radER vol 1.4

Case 1.4

A 56-year-old man was brought to your ED after bring involved in a MVC.  He was a restrained driver in a car that was traveling at 40 MPH and slammed into a tree.  The patient denies loss of consciousness.  A radiograph is seen below.

Questions:

1.  What is the abnormality on the radiograph?

2.  Name the nerve(s) that are frequently injured in this type of injury?

3.  What are the motor and sensory physical exam findings corresponding to these nerve(s)?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

7 Responses

  1. 1. left acetabular fracture
    2. obturator nerve and femoral nerve
    3. decreased hip flexion and adduction, decreased sensation over medial and anterior aspect of thigh

  2. 1. Left Pubic Ramus and possibly Left Acetabular Fracture.

    2. a) Obturator Nerve
    b) Femoral Nerve

    3. a) Inability to Adduct the Thigh
    b) Inability to Flex the Hip and Extend the Knee, Absence of Patellar Tendon DTR, and Sensory Deficit over the Anteromedial Thigh.

  3. 1. Fracture of Inferior pubic ramus
    2. Obturator Nerve can be injured.
    3. Sensory to inferiomedial thigh, motor to gracilis and adductors of thigh

  4. 1. Left Acetabular fracture – I need to see 2 oblique views/Judet (iliac and obturator). The fracture looks to be involving the iliopectineal line for anterior column, but I can’t tell if it involves the ilioischial line from this xray. The pelvic ring doesn’t obviously look to be involved, and I can clearly see the acetabular tear on the left.
    2. Nerves involved include, but aren’t limited to femoral (frequent), obturator(frequent), sciatic, and/or superior gluteal
    3. a.) obturator nerve – motor function to the adductor muscles and cutaneous sensation to a small area behind the knee
    b.) femoral nerve – weakness when you straighten the knee or bend at the hip. Sensation changes are located on the front of the thigh and inner calf. The knee jerk reflex may be decreased or absent. You may have a loss of muscle mass in the quadriceps muscles of the front of the thigh.
    c.) sciatic – pain, burning sensation, numbness, or tingling radiating from the lower back and upper buttock down the back of the thigh to the back of the leg. Sometimes aggravated by walking or bending at the waist and relieved by lying down.
    d.) superior gluteal – the gluteus medius, the gluteus minimus, and the tensor fasciae latae. Damage can lead to trendelenburg gait

  5. 1) Pubic Rami fracture

    2a) Femoral Nerve
    2b) Obturator nerver

    3a) anterioromedial thigh sensory deficit and weakness with extension of knee.
    3b) loss of adduction and internal rotation occur with gait pattern is that of an externally rotated foot. possibly diminished sensation along the medial thigh, distally.

  6. 1. Fracture of superior and inferior pubic ramus (appears as though superior ramus is displaced a little so i’m susspecting an inferior ramus fracture).

    2. Obturator nerve and possibly cutaneous branches from lumbar plexus

    3. ability to adduct the thigh as well as sensory exam throughout the nerve distribution.

  7. 1. Femoral head fracture
    2. Femoral and obturator nerves
    3. Leg may be externally rotated and shortened. Pts may have waddling gait (trendelenburg gait), and may have trouble with hip flexion or knee flexion. There may be decreased sensation to the anterior and medial thigh.

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