Wednesday, November 28, 2007

the doctor is in 6

It’s good to get back into the cyber-office after the Holidays. Trust yours was enjoyable and nobody got hurt too badly – remember, it’s all fun and games until the cops show up.

Today’s case is called, “Swelling and Pain in the Back and Hip of a 35-Year-Old Man.”

Let’s start out with an exterior shot.

Dang! That boy got some butt. No hair, cute little cheeks. Ut oh! What’s that up the top of the ole crack in the china? A little protruding buddy, eh, son? Sensitive to touch? Bet you have to hang up the thongs for a bit.

We need a better look. Have to go inside. No, not the anal-intrusion instrument – I am an internet doc; only “real” docs invade the chubster on any excuse. We’re gonna use one of those machines with letters for a name, whichever one is available. “Hey, tell the tech, top down, 32 degree lateral shots from points A to B, C to F, and X to A1.” I have no idea what that means, but everything I say they write down and these picture thingeys come back, so it must be something.

Let’s see what they found …

YOWO! Lookey here! The boy’s got an ALIEN in his BUTT! AN ALIEN!! This is so cool! It’s got floppy ears! The protrusion out of his butt is its HEAD! It must have parked itself there for the food supply. Smart, them aliens are. Got a bunch of fat to suckle and, of course, the ultimate food supply – the colon – food’s already digested, got that dark chocolate nutty flavor. This is a first in the annals of medical science! A documented alien in the butt!

Another pic? What’s this?

Oh, no! This guy is in trouble. See those two circles? Alien eggs embedded in his butt cheeks. Toast. Better schedule an untimely death and burn this dude’s carcass. He’s got one alien already hatched, ears fully deployed, and two more coming. Them butt cheeks ain’t gonna be so cute in another few weeks. I estimate about 4 to 6 weeks max gestation left. I wonder if we can toss him into coma somehow, then fix the records to show his brain waves isoelectric. That hatched alien decides to exit, it’ll get ugly! They sneak right out the butt when you are aren’t looking! Let’s hope it’s a mama alien and will stay put until the eggs hatch. Man, this is so sad.

Let’s hear the guy’s story …

BACKGROUND. A 35-year-old man presents to the emergency department (ED) complaining of sacral pain and right hip pain (damn straight. Hatched aliens HURT!). The pain is associated with increasing swelling in these regions that began 3 days before presentation (the little alien dude hatched just a little time ago. That’s good news, actually. Not likely to venture out soon.). The patient otherwise denies having any systemic symptoms, such as fevers, chills, nausea, or vomiting (I agree. Aliens don’t like it warm. Anyway, they eat vomit like ice cream before it ever gets a chance to leave). His past medical history is significant for a recent admission to the hospital after an accident with a motor vehicle approximately 2 weeks before presentation (I don’t like the sounds of this). As a pedestrian, the patient was struck by a car and sustained multiple rib fractures and facial lacerations (an alien hit-and-run. Typical. Once he was dazed, this stick the eggs in his butt. Notice the precision with which they placed the eggs – right cheek, left cheek, top of the crack. Very common in alien-egg insertions. This poor guy.). He was discharged to home from the hospital 10 days before presentation and has been doing relatively well, with adequate pain control for his rib fractures.

On physical examination, the patient’s temperature is 98.96°F(37.20°C) (I can tell you right now that everything is normal – aliens cover their tracks well. We’re lucky to have found these), with a blood pressure of 129/67 mm Hg and a heart rate of 89 bpm. His respiratory rate is 20 breaths/min, and his O2 saturation is 95% while breathing room air. The patient is not in acute distress. The head, eyes, ears, nose, and throat (HEENT) examination shows well-healing facial lacerations with intact sutures. His chest is clear to auscultation on both sides, with normal cardiovascular and abdominal findings. The lower extremities have normal sensation and 5/5 strength (on a scale of 0-5, with 0 being no strength and 5 being normal strength) (see? Normal across the board. Aliens in the butt. Man, I hate aliens).

A visible fluid collection is observed in the proximal lateral aspect of his right thigh (aliens gotta pee, too; it’s building up in his legs. We gotta act fast.). The fluid seems to track up (track UP? Idiots. It is flowing DOWN. Alien pee) around the gluteus maximus muscle to the lumbosacral region, with slight crossing of the midline to the left. The fluid appears to be a free-flowing, low-viscosity collection without evidence of erythema or ecchymosis (that is EXACTLY how alien pee presents). No loculation is noted on palpation, and the patient has no thickening or induration of the skin in the overlying and surrounding areas (all normal … see what I told you?).

What is the diagnosis? (One hatched alien distal to the butt crack; two alien eggs embedded one in each of his butt cheeks; accumulation of alien pee in his legs – simple – we’re done here!)

HINT. This fluid collection was not appreciated during the patient’s previous admission to the hospital. (Of course it wasn’t! The dang thing just hatched! What kind of hint was that? Ah, I get it! See, they are telling you they KNOW it is a recently hatched alien! A-HA!)

ANSWER. Closed, internal degloving injury (“degloving” is code for floppy-eared alien): The patient underwent computed tomography (CT) scanning of the pelvis, which showed a large, subcutaneous fluid collection extending from the region of the lumbosacral spine along the right lateral buttock to the thigh and down to the level of the femoral shaft (alien; pee). The fluid collection was not present on a previous CT scan that was obtained 2 weeks before presentation (the time of the motor vehicle collision) (you mean, before they implanted their eggs INTO him? Of course not!). The patient’s laboratory studies showed a white blood cell (WBC) count of 8.38 × 109/L; hematocrit, 0.363 (36.3%); platelet count, 953 × 109/L (953 × 103/µL); and an international normalized ratio (INR) of 1.0 (yep, yep, yep, yep – alien, alien, alien, alien. Wait until the pee starts to accumulate – that’ll crank his white count!).

The patient underwent CT-guided aspiration of the fluid collection under local anesthesia. An 8F catheter was used to aspirate 800 mL of dark red fluid (alien blood – careful, they bite!). Postaspiration CT images demonstrated near-complete resolution of the fluid collection (yeah, do you think they are stupid? It went to lunch! Just parked itself INSIDE the colon for a spell), and the catheter was removed (and the alien came back). A pressure dressing (elastic spica dressing) was applied. An elastic bandage was wrapped around the entire thigh, beginning just proximal to the knee, and continued upward across the proximal thigh and buttock. The bandage was wrapped around the waist several times and then brought back over the thigh to compress the entire lower back, buttock, and proximal thigh. The patient tolerated the procedure well and was discharged to home the following day. He was instructed to wear the compression dressing as much as possible, and a follow-up visit was scheduled. The aspirated fluid was sent for bacterial culture and found to be negative for bacteria (aliens don’t have Earth bacteria! Bet you didn’t scan for non-Earth bacteria, did you?).

(I can’t listen to these idiots anymore. Aspirate, my ass! This dude has a serious alien infestation. Let’s put him under, flat-line his results, fake an autopsy, and burn him. These things lay eggs like turtles – all plop, plop, plop until the hole is filled – and the hole, in this instance, is his two butt cheeks! I’m outta here – office closed!)

A closed, internal degloving injury is a clinically significant soft-tissue injury that is associated with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, which creates a potential space that can fill with serous fluid and/or a hematoma caused by the disruption of the arteries that perforate through the fascia mixed with viable and necrotic fat. The condition commonly occurs over the greater trochanter, but it can occur anywhere over the trunk, buttock, or thighs. When a closed, internal degloving injury occurs over the greater trochanter, the condition is known as a Morel-Lavallee lesion. As mentioned, this condition usually occurs in association with pelvic and acetabular fractures, but it can also occur in the absence of fractures. Direct crush injury to the pelvis or a high-speed motor vehicle crash are the most common mechanisms of injury. The importance of this soft-tissue injury may not be initially apparent; some patients present months after the initial event, complaining of soft-tissue swelling or contour abnormalities that are not resolving.

The diagnosis of a closed, internal degloving injury is usually based on physical findings (ie, a soft, fluctuant area over the lesion and a loss of local sensation). Diagnostic aids may include ultrasonography and CT imaging. Various methods or combinations of techniques for treating degloved areas have been suggested, including the application of compression dressings, fluid aspiration or liposuction, injection of sclerosing agents, deep fascial fenestration, prolonged closed surgical drainage, and open surgical debridement (ie, leaving the degloved area open for closure by secondary intention). A review of the available literature, while failing to reveal prospective comparisons, did demonstrate variable outcomes with different therapeutic approaches, ranging from complete resolution to the development of various complications, including infections and skin necrosis or breakdown. The complications associated with closed, internal degloving injuries often require extensive therapy and surgical management.

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