11/512. Delayed diaphragmatic herniation masquerading as a complicated parapneumonic effusion. Injury to the diaphragm following blunt or penetrating thoracoabdominal trauma is not uncommon. Recognition of this important complication of trauma continues to be a challenge because of the lack of specific clinical and plain radiographic features, the frequent presence of other serious injuries and the potential for delayed presentation. Delayed diaphragmatic herniation often presents with catastrophic bowel obstruction or strangulation. Early recognition of diaphragmatic injury is required to avoid this potentially lethal complication. The case of a 35-year-old man with a history of a knife wound to the left flank 15 years previously, who presented with unexplained acute hypoxemic respiratory failure and a unilateral exudative pleural effusion that was refractory to tube thoracostomy drainage, is reported. After admission to hospital, he developed gross dilation of his colon; emergency laparotomy revealed an incarcerated colonic herniation into the left hemithorax. Interesting clinical features of this patient's case included the patient's hobby of weightlifting, a persistently deviated mediastinum despite drainage of the pleural effusion and deceptive pleural fluid biochemical indices. ( info) |
12/512. Tentative injuries to exposed skin in a homicide case. A 28-year-old man stabbed both his wife and his 3-year-old son to death, before unsuccessfully attempting to commit suicide. The incident occurred against a background of marital conflict. The child's body exhibited six tentative wounds to the skin in the area of the heart, with no corresponding defects in the overlying clothing, a pattern normally seen only in suicide. Their presence can be explained by the fact that this can be considered an extended suicide, the father's motivation for the killing being comparable to that for true suicide. However, wounds of this nature can be produced in such cases only if the victim is severely limited in his ability to defend himself, here due to the superior physical strength of the father. ( info) |
13/512. neuroimaging of a wooden foreign body retained for 5 months in the temporalis muscle following penetrating trauma with a chopstick--case report. A 48-year-old female was stabbed by her husband with a chopstick made of wood in the left temporal region during a quarrel. She suffered laceration of the left temporal scalp. At initial examination, she concealed the assault with a chopstick. radiography showed no abnormality, so the wound was sutured. One month after the injury, a painless subcutaneous mass appeared in the left temporal region which grew rapidly for 3 months. She was then admitted to our department. Computed tomography (CT) on admission showed a hyperdense area at the center of the mass. This area was hypointense on both T1- and T2-weighted magnetic resonance (MR) images. Temporalis muscle tumor with accompanying central necrosis, old hematoma, and inflammatory granuloma was considered. The mass was totally resected for cosmetic purposes and was found to be wooden foreign body granuloma. High density on CT and hypointensity on both T1- and T2-weighted MR images are characteristic of a chronically retained wooden foreign body in the living body and are useful for detecting wooden foreign bodies in the chronic granulomatous phase. ( info) |
14/512. Unilateral exophthalmos caused by traumatic vertebral artery to vertebral and jugular vein fistula: problems in diagnosis and management. skull base venous fistulas are rare. A 15-year-old boy was stabbed in the left side of his neck, just below the mastoid process. Two years later, he presented with a protruded and pulsating left eye with red sclera. A soft murmur was audible all over his head and neck. angiography revealed an arteriovenous fistula between the third portion of the vertebral artery (V3) and the vertebral venous plexus, as well as the ipsilateral jugular vein (VVJF). The fistula recruited several arterial feeders and rising the venous pressure along the outflow system of the skull base had led to unilateral exophthalmos. ( info) |
15/512. Crossbow suicide: mechanisms of injury and neuropathologic findings. Crossbow injuries are rarely reported events in modern times. Two cases of death due to self-inflicted crossbow injuries to the head are reported in 2 men aged 18 and 27 years, respectively. Despite relatively low velocity and concussive force, the sharpness and propulsion force of crossbow bolts may be sufficient to enable penetration of the skull at short range. Due to the relatively low concussive force of the crossbow bolt, however, death may not be instantaneous but may occur from intraparenchymal cerebral damage sometime thereafter. Detailed neuropathologic evaluation of such cases may therefore demonstrate "red cell" hypoxic injury, as well as axonal injury, not limited to the region of the missile tract, but widely distributed, even to the point of extensive brain stem involvement. These changes may result from primary mechanical deformation at the time of injury, from secondary hypoxic damage, or from a combination of both factors. Immunohistochemical staining of brains for amyloid precursor protein to delineate more clearly the pattern of axonal damage may assist in determining the extent of injury in such cases. ( info) |
16/512. Serial abdominal ultrasound in the setting of trauma. Ultrasound is gaining wide acceptance in emergency medicine as an inexpensive and accurate examination modality. One of the leading uses of this technology is in the initial assessment of the trauma patient, where the ultrasound examination is often used to determine the need for immediate laparotomy or further diagnostic study. We present a series of four patients, all of whom sustained blunt or penetrating abdominal trauma. In each case, the initial screening abdominal ultrasound was negative for free intraperitoneal (i.p.) fluid but, when repeated by the same practitioner, became positive. These cases demonstrate the need for serial ultrasounds in evaluating the patient with abdominal trauma. Future studies of trauma ultrasound should investigate the utility of serial sonographic examinations. ( info) |
17/512. Traumatic intracranial aneurysms following penetrating stab wounds to the head: two unusual cases and review of the literature. Two patients with rare complications of traumatic intracranial aneurysms following penetrating cranial stab wounds are described. One patient had a good outcome despite a secondary rupture of a traumatic proximal middle cerebral artery aneurysm, while the second patient had a traumatic basilar bifurcation artery aneurysm. To our knowledge neither the survival from a secondary rupture of a traumatic intracranial aneurysm, nor the development of a basilar bifurcation aneurysm secondary to a transcranial stab wound has been described previously. Furthermore, this is the first report of the technique of deep hypothermic cardiac arrest utilized to treat a traumatic false aneurysm. Traumatic intracranial aneurysms are a rare clinical entity, most often diagnosed after rupture and often resulting in fatal haemorrhage. A high index of suspicion needs to be maintained when managing patients with transcranial stab wounds. Early surgical intervention improves outcome by preventing initial aneurysmal rupture or rebleeding. ( info) |
18/512. Delayed presentation of spinal stab wound: case report and review of the literature. Stab wounds to the spinal cord are relatively uncommon in north america, but even rarer is the presentation of such an injury in a delayed fashion. We report a case of a 31-year-old male who presented with neurologic deficit 4 weeks after a stab wound injury to the spine. Because of worsening neurologic deficit, the retained knife fragment was operatively removed, and the patient had an uneventful recovery. The management of such an injury is discussed, with a review of the literature. ( info) |
19/512. Traumatic arteriovenous fistulas. A follow-up study. Over the period 1958 to 1972 14 patients with traumatic arteriovenous fistulas were treated. The mean period from trauma to surgical closure of the fistula was 13.3 years. No form of reconstructive vascular surgery had been performed initially. The dominating symptom of arteriovenous fistula was a pulsating tumor with a marked thrill. Excision of the fistula and reconstruction of the artery and vein was performed in 11 patients. In 3 patients the fistula was first ligated resulting in early recurrence of the shunt. At follow-up 3-15 years postoperatively all fistulas were closed, but 5 patients had moderate symptoms. ( info) |
20/512. Forensic aspects of ocular injury. A case of homicidal stabbing resulting in bilateral penetrating ocular injuries is described. The case is noteworthy in that it highlights an unusual mechanism of death in homicidal stabbing. Disturbances in heart rhythm including asystole can be ascribed to the so-called oculocardiac or trigeminocardiac reflex. Although this phenomenon is well known to ophthalmologists, neurosurgeons, and anesthetists, it is much less familiar to forensic pathologists. This is a potential mechanism of death worthy of consideration in cases of sudden unexpected death occurring in the context of facial injury. ( info) |