Central Chest Pain - An Atypical First Presentation.

INTRODUCTION: The diagnosis of thoracic spondylodiscitis is challenging, given that it is a rare entity in itself and when unusual symptoms such as central chest pain predominate on presentation, it may pose a serious diagnostic challenge. CASE REPORT: A 54-year-old patient presented to accident and emergency with central chest pain and elevated inflammatory markers (C- reactive protein [CRP]: 21 mg/L). Following exclusion of life-threatening cardiac causes, he was discharged home with analgesia and no formal diagnosis. Over the course of the subsequent 6 weeks, he presented to his general practitioner on two different dates with worsening chest pain alongside a new symptom of back pain and progressively rising inflammatory markers. At 6 weeks, he presented back to the emergency department with clinical signs of sepsis, mid-thoracic tenderness with weakness and altered sensation to his legs. The CRP was raised at 297 mg/L. In view of these symptoms, a contrast magnetic resonance imaging scan was performed which revealed destruction of the sixth and seventh disc space with high signal intensity on T2 and short tau inversion recovery images in T6 and T7. Blood cultures were shown to have grown Staphylococcus aureus, and the patient was subsequently treated with combined intravenous antibiotics (flucloxacillin) and oral antibiotics (rifampicin) for 15 weeks resulting in complete resolution of his symptoms. CONCLUSION: Our case report highlights the need for a high index of suspicion of spondylodiscitis in patients presenting with central chest pain, unresolving back pain and elevated inflammatory markers especially in the absence of any other formal diagnosis.

Anterior humeral circumflex artery avulsion with brachial plexus injury following an isolated traumatic anterior shoulder dislocation.

A 70-year-old man presented to accident and emergency with an isolated anteriorly dislocated shoulder, in the absence of a concomitant fracture. There was no neurovascular deficit at presentation, and the shoulder was reduced under sedation, using the Kocher's technique. Following this, the patient developed signs of hypovolaemic shock. Clinical examination revealed an expanding fullness in the deltopectoral area, with compromise of the limb neurovascular status. CT imaging confirmed an expanding haematoma from the axillary vessels, restricting left lung expansion. Once resuscitated, the patient was transferred to theatre for exploration of the bleeding vessels. Intraoperative findings included an avulsed anterior circumflex humeral artery that was subsequently ligated. Postoperatively, the patient developed axillary, radial, median and ulnar nerve neuropraxia, which improved clinically prior to discharge. The patient was ultimately discharged home after a lengthy inpatient stay.

Delayed Presentation of Metacarpophalangeal Joint Dislocation of the Thumb in Children Requiring Open Reduction: Two Cases Reported and Review ofLiterature.

INTRODUCTION: Dislocation of the metacarpophalangeal joint (MCPJ) of the thumb is rare in children and delayed presentation of this injury is even more uncommon in the literature. We report two cases, both children, who presented to fracture clinic with a dislocated thumb over one week after initial injury. In each case closed reduction was attempted but failed, and open reduction was necessary. CASE REPORT: Case Presentation 1: A 4 year-old right-hand dominant girl sustained a hyper-extension injury to her right thumb while on holiday abroad. She was told she has "sprained" her thumb. On review in fracture clinic 10 days later, the MCPJ of her thumb remained swollen and bruised. Radiographs showed a dorsally dislocated MCPJ of the right thumb. Case Presentation 2: A four-year old right-hand dominant boy presented to fracture clinic after being referred from A&E with a left 'thumb injury' - his thumb had accidentally been jammed in a door 1 week previously. Radiographs were reviewed and repeated, confirming a MCPJ dislocation. CONCLUSION: Dislocation of the MCPJ of the thumb is extremely uncommon in children and therefore the diagnosis can be easily missed. Two unusual cases of dislocated MCPJ of the thumb in children that presented late because both radiological and clinical features had been missed are described. Closed reduction should always be attempted first but it should be recognised that conversion to an open reduction may be needed, particularly if there is a delay in presentation. There are various surgical options for open reduction including volar and dorsal approaches and arthroscopic procedures. The optimal method is controversial. We have explained a successful open reduction using a dorsal approach. In both cases the volar plate was found to be interposed within the joint blocking reduction. At follow up the patients had regained a full range of movement, normal power and grip strength.