Ingested foreign body mimicking acute appendicitis.

INTRODUCTION: The incidence of acute appendicitis is approximately 250,000 cases per year in the United States with a lifetime risk of 7% (Gupta & Dupuy, 1997). However, despite strongly associated clinical signs, diagnostic accuracy based on history and physical exam alone is only 70% (Jess et al., 1981). This is in large part due to the multitude of mimics found in the differential diagnosis of appendicitis. As a result highly sensitive imaging such as computed tomography scan has become standard of care. PRESENTATION OF CASE: We present a case of an otherwise healthy 20year old male presenting to the emergency department with acute onset of right lower quadrant pain and leukocytosis consistent with a diagnosis of appendicitis. Ultrasonography was grossly negative as was a computed tomography scan. Given the peritoneal nature of the patient's abdominal exam, general surgery was consulted. The patient was taken for exploratory laparoscopy where a long, thin, metallic foreign body was found to have perforated the small intestine. DISCUSSION: Discussion includes a literature review of computed tomography negative appendicitis, as well as the frequency of foreign body mimicking appendicitis. This case demonstrates the importance of the clinical exam even in the face of negative highly sensitive imaging modalities. CONCLUSION: In conclusion, there are several mimics of acute appendicitis and we present an unusual case of a foreign body mimicking this disorder in a young person. Highly sensitive imaging coupled with history and physical examination remains the standard of care for diagnosing appendicitis; however, clinical acumen must be utilized to formulate a broad differential.

Innervation of the Long Head of the Triceps Brachii in Humans-A Fresh Look.

The triceps brachii muscle occupies the posterior compartment of the arm in humans and has three heads. The lateral and medial heads originate from the humerus and the long head arises from the infraglenoid tubercle of the scapula. All heads form a common tendon that inserts onto the olecranon and the deep antebrachial fascia on each side of it. Each head receives its own motor branch, which all are thought to originate from the radial nerve. However, several studies reported that the motor branch of the long head of the triceps (LHT) arises from the axillary nerve or the posterior cord. Here, we dissected 27 triceps in 15 cadavers to analyze the innervation of the LHT and found only radial innervation, which contradicts those studies. We examined studies reporting that the motor branch to the LHT in humans does not arise from the radial nerve as well as studies of the triceps in primates. Occasional variations of the innervation of skeletal muscles are normal, but a change of principal motor innervation from radial to axillary nerve has important implications. This is because the axillary nerve is often involved during shoulder injuries. The precise identification of the prevalence of axillary versus radial innervation is therefore clinically relevant for surgery, nerve drafting, and occupational and physical therapy. We conclude that the primary motor branch to the LHT arises from the radial nerve but axillary/posterior cord innervations occur occasionally. We suggest the development of a standard methodology for further studies. Anat Rec, 301:473-483, 2018. © 2018 Wiley Periodicals, Inc.

Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization.

BACKGROUND: There are many reasons for hypotension in trauma patients with multiple injuries; one uncommon source is facial fractures. The treatment algorithm is volume replacement and local control of the bleeding. A retrospective study was undertaken to evaluate the treatment of patients with life-threatening hemorrhage secondary to facial fractures, and to develop a treatment algorithm. METHODS: A retrospective chart review was undertaken to determine the incidence of hemorrhagic shock in patients with facial fractures exclusive of others sources, and the use of transcatheter arterial embolization to control the bleeding was evaluated. RESULTS: Over a 4-year period, 7562 patients were treated at Palmetto Richland Memorial Hospital, a Level I trauma center. There were 912 patients with facial injuries, with 11 of these patients presenting with life-threatening hemorrhage secondary to facial fractures. The incidence of life-threatening hemorrhage from facial fracture was 1.2%. The mechanism of injury was blunt in 10 patients and penetrating in 1. The blunt injuries resulted from six motor vehicles crashes, three motorcycle crashes, and one plane crash. The one penetrating injury was a shotgun blast. There were six patients with Le Fort III fractures, two patients with Le Fort II fractures, and three patients with a combination of Le Fort II and III fractures bilaterally. The average volume infused before the embolization was 7 L; this included blood and crystalloid. There were four complications: two minor groin hematomas, one partial necrosis of the tongue, and one facial nerve palsy. There were two deaths, both secondary to concomitant intracranial injury as a result of blunt trauma. CONCLUSION: The incidence of severe hemorrhage secondary to facial fractures is rare; however, it can be life threatening. When common modalities of treatment such as pressure, packing, and correction of coagulopathy fail to control the hemorrhage, transcatheter arterial embolization offers a safe alternative to surgical control.