EMERGENCY – Long case 2

47-year-old male, fall on outstretched hand.

What do you see?
Pain. Fracture?

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Findings:

* The lunate is displaced and rotated volarly and there is no normal alignment with the radius, consistent with lunate dislocation (stage IV carpal dislocation).

* Lunate dislocations are relatively uncommon and typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. 

* There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. 

Teaching point:
Be sure it is a lunate dislocation, and not a perilunate dislocation (stage II carpal dislocation)! In this case, the lunate remains in normal alignment with the distal radius, but the carpus is dislocated dorsally relative to the lunate. This injury has 60% association with scaphoid fractures.

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EMERGENCY – Long case 1

45-year-old male with acute chest pain radiating to the back and hypertension

Type A or type B dissection?

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Type B, entry zone/intimal tear after left subclavian artery.

False lumen often of lower contrast density due to delayed opacification, as in this case. Origin of coeliac trunk, SMA and right renal artery usually from true lumen and origin of left renal artery usually from false lumen.

Teaching point: Notice that dissection continues in the SMA with intramural thrombus. Usually no fear of bowel ischemia due to arc of Riolan with IMA

Notice in this case: Right renal artery comes off from false lumen and dissection continues in it. Right kidney parenchyma enhances less than left, due to hypoperfusion, high risk of ischemia.

Aortic Dissection Stanford type B

What are possible complications of an aortic dissection?

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* Dissection and occlusion of branch vessels
* Abdominal organ ischaemia
* Distal thromboembolism
* Aneurysmal dilatation: this is an indication for endovascular or surgical intervention 
* Aortic rupture

What is the appropriate management?

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Aggressive blood pressure control with beta blockers as they reduce both blood pressure and also heart rate hence reduce extra pressure on the aortic wall.

In this case: Complicated type B dissection and persistent hypertension led to Bentall thoracic surgery with stent, due to risk of proximal continuation in ascending aorta, coronaries and neck vessels.