Archives for August 2013

A common Kiwi presentation.

 I recently saw a patient for an off work certificate who was somewhat unusual for New Zealand.

He worked on a mine in Queensland and had been having a holiday before returning to NZ. Whilst wandering in the shallows he stood on something sharp and had severe pain in his foot. Lifting his foot he had four puncture marks and assumed he had stood on some coral.

He then describes ascending pain,  spreading erythema and severe oedema and pre-syncopal symptoms.

His mates loaded him into the Ute and rushed him to the local hospital.

On arrival he was mildly hypotensive BP 100/60 with a relative bradycardia of 50bpm for a patient in severe pain.

He was treated with a combination of oral, IV analgesia and hot water immersion (which he reports no effect from) and was kept for observation. Discharged with oral antibiotics and returned to NZ.

Discharge diagnosis of “Fish envenomation NOS”

He was kind enough to share his photos from the “holiday from hell”

 

foot 1

24 hours post injury.

foot 3

 Impressive oedema.

foot 4

 72 hours post injury.

When seen in clinic (2 weeks post injury) the patients oedema was resolving but he couldn’t get his boot on yet. The blistered areas had sloughed off and good granulation tissue in the bases. As he was working for a rich Aussie mining company I put him off for another week ;)

So I went looking for some info on fish envenomation’s. The Team at LITFL did a great review in 2009 so I chased about to see what the literature has come up with since then.

http://lifeinthefastlane.com/2009/04/scorpionfish-stonefish-lionfish/ (LITFL discussion of management)

Published at the exact same time as the LITFL review was a case series from Singapore hospital of 30 patients, showing most did very well and antivenom was not used very often.

http://www.ncbi.nlm.nih.gov/pubmed/19495521

 An article in French which discusses a case leading to cardiovascular collapse:

 http://www.ncbi.nlm.nih.gov/pubmed/20099677

My hand’s a bit munted.

Bloke arrived in ED holding  his “Munted hand!”

Patient was clearly in pain with a deformed hand:

image

Mechanism of injury was fall from BMX wedging hand between a large rock and tree.

image

Analgesia and off to x-ray:

metacarpal disolcation 3

 

Metacarpal dislocation 2

The films show Carpometacarpal dislocations of 3rd 4th and 5th (and possibly 2nd according to radiology) But no associated fractures on any views.

Titrated fentanyl was given for analgesia and midazolam was added for the reduction.
The reduction only required minor force applied to base of metacarpals and longitudinal traction.

Post reduction films showed:

metacarpal dislocation reduced

Patient was taken to theatre later that day for K-wire fixation.

The patient was planning to be back on the bike after removal but couldn’t help himself and was out riding 4 days post cast removal (day 11 post reduction)

So the Munter with the munted hand is doing well. K-wires removed at clinic increasing strength and not too much stiffness. (the benefit of early mobilisation?)

I was going to write more about Carpometacarpal Dislocations but Chris Partyka has covered it so well over at The blunt dissection I thought pointing you there would be better.

http://thebluntdissection.org/2013/04/quick-case-01/