinicians mind, particularly those from a golf club. Head injury in children is a common presentation to any Paediatric Emergency Department. With effective examination skills, recognition of signs of basal skull fracture such as haemotympanum, even in the absence of altered neurological findings, ensures safe and effective practice enabling correct and justifiable clinical decisions to be made. This is vital to ensure not only the correct investigative procedure is requested and performed, but also on discussion with the appropriate specialists, the correct treatment is also prescribed. This case study examines the use of computed tomography in the diagnosis of basal skull fractures and highlights further discussion into the appropriate treatment of children diagnosed with basal skull fractures.     

An unusual case of paralytic ileus after jellyfish envenomation

A 31 year old tourist presented with paralytic ileus after jellyfish sting. This unusual presentation after jellyfish envenomation is reported and the literature reviewed for jellyfish envenomation syndromes.     

螺旋CT三维重建在颅骨凹陷性骨折诊治中的应用价值

目的总结螺旋CT三维重建在颅骨凹陷性骨折诊治中的应用价值。方法对18例颅骨凹陷性骨折进行CT扫描及螺旋CT三维重建,指导临床治疗。结果23例经CT-3D均能清楚显示凹陷骨折部位及深度,诊断明确,保守及手术的病例恢复效果均良好。结论螺旋CT三维重建在颅骨凹陷性骨折诊治中具有较高价值。     

An unusual case of the cephalic vein with a supraclavicular course

While the subclavian or axillary vein can be safely and successfully punctured in the majority of cases, some device implanters still prefer cut down to the cephalic vein as the initial approach to venous access for transvenous placement of pacemaker or defibrillator leads out of concern for the risk of pneumothorax, subclavian crush, and other possible complications. However, very occasionally, the cephalic vein crosses superficial to the clavicle to join the external jugular vein, making it rather unappealing for this purpose. Relying on a guide wire introduced through the cephalic vein to guide puncture of the subclavian vein is unlikely to be successful in such a situation and may cause accidental damage to the vital structures in the thoracic inlet region. Device implanters need to be aware of this anatomical anomaly because of the implications for transvenous lead placement.     

Postpartum sacral stress fracture: an unusual case of low-back and buttock pain

Low-back and buttock pain is a common complaint during pregnancy and the postpartum period and is usually attributable to mechanical lesions of the pelvis. Sacral stress fractures are unusual but important causes that should be considered in differential diagnosis. To date, only eight postpartum sacral stress fractures have been reported in the literature. A 32-yr-old woman presented with low-back and right buttock pain that started 15 days after uneventful cesarean section delivery. Imaging studies revealed a right sacral stress fracture. Lumbar spine and femoral neck bone mineral density were normal and, except for pregnancy and lactation, no risk factors for osteoporosis were identified. There was no history of trauma, excessive weight gain, strenuous physical activity, or contribution of mechanical factors. The question remains whether this is an insufficiency fracture or a fatigue fracture. Clinicians should consider sacral fracture during pregnancy and the postpartum period as a diagnostic possibility in patients with low-back and/or buttock pain.     

An unusual transcapitate fracture of the wrist

A patient sustained a crush-type hyperextension injury to his wrist, and presented to the emergency department (ED) with wrist pain, swelling, and paresthesias along the median and superficial radial nerve distributions. His initial radiographic study was interpreted as showing a radial styloid fracture. The next day, he returned for a scheduled revisit with continued wrist pain and swelling. He also had loss of two-point discrimination in the median nerve distribution and loss of thumb opposition. Repeat radiographs were interpreted as showing not only a radial styloid fracture, but also a fracture of the capitate with the proximal fragment rotated 180° in the sagittal plane. The patient was admitted for surgery, and did well, with good return of function. The unusual position of the capitate fracture obscured the common signs of fracture recognition and thus went unnoticed on the patient's initial ED visit. However, in light of the patient's disproportionate symptoms with seemingly negative diagnostic study results, appropriate follow-up care was given, and definitive treatment was appropriately rendered.     

An unusual case of poisoning

The case of a 49-year-old alcoholic man with obtundation is presented. The patient was presumptively diagnosed with methanol intoxication due to the presence of metabolic acidosis with high anion and osmolar gaps. Laboratory testing revealed toxic levels of propylene glycol instead. An exercise in estimating the concentration of toxic alcohols and glycols is given, and the literature on poisoning with this unusual but commonly encountered intoxicant is briefly reviewed.     

An unusual case of pneumonia

A previously healthy 37-year-old man was admitted with a two-month history of increasing shortness of breath and high temperature. A chest X-ray demonstrated bibasal shadowing and small bilateral pleural effusions; arterial blood gases demonstrated low pO2. Despite intravenous antibiotics no significant improvement was observed. A high-resolution chest computed tomography showed diffuse ground-glass opacification with segmental and subsegmental airways opacification, indicating fine fibrosis. Subsequently, open lung biopsy showed diffuse alveolar damage and a histopathological diagnosis of acute interstitial pneumonia (Hamman-Rich syndrome) was made. Antibiotics were stopped and high intravenous doses of steroids were given with a dramatic improvement in the patient's breathing and radiographic findings. The pathophysiological mechanisms of acute interstitial pneumonia and current therapeutic options are discussed.