Oh bother *sigh* its Thursday April 11, 2013. Cloudy today 56 degrees with 30% chance of rain, going down to 44 degrees tonight with 60% chance of rain.
Let’s try to brighten up our day with another wonderful pearl by yours truly!
55 year old Caucasian male, presents with right shoulder pain after bicycle accident. Helmeted, patient fell off after hitting a rock with his bike, landing on his right shoulder. Although wanting to go home and sleep it off, like most men who like to stay married, patient listened to his wife and came to ED to get checked out and go home quickly. He denies any other issues, signs, symptoms, or complaints.
Vital signs are stable.
Exam is unremarkable except for right shoulder abrasions and large ecchymoses at the AC joint. Range of motion is intact, significant tenderness to AC joint area with no deformity or step-offs noted. X-ray of shoulder is below. And of course, we will expect to find something in our AC joint area.
So what do we have?
Yes! Its a lateral clavicular fracture. Low grade, minimal to non displacement. So you call ortho and have the patient get setup for a follow up appointment and sling and we are done. On to our next patient!
But wait! What else is that?!
So you, the ortho team, your attending are so quick to want to discharge this otherwise very well appearing patient that we don’t notice the diffuse subcutaneous air in this man’s chest.
Even the radiology resident didn’t notice it on their first read. It wasn’t until the attending radiologist, who was present because it was during the daytime morning, supplemented the read two hours later, that we were notified about the subcutaneous air.
And then here’s the dedicated PA x-ray of the chest.
So, to make a long post short, this gentleman started having a throat tightening sensation 4 hours later. ENT noticed ‘bubbling’ in the posterior wall area near the vocal cords. He was awake, nasal-tracheo intubated, was given a chest tube to relieve the pneumothorax.
He eventually healed on his own and was eventually discharged after an inpatient stay of a few days upstairs.
So always, always, look for the forest! And especially the ENTS!!!