Obvious Trauma Research Articles

Morphological and Morphometric Study of the Pterion – A Cadaveric Study in Sri Lanka

Introduction: Pterion is an important landmark as its relation to the anterior branch of middle meningeal artery, Broca’s motor speech area on the left side, and surgical interventions relating to pathologies of the sphenoid ridge and optic canal as it provides access to vital structures such as sylvian fissure, circle of Willis, optic nerve, para-sellar regions, middle meningeal vessels and cavernous sinus. Approach through pterion is mostly used to treat lesions of anterior and middle cranial fossa. Pterion ossicle or Epipteric bone are sometimes mistaken as a fracture at this point.Objective: The aim is to study the types of pterions and measure the distance from various bony landmarks on skull to the midpoint of pterion.Methods: Specific measurements were taken, and type of the pterion recorded by two independent investigators in the Frankfurt plane on both sides of 37 adult dry skulls of unknown age, gender and race, without calvaria which were prepared for academic purposes, none of which showed any obvious pathology or trauma. The skulls with broken lateral walls were excluded. The linear distance from the center of the pterion to four anatomical landmarks were measured using a Vernier caliper with an accuracy of 0.1 mm.Results: The sphenoparietal type of pterion was the most common (83.8% left, 81.1% right), followed by the frontotemporal (8.1% left, 13.5% right), and epipteric (8.1% left, 2.7% right) types and the stellate type was the least commonly observed (2.7% left side only). The distances on the left and right sides respectively from the center of the pterion to the frontozygomatic suture were 3.60 ± 0.57 cm and 3.68 ± 0.50 cm, to the zygomatic arch 3.76 ± 0.39 cm and 4.03 ± 0.40 cm, to the tip of the mastoid process 7.96 ± 0.58 cm and 8.16 ± 0.61 cm, and to the topmost part of the external auditory meatus 5.42 ± 0.34 cm and 5.53 ± 0.35 cm.Conclusions: This knowledge is essential in surgical approaches and interventions via the pterion, especially for neurosurgeons while drilling a burr hole at the pterion to prevent orbital penetration due to an anterior drilling and an ineffective access for instrumentation due to a posterior drilling. It will also be helpful for surgeons, radiologists, anthropologists, forensic pathologists in their diagnosis and treatment.

Characterization and Prevalence of Pediatric Ramp Lesions Associated with Anterior Cruciate Ligament Tears.

Background: Ramp lesions correspond to posterior meniscocapsular tears of the medial meniscus and are common with anterior cruciate ligament (ACL) tears. They cannot be recognized easily on preoperative magnetic resonance imaging (MRI) scans and are difficult to visualize even using standard arthroscopic approaches. We aim to (1) characterize and evaluate the prevalence of ramp lesions in pediatric patients at a major tertiary children's hospital, providing important insights into demographics, diagnosis, treatment, and functional disability and (2) evaluate the efficacy of MRI in its diagnosis.
 Materials and Methods: We retrospectively reviewed patients under 21 years old undergoing posterior medial meniscal injuries and anterior cruciate ligament ruptures with arthroscopic examination and positive ramp lesions from 2018 to 2021. Patient demographics (including gender and age), initial presentation, physical examination findings, mechanism of injury, pre-operative radiologic findings, and treatment were collected and reviewed via electronic medical record. Exclusion criteria included patients over 18 years old, patients, that did not have an MRI, and patients that were not treated surgically.
 Results: There were 117 patients that met the inclusion criteria out of 690 patients. The mean age at diagnosis was 15.6±1.6 years and the mean BMI was 26.7±6.4. 83% of injuries occurred secondary to sporting activities. Ramp lesions were only detected on preoperative MRI in 63% of cases, suspected in 3%, and not detected in 33%. The sensitivity of the MRI was 63%.
 Conclusions: Ramp lesions were found in 117/690 (16.9%) of patients undergoing ACL reconstruction. MRI had a low sensitivity rate of 63%. During ACL reconstruction, a careful review of the posteromedial compartment is important to recognize less obvious trauma. Lack of treatment may lead to continued instability and risk of complications in these patients.

Sudden Spontaneous Neck Swelling Due to Thyroid Malignancy: A Case Report.

Sudden spontaneous swelling in the neck is an emergency condition required to be addressed immediately. It poses a diagnostic dilemma. It is extremely rare for a thyroid malignancy to present as a sudden onset neck swelling in a euthyroid young male with no obvious trauma to the neck. This is a rare case report of a follicular variant of papillary carcinoma thyroid presenting as sudden neck swelling to the extent of shifting trachea to other side in a young euthyroid male.

Retrospective analysis of 71 patients with cutaneous sporotrichosis

To summarise 71 cases of cutaneous sporotrichosis in Zhejiang over the past 9 years and analyse clinical and epidemiological characteristics. This was a retrospective review of patients with cutaneous sporotrichosis attending the Department of Dermatology of the Hangzhou Third People's Hospital between 2013 and 2022. The male-to-female ratio was 1.15:1 among the 71 patients, with a mean age of 55.90 years (±2.02) and an age range of 3 to 94 years. The disease duration was unknown for 17 patients. The intermediate course for the remaining 54 patients lasted 11.90 months, ranging from 1 to 120 months. Thirty-four patients were involved in mixed occupations, 28 were farmers, 4 were housewives, 3 were manufacturing workers, and 2 were carpenters; 23.95% of cases had a history of trauma. The most common clinical manifestation was fixed cutaneous (69.01%), followed by lymphocutaneous (29.58%) and disseminated cutaneous (1.41%). There were 72 affected sites; the upper limbs (69.44%) were affected the most, followed by the face (16.67%) and lower limbs (12.50%). Forty-nine patients showed open lesions (69.01%), 15 showed mixed lesions (21.13%), and seven showed closed lesions (9.86%). Seventy-one patients were confirmed by biopsied tissue or tissue fluid culture. Forty-four patients underwent direct microscopy; of these, 18 (40.91%) were positive and 26 were negative. Molecular analysis confirmed that all fungal strains were Sporothrix globosa. Fifty-nine patients underwent histopathological examination, of whom 18 (18.64%) were positive for periodic acid-Schiff (PAS) staining. Eighteen patients were lost to follow-up; the remaining patients were cured. Consistent with the epidemiological situation of sporotrichosis in other areas of China, S. globosa is the primary pathogen in the Zhejiang province. The primary clinical form of sporotrichosis is fixed cutaneous. Susceptible subjects are mainly middle-aged and elderly rural populations, and males are affected more than females. Patients with cutaneous sporotrichosis do not commonly have a history of obvious trauma. Direct microscopy is important for the diagnosis of sporotrichosis, and itraconazole is a safe and effective treatment option.

Minor Traumas with Major Consequences: Penetrating Transorbital Injuries with Sharp Objects

Transorbital penetrating injuries are rare but can cause severe life-threatening intracranial injuries to the brain, brainstem, or internal carotid artery. They often present dramatically with an obvious trauma and extensive collateral damage to surrounding structures [1]. However, some injuries are subtle, with a seemingly trivial trauma and little or no obvious damage to the surrounding tissues. These innocuous injuries carry the risk of being overlooked and the extent of the injury not being recognized. Very rarely are isolated third and sixth nerve palsies caused by penetrating trauma [2], [3]. We present two rare cases of penetrating transorbital traumas leading to third and sixth nerve palsies.

Lateral meniscal status, chronicity of anterior cruciate ligament (ACL) deficiency, and initial graft tension were associated with abnormal knee laxity after anatomical ACL reconstruction

PurposeGraft failure or recurrence of instability without obvious trauma remains one of the problems following anterior cruciate ligament (ACL) reconstruction. This retrospective study aimed to identify risk factors for abnormal knee laxity after anatomical ACL reconstruction. MethodsA total of 291 patients who underwent primary anatomical ACL reconstruction were included in this study. Sex, age, body mass index (BMI), time to surgery, medial meniscal status, lateral meniscal status, graft materials, initial graft tension protocol, preoperative and postoperative pivot shift test and side-to-side differences in anterior tibial translation using the arthrometer were reviewed. Abnormal knee laxity was defined as constituting one or both of the following criteria: (i) a side-to-side difference of ≥3 mm by arthrometer; and (ii) a positive pivot shift test, being “glide,” “clunk”, or “gross”. ResultsAbnormal knee laxity occurred in 30 patients (10.3%) at a median follow-up of 25 months. Results of univariate analysis indicated that a higher likelihood of abnormal knee laxity was associated with female sex, greater BMI, longer time to surgery, higher initial graft tension protocol, and lateral meniscus resection. Multivariate logistic regression analysis showed that abnormal knee laxity was significantly associated with time to surgery [1-month increase; odds ratio (OR), 1.01], higher initial graft tension protocol (vs. lower tension; OR, 3.5), and lateral meniscus resection (vs. intact and repaired lateral meniscus; OR, 12.8). ConclusionHigher initial graft tension protocol, chronicity of ACL deficiency, and lateral meniscus resection were risk factors for abnormal knee laxity after anatomical ACL reconstruction. Level of evidenceLevel III retrospective prognostic study.

脂漏性角化症が侵入門戸と考えられた破傷風の1例(A case of tetanus in which the portal of entry was presumed to be seborrheic keratosis)

要旨87歳の男性が開口障害，嚥下困難のため経口摂取不能となり，他院に入院した。入院後から徐々に刺激による下肢の痙攣，筋緊張が出現し，気道閉塞による一過性の呼吸停止があり，当院へ転院搬送された。破傷風と診断し，破傷風トキソイド，破傷風免疫グロブリン，ペニシリンGを投与し，人工呼吸器管理および筋弛緩薬，鎮静薬，鎮痛薬，マグネシウム製剤などで全身管理を行った。明らかな外傷はなかったが，右前胸部の脂漏性角化症に浸出液を認めたため培養に提出したところ，Clostridium tetaniが検出され，腫瘤を切除した。経過は良好であり，気管切開孔を閉鎖し，リハビリ継続目的に転院した。脂漏性角化症が侵入門戸となって破傷風を発症した症例は，過去に報告されていない。破傷風は本邦では高齢者に多い疾患であり，高齢者には脂漏性角化症がほぼ必発である。また破傷風の治療においては，侵入門戸を検索し，必要があれば処置を行わなければならない。したがって，高齢者にごくありふれた疾患である脂漏性角化症が，Clostridium tetaniの侵入門戸となりうるということを，救急医が認識することは極めて重要と考える。

Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider.

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Os Navicular Syndrome: A Symptomatic Accessory Ossicle of the Foot

Accessory navicular bone occurs due to failure of fusion of a secondary ossification center with the navicular. It is the second most common ossicle of the foot, with majority of them being identified incidentally on imaging studies. We report a case of 45-year-old female who presented with complaints of pain and localized redness over the medial aspect of the right foot which was aggravated on walking. This brief review aims to describe the pathophysiology, radiographic findings and management of Os naviculare syndrome. We also wish to highlight to the physicians that it must be suspected in patients with localized painover the medial aspect of the midfoot without obvious trauma. The presence of accessory navicular should not be disregarded as an incidental radiological variant in a symptomatic patient.

63 Dental aspects in osteogenesis imperfecta type IV

Abstract Background The term “dentinogenesis imperfecta” includes dental anomalies quite similar to hereditary opalescent dentin and osteogenesis imperfecta. We present dental findings in a boy with osteogenesis imperfecta type IV Case Presentation A young boy was referred to the pediatric department for management of vertebral compression and a recurrent femoral fracture without obvious trauma. The appearance of his teeth with the overall assessment of this patient reveals dentinogenesis imperfecta compatible with osteogenesis imperfecta type IV, associated with major vertebral involvement Discussion Osteogenesis imperfecta (OI), also known as also known as « brittle bone disease » is a heterogeneous group of rare genetic diseases involving connective tissue. A reduction in the amount of normal collagen leads to Type I, while qualitative and quantitative abnormalities in collagen synthesis lead to Types II, III and IV of OI. This type IV is subdivided into groups A and B: the group B depicting the characteristic dentinogenesis imperfecta like in our patient. Conclusion Dentinogenesis imperfecta is a major sign of osteogenesis imperfecta. Skeletal phenotype, scleral colour and deafness complete the picture allowing the final classification of this inherited disorder The peculiar bone lesions with normal dental aspects are highly suggestive of the extreme rare osteogenesis imperfecta type IV.

Suicide Risk and Association With the Different Trauma During the COVID-19 Pandemic Period: A Cross-Sectional Study on Adolescent With Different Learning Stage in Chongqing, China.

This study aimed to examine the current suicidal risk and whether the suicidal risk was associated with a wide range of trauma. The self-administered online questionnaire was adopted to collect suicide risk (SR) such as suicidal ideation, self-harm, suicide attempts, and different trauma information of the adolescents by cluster sampling in Chongqing, China. Multivariable linear regression was presented to assess the association between different risks of trauma and SR scores. Approximately 14.7% of adolescents enrolled reported suicide ideation and more than 10% of adolescents have experienced one kind of trauma during the Coronavirus disease 2019 (COVID-19) pandemic period. After adjusting for confounding variables, adolescents who suffered family hurt had a higher risk score of SR (beta coefficients (β) = 0.289, 95% confidence interval (CI) = 0.115–0.463). A positive association was found among participants from junior and senior school (β = 0.415, 95% CI = 0.152, 0.768), and the SR score was positively associated with sexism among participants from the university/college (β = 0.238, 95% CI = 0.042, 0.434). The most potentially obvious trauma that contributed to SR in junior and senior school adolescents might be cyberbullying. Family neglect or abuse might be a detrimental factor in SR for adolescents whether those in junior school or those in university school in China. More interventions, like education related to cyberbullying and family abuse, should be prioritized to reduce the risk of suicide.

Severe injuries of proximal hamstrings in high performance sport climbers

Injuries of the hamstrings are well known in all kinds of sports. According to the associated mechanisms, literature divides between a running and a stretch type lesion. A variant of the stretch type has been observed in sports climbing based on two almost identical lesions of the hamstrings due to high-elevation heel hooking. This specific movement is characterised by isometric muscle tension in extensive hip flexion with a flexed knee. Even without an obvious trauma, we found severe injuries of the proximal hamstrings. These may cause serious consequences to the further career of a climber. Trainers and route setters should keep this in mind.

Displaced femoral neck fracture in a pregnant patient diagnosed with transient osteoporosis of the hip.

Transient osteoporosis of pregnancy (TOP) is a self-limiting pathology with unspecified etiology. It is typically found in women in late pregnancy or early postpartum. A femoral neck fracture is an infrequent complication. Herein, we describe a TOP case in a 38-year-old female who suffered a displaced sub-capital femoral neck fracture without obvious trauma at 28weeks of gestation. The patient underwent operative treatment using closed reduction and internal fixation (CRIF), using cannulated screws, with no intraoperative complications. The postoperative radiograph revealed a collapse and further displacement of the femoral neck. A decision was made to postpone a definitive treatment to a postpartum date. The patient underwent a cesarean section at 38-week of gestation with no complications. At her latest follow-up, 24months postoperatively, the patient was asymptomatic. Pelvic and hip radiographs demonstrated consolidation of the fracture. Level of evidence: IV.

CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls.

Abdominal and pelvic hemorrhage may be secondary to a number of causes and is often a medical emergency. Patient presentation ranges from obvious trauma with evidence of hemodynamic instability to vague symptoms. CT has become the imaging modality of choice for identifying abdominopelvic hemorrhage. Recognizing acute hemorrhage as well as identifying its location and severity are key to expediting management. In the Emergency Department, ultrasound often used in the initial evaluation of trauma patients, but is not sensitive for subtle bleeds or injuries. CT is the best first-line imaging tool to identify abdominal hemorrhage and, compared with angiography, has been shown to be superior in detecting intra-abdominal bleeding, especially when the bleeding rate is low. Depending on location and etiology, abdominopelvic hemorrhage may have a characteristic appearance, such as the "sentinel clot" sign associated with blunt trauma to the solid organs or the "triangle sign" of a mesenteric bleed. The following pictorial essay reviews CT technique, study interpretation, and interpretative pearls and pitfalls in the recognition of acute abdominopelvic hemorrhage.

Survival probability in avalanche victims with long burial (≥60 min): A retrospective study

BackgroundThe survival of completely buried victims in an avalanche mainly depends on burial duration. Knowledge is limited about survival probability after 60 min of complete burial. AimWe aimed to study the survival probability and prehospital characteristics of avalanche victims with long burial durations. MethodsWe retrospectively included all completely buried avalanche victims with a burial duration of ≥60 min between 1997 and 2018 in Switzerland. Data were extracted from the registry of the Swiss Institute for Snow and Avalanche Research and the prehospital medical records of the physician-staffed helicopter emergency medical services. Avalanche victims buried for ≥24 h or with an unknown survival status were excluded. Survival probability was estimated by using the non-parametric Ayer–Turnbull method and logistic regression. The primary outcome was survival probability. ResultsWe identified 140 avalanche victims with a burial duration of ≥60 min, of whom 27 (19%) survived. Survival probability shows a slight decrease with increasing burial duration (23% after 60 min, to <6% after 1400 min, p = 0.13). Burial depth was deeper for those who died (100 cm vs 70 cm, p = 0.008). None of the survivors sustained CA during the prehospital phase. ConclusionsThe overall survival rate of 19% for completely buried avalanche victims with a long burial duration illustrates the importance of continuing rescue efforts. Avalanche victims in CA after long burial duration without obstructed airway, frozen body or obvious lethal trauma should be considered to be in hypothermic CA, with initiation of cardiopulmonary resuscitation and an evaluation for rewarming with extracorporeal life support.

A photoactivatable antibody–Chlorin e6 conjugate enabling singlet oxygen production for tumor-targeting photodynamic therapy

Photodynamic therapy is a new technology for disease diagnosis and treatment in modern medical clinics. The main advantages of photodynamic therapy are low toxicity and side effects, a wide range of applications, no drug resistance, and no obvious trauma in the treatment process. However, to achieve effective photodynamic therapy, new photosensitizer carriers need to be constructed, which can selectively deliver photosensitizers into tumor tissues. In this work, a photoactivatable antibody–Chlorin e6 conjugate with a dual-function to target tumor tissue and realize cancer photodynamic therapy is constructed. Both in vitro and in vivo experiments indicate that the antibody–Chlorin e6 conjugate has the ability to target tumors rapidly and efficiently, and has the ability to generate reactive oxygen species and kill tumor cells. Overall, this photoactivable antibody–Chlorin e6 conjugate may provide a promising strategy to address the current challenges of cancer photodynamic therapy.

S2733 A Curious Case of a Bleed Without a Cause

INTRODUCTION: Spontaneous subcapsular hematoma of the liver is usually associated with pregnancy, coagulopathy or liver lesion. We report a rare case of spontaneous subcapsular liver hematoma without any of the above risk factors. CASE DESCRIPTION/METHODS: A 59-year-old lady with a history of hypertension presented with sudden-onset in the right upper abdomen, right chest, shoulder and neck pain. She was otherwise hemodynamically stable other than being mildly hypertensive. Work-up for cardiac ischemia was negative. She was noted to have a low hemoglobin of 10.4 g/dl (prior baseline was 13.7 g/dL) and she had mild hepatocellular injury (ALT 32 IU/L, AST 31 IU/L). She underwent CT scan to rule out pulmonary embolism which incidentally revealed a large subcapsular liver hematoma. MRI abdomen confirmed a large lenticular shaped subscapular collection along the right lobe of the liver measuring approximately 12 × 4 × 16 cm. There was no focal hepatic lesion to explain the cause of bleeding. She did not recall any preceding trauma and there was no obvious trauma on exam. She was not taking any blood thinners. She admitted to inadvertently using oral contraceptives (OCP) for over 30 years for purely birth control purposes. The patient was admitted for observation and remained clinically stable over the next few days. At her 1-month follow-up, an office ultrasound showed that the size of the hematoma had decreased when compared to her prior ultrasound during her hospitalization (thickness from intercostal view decreased from 42 mm to 35 mm). At her 1-year follow-up, an MRI abdomen was repeated that showed a minimal residual hematoma and no discrete underlying lesion. DISCUSSION: Spontaneous subcapsular hematoma of the liver represents an accumulation of blood between the capsule of Glisson and the liver parenchyma, and is frequently located around the right lobe. If it ruptures into the peritoneum, it can be potentially fatal. Our case is unique in that none of the usual risk factors such as pregnancy, trauma, blood thinner use or underlying liver lesion were present. To our knowledge, there are very few similar case reports that describe spontaneous subcapsular hepatic hematoma. OCP use is generally associated with the development of hepatic adenoma, which can in turn cause spontaneous subcapsular hematoma. Theoretically, long-term OCP use in a post-menopausal hypertensive lady (such as in our case) may mimic the pathophysiology of pregnancy and independently lead to spontaneous subcapsular bleeding.Figure 1.: MRI showing large hepatic subcapsular hematoma and no focal lesion.Figure 2.: MRI showing nearly resolved hepatic subcapsular hematoma.

A rare finding of suspected synovial chondromatosis

IntroductionHuman gross anatomy laboratory dissections provide a rich learning environment, sometimes including rare anatomical variation or pathological findings. Here we describe a rare knee joint abnormality, which provided an opportunity to review pathological processes unique to this region and expand the learning experience beyond the standard curriculum.FindingsDuring a routine lower limb dissection of an 88‐year‐old formalin‐fixed Caucasian male donor, first‐year medical students discovered an enlarged semimembranosus bursa in the superomedial corner of the right popliteal fossa. Opening of the bursa revealed nine irregular‐shaped osteochondral bodies bathed in synovial fluid, with an average length of 1.76 cm and an average width of 1.25 cm. The donor exhibited no obvious trauma, however bilateral knee joint dissections revealed advanced osteoarthritis. Glenohumeral and acetabulofemoral joint cavities and their surrounding bursae were explored bilaterally, with the only significant finding being bilateral glenohumeral osteoarthritis. Histological studies supplemented by a review of the literature suggests a diagnosis of secondary synovial chondromatosis.DiscussionSynovial chondromatosis outlines a rare, benign process characterized by the metaplasia of synovial tissue into chondrocytes within joint cavities, tendinous sheaths, or bursae. It can be further classified into one of two categories: primary, where the proliferation of hyaline cartilage in synovial membranes is seemingly spontaneous, or secondary, in which osteocartilaginous bodies are generated as a result of trauma or inflammatory joint pathologies. The condition most often affects males, has a monoarticular presentation, with a proclivity for the knee joint, followed by the shoulder and hip. Cases in the ankle, elbow, wrist, and temporomandibular joints have also been described. Although it is classified as benign and non‐metastatic, pain, swelling, and functional deficits have been reported. Treatment most often consists of surgical excavation of loose bodies with open arthrotomy and synovectomy.ConclusionAnomalies discovered through anatomical dissection provide unique opportunities to research pathological processes that may not otherwise be covered in standard anatomical curricula.

NECROTIZING FASCIITIS TRIGGERED BY TRAUMA - BUT NOT TRAUMA

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Necrotizing fasciitis (NF) has approximately 1500 incident cases per year in the United States, with Group A Streptococcus (GAS) as the most common pathogen implicated1. Most patients have an identifiable comorbidity including immunosuppression or trauma. There is a paucity of data describing the development of NF in a person without risk factors. We describe an unusual case of fulminant NF by GAS with toxic shock syndrome (TSS). CASE PRESENTATION: A 49-year-old male from Canada with no comorbidities presented to the emergency department with a 2-day history of malaise and left leg pain. He had sustained a minor fall while skiing six days ago without any obvious local trauma. Vital signs were concerning for hypotension and tachycardia. Physical exam revealed a diffuse erythematous rash and erythematous left lower extremity (LLE) with exquisite pain upon movement. Total body survey did not reveal open wounds, hematomas or crepitus. Labs were notable for lactic acidosis, elevated creatinine and leukocytosis. CT of LLE showed fluid tracking along posterolateral myofascial planes from distal thigh to calf without subcutaneous emphysema or abscess. The patient rapidly progressed to septic shock and acute respiratory failure requiring mechanical ventilation and vasopressor support. Within hours of presentation, emergent fasciotomy with debridement was performed (Figure 1, 2, 3) and he was started on broad spectrum antibiotics. Blood and wound cultures grew GAS. Multiorgan dysfunction ensued with septic cardiomyopathy, shock liver and acute kidney injury requiring hemodialysis. Despite appropriate treatment, the patient continued to decompensate. Intravenous immunoglobulin (IVIg) was administered for 3 days and antibiotics were escalated to Linezolid for its anti-toxin effect. After a prolonged course, clinical improvement was noted with resolution of septic shock and subsequent liberation from mechanical ventilation. He was transferred to a hospital in Canada per his wish for skin grafting and physical rehabilitation. DISCUSSION: As seen in this case, GAS NF need not be preceded by trauma and can arise in the absence of immune-suppressing risk factors with postulated sources being oropharyngeal or colonic flora. Treatment involves emergent surgical debridement and intravenous antibiotics. Linezolid may be utilized for its anti-toxin effect in patients with TSS. Although conclusive data regarding use of IVIg is lacking2, its use may be warranted as an adjunct therapy in fulminant cases. CONCLUSIONS: Necrotizing fasciitis is a life-threatening surgical emergency. Clinicians need to be on high vigil to anticipate NF in the absence of trauma or risk factors and the armamentarium available to treat this life-threatening condition. Reference #1: Hussein QA, Anaya DA. Necrotizing soft-tissue infections. Crit Care Clin 2013 Oct;29(4):795-806. https://doi.org/10.1016/j.ccc.2013.06.001. Epub 2013 Jul 25 Reference #2: Intensive Care Med. INSTINCT trial, 2017 Nov;43(11):1585-1593. https://doi.org/10.1007/s00134-017-4786-0. Epub 2017 DISCLOSURES: No relevant relationships by Da Eun Cha, source=Web Response No relevant relationships by Mabel Chan, source=Web Response No relevant relationships by Jason Cheng, source=Web Response No relevant relationships by Andrew Jones, source=Web Response No relevant relationships by Sridevi Rajeeve, source=Web Response No relevant relationships by James Salonia, source=Web Response

Silent subperiosteal iliac hematoma with bone radiolucency in adolescent male athletes

BackgroundSubperiosteal hematoma of the iliac bone is reported as a rare disorder that specifically occurs in young patients after obvious trauma. This report presents seven cases of male adolescent athletes with subperiosteal iliac hematoma without blunt trauma that was identified as an incidental radiolucent lesion on the iliac bone mimicking neoplasm. The purpose of this report is to describe clinical features and radiological findings of silent subperiosteal hematoma of the iliac bone. Subjects and methodsWe retrospectively reviewed the clinical data and radiological appearance of 7 patients who presented with subperiosteal hematoma of iliac bone. ResultsAll seven patients had no obvious trauma and no serious symptoms. All patients were middle school or high school male students who regularly participated in vigorous sports activity; five soccer players, one baseball catcher, and one basketball player. The X-ray showed radiolucent lesion on the iliac bone. Lens-shaped mass without involvement of psoas muscle with ghost native cortex sign and overlying periosteal calcification on CT scan was characteristic radiological finding on subperiosteal iliac hematoma. ConclusionSubperiosteal iliac hematomas can be caused by vigorous sports activity in adolescence. This condition is not always associated with serious symptom. It can be identified as a radiolucent lesion mimicking a neoplasm.