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Acute nerve injury as a complication of closed fractures or dislocations of the elbow
sis. Splenic vein thrombosis can follow a single mild episode of pancreatitis as well as chronic severe cases, and pseudocysts are not necessarily associated. Some patients may have jaundice and a pancreatic mass which has been shown to be inflammatory. The key to diagnosis is angiography, in which the venous phase of the study demonstrates the pathology. Some patients may have splenomegaly. Treatment depends on the presence or absence of bleeding and its severity. In cases unresponsive to medical therapy, splenectomy is indicated. Risk of bleeding in patients with splenic vein thrombosis and varices is not known. This study suggests the incidence may be as high as 70%. ( E d i t o r ' s note: It is curious that more cases of this entity have not been encountered since pancreatitis is so common in the alcoholic population. We will certainly look for it, especially in the bleeding alcoholic who lacks ascites or jaundice.)
Nancy Bodelson, MD
splenic vein thrombosis Fractures of the scapula. McGahan JP, Rab GT, Dublin A, J Trauma 20:880-883, (Oct) 1980. A retrospective study of 121 p a t i e n t s s u s t a i n i n g scapular fractures over an eight-year period was performed. The average age of patients with such fractures was 35 years; twothirds of those injured were men. A great deal of force was necessary to break the scapula, as is evident in t h a t 81% of patients were involved in some type of vehicular accident. A significant n u m b e r of patients had t h e i r fractures overlooked initially, which reflects the fact t h a t a high percentage (88%) had associated injuries t h a t detracted from careful evaluation of the scapula. Forty-four percent had rib fractures; 26%, clavicle fractures; 13%, neurologic deficit; and 16%, pulmonary complications. Peripheral nerve injuries were uncommon, and were almost always associated with fractures of the acromion process. The most common injured regions of the scapula were the body and neck, being injured in 43% and 26% of patients, respectively. Treatment of these injuries consisted of immobilization for three weeks with emphasis on early ROM. Most patients were able to r e t u r n to work in four to six weeks a n d r a r e l y were t h e r e l a t e r complications. (Editor's note: Another fracture along with rib number 1, 2 or 11, 12 in which the significance of bone injury is of lesser importance than associated or underlying damage.)
Ken Jackimczyk, MD
fracture, scapula Acute nerve injury as a complication of closed fractures or dislocations of the elbow. Galbraith K, McCulIough C, Injury 11:159, (Oct) 1980. A retrospective review of 1,540 p a t i e n t s s u s t a i n i n g closed fractures or dislocations of the elbow was performed. Among these patients, 21 cases with objective neurologic deficits were found and analyzed. Those cases with t r a n s i e n t parasthesias were not considered. Nerves involved were u l n a r (nine cases), median (five cases), radial (three cases), anterior interosseous (two cases), a n d posterior interosseous (two cases). Nine of the 21 cases had persistent nerve damage. Uln a r nerve palsy was seen most commonly with posterior elbow dislocations (six), b u t also with h u m e r u s fractures (two) and medial epicondyle fracture (One). Only two patients with u l n a r deficits had full recovery. Radial nerve deficit was seen in three patients, two with Monteggia fractures and one with a fractured capitellum. One had a persistent defect. Four h u n d r e d sixty-five supracondylar fractures produced five median nerve palsies. Anterior interosseus involvement
108/558
Ann Emerg Med
was seen in two patients, one with a supracondylar fracture and one with an olecrannon fracture. Both patients had full recovery. Two patients sustained posterior interosseus deficits secondary to Monteggia injuries and both showed full recovery. ( E d i t o r ' s n o t e : While these troublesome complications are rare, early recognition in the emergency department permits appropriate foUowup and early therapy.)
Ken Jackimczyk, MD
fracture, elbow, compfications; injury, nerve
Clinical setting and prognostic significance of high degree atrioventricular block in acute inferior myocardial infarction: A study of 144 patients. Tans AC, Lie KL, Durrer D., Am Heart J 99:4-8, (Jan) 1980. Of 843 patients with acute inferior infarction, 144 (17%) developed high degree A-V block. The hospital mortality rate of the cases complicated by high degree A-V block was 22~ compared to 9% in the patient group without high degree A-V block. Seventy-five percent of in-hospital deaths were due to pump failure. The maximal degree of A-V block did not influence the immediate prognosis. Forty-eight percent of cases of high degree A-V block were present on admission and 92% within 72 hours of admission. Fifty-nine percent of patients with high degree A-V block were temporarily paced and 41% were successfully managed without pacing. There was no significant difference in mortality between those who were paced and those who were not. However, of the 42 patients who demonstrated shock, 31 had ventricular rates less t h a n 50, and in 24 of 29 of these patients who were paced, the shock was reversed. In patients with ventricular rates greater t h a n 50, pacemaker insertion did not affect the immediate prognosis. ( E d i t o r ' s note: High degree block was defined as 2 ° A - V block occurring via a Type I mechanism + 2:1 block, atrial fibrillation with ventricular response less than 60 minutes in the absence of digitalis, and 30 A - V block. It is interesting that in most instances p u m p failure, rather than block, caused the death.) Brian Allen, MD
myocardial infarction
Use of intraperitoneal Xenon-133 for imaging of intestinal strangulation in small bowel obstruction. Bulkley GB, et al, Am J Surg 141:128-135, (Jan) 1980. Clinically and diagnostically, identification of small bowel ischemia by radionuclide imaging previously has been very difficult. Based on the principle of reduced radionuclide clearance, or delay in externally detected isotope washout seen with decreased blood flow in ischemic tissue, a new method of detection was accidentally discovered. Rat and dog models were used to demonstrate t h a t intraperitoneal injection of Xenon-133 dissolved in normal saline could accurately detect small bowel ischemia at one hour post injection, using external gamma ray counting. This new method overcomes the usual drawbacks found in conventional intravenous radionuclide imaging and, more important, allows identification of mechanical i n t e s t i n a l obstruction at a time w h e n surgical correction and bowel tissue salvage is still possible. (Editor's note: This promising work is still experimental and its validity in m a n is as yet untested. To be answered is whether this would identify early post-operative bowel ischemia, mesenteric vascular impairments, and bowel compromise in the face of intraperitoneal adhesions. It would also be helpful i f the radionuclide could be instilled intraluminally rather than intraperitoneally.) Nancy Bodelson, MD bowel, obstruction, i m a g i n g
10:10 (October) 1981
Nancy Bodelson, MD
splenic vein thrombosis Fractures of the scapula. McGahan JP, Rab GT, Dublin A, J Trauma 20:880-883, (Oct) 1980. A retrospective study of 121 p a t i e n t s s u s t a i n i n g scapular fractures over an eight-year period was performed. The average age of patients with such fractures was 35 years; twothirds of those injured were men. A great deal of force was necessary to break the scapula, as is evident in t h a t 81% of patients were involved in some type of vehicular accident. A significant n u m b e r of patients had t h e i r fractures overlooked initially, which reflects the fact t h a t a high percentage (88%) had associated injuries t h a t detracted from careful evaluation of the scapula. Forty-four percent had rib fractures; 26%, clavicle fractures; 13%, neurologic deficit; and 16%, pulmonary complications. Peripheral nerve injuries were uncommon, and were almost always associated with fractures of the acromion process. The most common injured regions of the scapula were the body and neck, being injured in 43% and 26% of patients, respectively. Treatment of these injuries consisted of immobilization for three weeks with emphasis on early ROM. Most patients were able to r e t u r n to work in four to six weeks a n d r a r e l y were t h e r e l a t e r complications. (Editor's note: Another fracture along with rib number 1, 2 or 11, 12 in which the significance of bone injury is of lesser importance than associated or underlying damage.)
Ken Jackimczyk, MD
fracture, scapula Acute nerve injury as a complication of closed fractures or dislocations of the elbow. Galbraith K, McCulIough C, Injury 11:159, (Oct) 1980. A retrospective review of 1,540 p a t i e n t s s u s t a i n i n g closed fractures or dislocations of the elbow was performed. Among these patients, 21 cases with objective neurologic deficits were found and analyzed. Those cases with t r a n s i e n t parasthesias were not considered. Nerves involved were u l n a r (nine cases), median (five cases), radial (three cases), anterior interosseous (two cases), a n d posterior interosseous (two cases). Nine of the 21 cases had persistent nerve damage. Uln a r nerve palsy was seen most commonly with posterior elbow dislocations (six), b u t also with h u m e r u s fractures (two) and medial epicondyle fracture (One). Only two patients with u l n a r deficits had full recovery. Radial nerve deficit was seen in three patients, two with Monteggia fractures and one with a fractured capitellum. One had a persistent defect. Four h u n d r e d sixty-five supracondylar fractures produced five median nerve palsies. Anterior interosseus involvement
108/558
Ann Emerg Med
was seen in two patients, one with a supracondylar fracture and one with an olecrannon fracture. Both patients had full recovery. Two patients sustained posterior interosseus deficits secondary to Monteggia injuries and both showed full recovery. ( E d i t o r ' s n o t e : While these troublesome complications are rare, early recognition in the emergency department permits appropriate foUowup and early therapy.)
Ken Jackimczyk, MD
fracture, elbow, compfications; injury, nerve
Clinical setting and prognostic significance of high degree atrioventricular block in acute inferior myocardial infarction: A study of 144 patients. Tans AC, Lie KL, Durrer D., Am Heart J 99:4-8, (Jan) 1980. Of 843 patients with acute inferior infarction, 144 (17%) developed high degree A-V block. The hospital mortality rate of the cases complicated by high degree A-V block was 22~ compared to 9% in the patient group without high degree A-V block. Seventy-five percent of in-hospital deaths were due to pump failure. The maximal degree of A-V block did not influence the immediate prognosis. Forty-eight percent of cases of high degree A-V block were present on admission and 92% within 72 hours of admission. Fifty-nine percent of patients with high degree A-V block were temporarily paced and 41% were successfully managed without pacing. There was no significant difference in mortality between those who were paced and those who were not. However, of the 42 patients who demonstrated shock, 31 had ventricular rates less t h a n 50, and in 24 of 29 of these patients who were paced, the shock was reversed. In patients with ventricular rates greater t h a n 50, pacemaker insertion did not affect the immediate prognosis. ( E d i t o r ' s note: High degree block was defined as 2 ° A - V block occurring via a Type I mechanism + 2:1 block, atrial fibrillation with ventricular response less than 60 minutes in the absence of digitalis, and 30 A - V block. It is interesting that in most instances p u m p failure, rather than block, caused the death.) Brian Allen, MD
myocardial infarction
Use of intraperitoneal Xenon-133 for imaging of intestinal strangulation in small bowel obstruction. Bulkley GB, et al, Am J Surg 141:128-135, (Jan) 1980. Clinically and diagnostically, identification of small bowel ischemia by radionuclide imaging previously has been very difficult. Based on the principle of reduced radionuclide clearance, or delay in externally detected isotope washout seen with decreased blood flow in ischemic tissue, a new method of detection was accidentally discovered. Rat and dog models were used to demonstrate t h a t intraperitoneal injection of Xenon-133 dissolved in normal saline could accurately detect small bowel ischemia at one hour post injection, using external gamma ray counting. This new method overcomes the usual drawbacks found in conventional intravenous radionuclide imaging and, more important, allows identification of mechanical i n t e s t i n a l obstruction at a time w h e n surgical correction and bowel tissue salvage is still possible. (Editor's note: This promising work is still experimental and its validity in m a n is as yet untested. To be answered is whether this would identify early post-operative bowel ischemia, mesenteric vascular impairments, and bowel compromise in the face of intraperitoneal adhesions. It would also be helpful i f the radionuclide could be instilled intraluminally rather than intraperitoneally.) Nancy Bodelson, MD bowel, obstruction, i m a g i n g
10:10 (October) 1981