Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 5
426
40 per cent should rupture occur (Hark&is and Akin, 1977). We did not appreciate the importance of a small, non-pulsatile hepatoduodenal haematoma; as a consequence, a pseudoaneurysm was treated 5 months later. Therefore, in the presence of such a haematoma, exploration of the hepatoduodenal ligament during emergency laparotomy should be performed to avoid this complication. Conversely, an early diagnosis of uncomplicated posttraumatic aneurysm should be considered in the presence of appropriate symptoms and signs. The clinical picture may precede rupture of a pseudoaneurysm by 4.5 to 5 months (Pinsky et al., 1987). We conclude that careful exploration of the hepatoduodenal ligament containing haematoma is indicated to exclude arterial injury and so avoid a potential high mortality from rupture of a pseudoaneurysm of the hepatic artery.
References Busutill R. W., Kitahama A., McFadden
Spinal fractures spondylitis
M. et al. (1980) Manage-
ment of blunt trauma and penetrating injuries to the porta hepatis. Am. 1. 4rg. 191, 641. Chiarugi M., Goletti O., Buccianti P. et al. (1990) Lesioni da trauma chiuso dell’arteria epatica e dei suoi rami principali. J. Emerg. surg. 13,34. Harlaftis N. N. and Akin J. T. (1977) Hemobilia from ruptured hepatic artery aneurysm. Report of a case and review of the literature. Am. 1. Surg. 133, 229. Pinsky M. A., May E. S., Taxier M. S. et al. (1987) Late manifestation of hepatic artery pseudoaneurysm: case presentation and review. Am. 1. Gastroenterol. 82,467. Sheldon G. F., Lim R. C., Yee E. S. et al. (1985) Management of injuries of the porta hepatis. Ann. Surg. 196, 539.
Paper accepted 3 January 1991.
Requests for reprints should be addressed to: Dr Massimo Chiarugi MD, Department of Emergency Surgery, University of Pisa, Via Roma, 67, I-56100 Pisa, Italy.
in patients with ankylosing
G. I’. Graham and P. D. Evans The Department
of Traumatic
and Orthopaedic
Surgery, Cardiff Royal Infirmary, Cardiff, UK
Introduction Patients with ankylosing spondylitis tend to present with restriction of spinal movement and progressive deformity. We report on two patients who complained of persistent back pain due to occult fractures of the lumbar spine following minor trauma.
Case reports Case 7 A 63-year-old man presented with back pain after a fall. The initial radiographs, while showing ankylosing spondylitis, showed no sign of a fracture. He reattended 6 weeks later with persistent back pain. An isotope bone scan was performed and this revealed increased activity at the thoracolumbar junction (Figure I). Further coned radiographs confirmed a fracture of the Dll vertebra (Figure 2). Case 2 A 76-year-old lady was admitted after a fall. She was known to suffer from ankylosing spondylitis and was complaining of pain in her lumbar spine. Examination showed her to be in pain but with no localized tenderness. 0 1991 Butterworth-Heinemann 0020-1383/91/05042&02
Ltd
Figure 1. Bone scan showing vertebra in Case 7.
increased
uptake
in the
DII
Case reports
427
this region confirmed a fracture. She was treated with a neofract corset. At 8 weeks after her injury her pain had settled and there was radiological evidence of union.
Discussion In patients with ankylosing spondylitis, persistent pain, particularly after an injury, should raise the suspicion of a fracture. In this condition the spine is brittle due to ossification of the discs and supporting ligaments and may fracture either spontaneously or following minor trauma (Rapp and Kemek, 1974). A fracture in ankylosing spondylitis is analogous to snapping a stick of rock and is therefore very unstable. If missed or inappropriately treated neurological damage or spinal deformity may occur. In the two cases reported, conventional radiography failed to define the extent of the injury. Isotope scanning of the lumbar spine delineated the level of the fracture, allowing suitably coned radiographs to be performed and appropriate treatment to be instituted. Patients with ankylosing spondylitis are at risk of spinal fracture after relatively minor injury. If conventional radiographs fail to delineate a spinal fracture in a patient with persistent pain an isotope bone scan is indicated.
Reference Figure 2. Coned radiograph showing fied by the bone scan in Case I.
the fracture of DI 1 identi-
Radiographs of the lumbar spine showed bony ankylosis and an old wedge fracture of the Ll vertebra but no other abnormality. Treatment with bed rest and analgesics did not relieve her pain. Tomography of the L1 region showed no evidence of a recent fracture. She continued to be in pain 10 days after admission. A bone scan revealed a hot spot in the L5 vertebra. Coned views of
Rapp G. F. and Kemek C. B. (1974) Spontaneous lumbar spine with correction of deformity spondylitis. 1. Bone Joint Surg. 56A, 1277.
Paper accepted
1 February
fracture of the in ankylosing
1991.
Reqclests for reprints should be addressed to: P. D. Evans FRCS, the Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 ISZ, UK.
Puncture wound of the foot? Persistent pain? Thi’nk of Pseudomonas aeroginosa osteomyelitis D. W. Gale and R. Scott Department
of Orthopaedic
Surgery, Leicester Royal Infirmary, Leicester, UK
Introduction a puncture wound of the foot, in a child who is otherwise well, must arouse suspicion of Pseudomonas aeroginosa osteomyelitis. Appreciation that this organism may be responsible will allow prompt diagnosis and definitive treatment. Treatment should consist of surgical drainage and excision followed by parenteral antibiotics. Antibiotic therapy should continue until the erythrocyte sedimentation rate (ESR) or plasma viscosity (PV) has returned to normal.
Persistent
pain following
0 1991 Butterworth-Heinemann 0020-1383/91/050427-02
Ltd
Case report A o-year-old male sustained a puncture wound of his right heel. He presented 5 days later complaining of persistent pain at the puncture site. Clinical examination was unremarkable. Radiographs of the foot were normal with no evidence of a foreign body. A tetanus booster was given and the wound dressed. He returned 2 weeks later with continued pain. The patient was apyrexial and systemically well, with no signs of infection in the foot other than local tenderness. The white cell count was
426
40 per cent should rupture occur (Hark&is and Akin, 1977). We did not appreciate the importance of a small, non-pulsatile hepatoduodenal haematoma; as a consequence, a pseudoaneurysm was treated 5 months later. Therefore, in the presence of such a haematoma, exploration of the hepatoduodenal ligament during emergency laparotomy should be performed to avoid this complication. Conversely, an early diagnosis of uncomplicated posttraumatic aneurysm should be considered in the presence of appropriate symptoms and signs. The clinical picture may precede rupture of a pseudoaneurysm by 4.5 to 5 months (Pinsky et al., 1987). We conclude that careful exploration of the hepatoduodenal ligament containing haematoma is indicated to exclude arterial injury and so avoid a potential high mortality from rupture of a pseudoaneurysm of the hepatic artery.
References Busutill R. W., Kitahama A., McFadden
Spinal fractures spondylitis
M. et al. (1980) Manage-
ment of blunt trauma and penetrating injuries to the porta hepatis. Am. 1. 4rg. 191, 641. Chiarugi M., Goletti O., Buccianti P. et al. (1990) Lesioni da trauma chiuso dell’arteria epatica e dei suoi rami principali. J. Emerg. surg. 13,34. Harlaftis N. N. and Akin J. T. (1977) Hemobilia from ruptured hepatic artery aneurysm. Report of a case and review of the literature. Am. 1. Surg. 133, 229. Pinsky M. A., May E. S., Taxier M. S. et al. (1987) Late manifestation of hepatic artery pseudoaneurysm: case presentation and review. Am. 1. Gastroenterol. 82,467. Sheldon G. F., Lim R. C., Yee E. S. et al. (1985) Management of injuries of the porta hepatis. Ann. Surg. 196, 539.
Paper accepted 3 January 1991.
Requests for reprints should be addressed to: Dr Massimo Chiarugi MD, Department of Emergency Surgery, University of Pisa, Via Roma, 67, I-56100 Pisa, Italy.
in patients with ankylosing
G. I’. Graham and P. D. Evans The Department
of Traumatic
and Orthopaedic
Surgery, Cardiff Royal Infirmary, Cardiff, UK
Introduction Patients with ankylosing spondylitis tend to present with restriction of spinal movement and progressive deformity. We report on two patients who complained of persistent back pain due to occult fractures of the lumbar spine following minor trauma.
Case reports Case 7 A 63-year-old man presented with back pain after a fall. The initial radiographs, while showing ankylosing spondylitis, showed no sign of a fracture. He reattended 6 weeks later with persistent back pain. An isotope bone scan was performed and this revealed increased activity at the thoracolumbar junction (Figure I). Further coned radiographs confirmed a fracture of the Dll vertebra (Figure 2). Case 2 A 76-year-old lady was admitted after a fall. She was known to suffer from ankylosing spondylitis and was complaining of pain in her lumbar spine. Examination showed her to be in pain but with no localized tenderness. 0 1991 Butterworth-Heinemann 0020-1383/91/05042&02
Ltd
Figure 1. Bone scan showing vertebra in Case 7.
increased
uptake
in the
DII
Case reports
427
this region confirmed a fracture. She was treated with a neofract corset. At 8 weeks after her injury her pain had settled and there was radiological evidence of union.
Discussion In patients with ankylosing spondylitis, persistent pain, particularly after an injury, should raise the suspicion of a fracture. In this condition the spine is brittle due to ossification of the discs and supporting ligaments and may fracture either spontaneously or following minor trauma (Rapp and Kemek, 1974). A fracture in ankylosing spondylitis is analogous to snapping a stick of rock and is therefore very unstable. If missed or inappropriately treated neurological damage or spinal deformity may occur. In the two cases reported, conventional radiography failed to define the extent of the injury. Isotope scanning of the lumbar spine delineated the level of the fracture, allowing suitably coned radiographs to be performed and appropriate treatment to be instituted. Patients with ankylosing spondylitis are at risk of spinal fracture after relatively minor injury. If conventional radiographs fail to delineate a spinal fracture in a patient with persistent pain an isotope bone scan is indicated.
Reference Figure 2. Coned radiograph showing fied by the bone scan in Case I.
the fracture of DI 1 identi-
Radiographs of the lumbar spine showed bony ankylosis and an old wedge fracture of the Ll vertebra but no other abnormality. Treatment with bed rest and analgesics did not relieve her pain. Tomography of the L1 region showed no evidence of a recent fracture. She continued to be in pain 10 days after admission. A bone scan revealed a hot spot in the L5 vertebra. Coned views of
Rapp G. F. and Kemek C. B. (1974) Spontaneous lumbar spine with correction of deformity spondylitis. 1. Bone Joint Surg. 56A, 1277.
Paper accepted
1 February
fracture of the in ankylosing
1991.
Reqclests for reprints should be addressed to: P. D. Evans FRCS, the Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 ISZ, UK.
Puncture wound of the foot? Persistent pain? Thi’nk of Pseudomonas aeroginosa osteomyelitis D. W. Gale and R. Scott Department
of Orthopaedic
Surgery, Leicester Royal Infirmary, Leicester, UK
Introduction a puncture wound of the foot, in a child who is otherwise well, must arouse suspicion of Pseudomonas aeroginosa osteomyelitis. Appreciation that this organism may be responsible will allow prompt diagnosis and definitive treatment. Treatment should consist of surgical drainage and excision followed by parenteral antibiotics. Antibiotic therapy should continue until the erythrocyte sedimentation rate (ESR) or plasma viscosity (PV) has returned to normal.
Persistent
pain following
0 1991 Butterworth-Heinemann 0020-1383/91/050427-02
Ltd
Case report A o-year-old male sustained a puncture wound of his right heel. He presented 5 days later complaining of persistent pain at the puncture site. Clinical examination was unremarkable. Radiographs of the foot were normal with no evidence of a foreign body. A tetanus booster was given and the wound dressed. He returned 2 weeks later with continued pain. The patient was apyrexial and systemically well, with no signs of infection in the foot other than local tenderness. The white cell count was
![[Spinal fractures in ankylosing spondylitis].](/assets/img/hold.png)
