Senior Report 7.11

Case Presentation by Dr. Vit Kraushaar, MD

1.  A 63 year old woman with a history of schizophrenia and IV heroin use presents with complaints of right hip pain with movement and inability to bear weight for the last day. Patient’s vital signs are significant for low grade fever with temperature of 38.2 Celsius. An MRI of the pelvis with contrast demonstrates a fluid collection concerning for abscess. In which structure is the abscess located?

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2. A 59 year old woman with a history of untreated hypertension presents with complaints of right arm and leg numbness for the last three days, as well as a left sided headache yesterday which has since resolved. CT head without contrast is unremarkable. MRI (below) shows a small subacute area of infarction. In which brain structure is the lesion located?

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a) Internal capsule, anterior limb

b) Internal capsule, posterior limb

c) Thalamus

d) Basal ganglia

3.  A 72 year old man presents with pain in his left thumb after he fell asleep at the wheel of his car and crashed into a barn. He says he was gripping the steering wheel very tightly when the car made impact, and he felt immediate pain afterwards.  X-ray of the left thumb shows the following:

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What is the most appropriate treatment for this patient?

a)     Admit for open reduction and internal fixation of the fracture

b)     Apply thumb spica splint and arrange hand/orthopedic surgery follow up

c)     Discharge with RICE instructions with orthopedic surgery follow up

d)     Closed reduction with orthopedic surgery follow up

Answers & Discussion

1) Iliopsoas muscle.

MRI shows a right sided iliopsoas and iliacus muscle abscess. A iliopsoas abscess is a fluid collection within the iliopsoas muscle compartment. A primary abscess is secondary to hematogenous or lymphatic spread, with risk factors including intravenous drug abuse, diabetes, HIV, and other immunosuppressed states. Secondary abscesses occur from direct spread of infection from a nearby structure (e.g. vertebral osteomyelitis, intra-abdominal infection). Signs and symptoms include back or flank pain, fever, inguinal mass, limp, anorexia, and weight loss. Pain is exacerbated by extension of the hip. Treatment is aimed at drainage and prompt initiation of appropriate antibiotics, and incases of secondary abscess, management of the adjacent infection.

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http://en.wikipedia.org/wiki/Iliopsoas

 

References:

UpToDate: Psoas Abscess

2) Answer: c) thalamus. The MRI demonstrates a subacute lacunar infarction in the left thalamus. A lacune refers to a cavity that develops after a localized area of infarction from occlusion of a penetrating branch of a large cerebral artery. This patient has a “pure sensory stroke”, which is one of the classic thalamic stroke syndromes. Pure sensory stroke refers to persistent or transient unilateral numbness and mild sensory loss. It is usually due to a lacunar infarct in the thalamus, but has also been associated with a small hemorrhage involving the corona radiata and the posterior limb of the internal capsule.  The sensory loss is contralateral to the side of the thalamic lesion. Prognosis is good, with most patients having complete resolution of their symptoms.

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http://www.blackwellpublishing.com/clinicalanatomy/flashcard_239.asp

Reference:

http://emedicine.medscape.com/article/1163029-overview#aw2aab6b8

 

3 )Answer: b) Apply thumb spica splint and arrange orthopedic surgery follow up.

This patient’s history, exam, and x-ray are concerning for ulnar-collateral ligament injury (also referred to as “gamekeeper’s thumb” or “skier’s thumb”). The x-ray shows an avulsion fracture of the ulnar aspect of the base of the proximal phalanx of the left thumb concerning for associated ulnar collateral ligament injury.   Ulnar collateral ligament injury is caused by forced abduction and hyperextension of the metacarpophalangeal (MCP) joint (such as from a fall onto the thumb or from a ski-pole driving the thumb into the pole handle). Patients complain of pain at the base of the thumb that is exacerbated by thumb extension or abduction. Valgus stress testing reveals joint laxity. Radiographs are obtained to identify associated avulsion injuries, but may be normal. Treatment includes applying a thumb spica splint and referral to a hand surgeon. Complications of inadequate treatment may lead to chronic pain and instability of the MCP joint.

 

References:

UpToDate: Ulnar collateral ligament injury

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