Emergency #8 – Long case

83-year-old man with:
* Painful swelling in the right groin
* No fever
* Nausea but no vomiting, difficulty passing stools
* Swelling not reducible

What do you see? Is it an incarcerated inguinal hernia?

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Imaging findings

* Right-sided inguinal hernia with intestines inside
* Mechanical small bowel obstruction proximal of hernia
* Normal enhancement of the bowel wall

No signs of ischemia.

Differential diagnosis

Mechanical small bowel obstruction: Adhesions/bands–volvulus–internal hernia–obstructing tumour/tumoural implants–other hernia’s–congenital or acquired stenosis

Groin swelling: Adenopathy–femoral hernia–psoas abscess–retracted testicle

Management

If no signs of ischemia are present:
* Careful manual reduction attempt
* If not successful: emergency surgery (risk of strangulation)

If signs of ischemia are present:
* Emergency surgery

Key points

Incarceration only means the hernia is not reducible and does not say anything about the content. An incarcerated inguinal hernia can also contain abdominal fat without bowel loops

Incarcerated hernia can turn into strangulated hernia and lead to small bowel obstruction

Carefully inspect the enhancement of the implicated loop of small bowel

Lack of enhancement is an early sign of ischemia (strangulation) and an indication for urgent surgery

Emergency #7 – Long case

21-year-old male
* High-energy trauma (HET)
* Car vs. car

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What do you see?

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Findings:

* Complex transverse and longitudinal type petrous temporal bone fracture.
* Involvement of inner ear (cochlea, posterior semicircular canal) round window and facial canal.
* Fracture through middle ear ossicular chain (malleolus and incus).
* Soft tissue in middle ear and filled mastoid air cells.
* Some free air bubbles intracranial (pneumocephalus).
* Fracture continuation (not shown here) in temporal, occipital and parietal bone, occipital condyles.

Late complications:
* Sensory and conductive hearing loss
* Facial nerve involvement

Teaching point: Beware of fracture through carotid canal (not shown here), indication to perform additional CTA to look for carotid dissection
Teaching point: Beware of rupture of tegmen tympani, for late complication CSF leakage otorrhoea, with probable CSF hypotension.