DESCRIPTIONA 32-year-old policeman presented to the emergency department with acute right knee pain and swelling after a fall. The injury was sustained while playing kabbadi (an Indian game) as a result of a twisting injury to the knee. He was initially treated at a local hospital where they diagnosed it as a knee dislocation. However, he was referred to our institution after an unsuccessful attempt at closed reduction. On clinical evaluation, the patient was haemodynamically stable and all vital parameters were within normal limits. Clinical examination of the right knee revealed a painful and mildly swollen right knee with 'puckering' of the skin overlying the medial femoral condyle ( figure 1A,B). It appeared as though the skin overlying the medial femoral condyle was trapped inside the knee joint.Range of movement of the right knee was painful and limited. Clinical evaluation for ligamentous instability could not be performed due to pain. A thorough clinical evaluation for neurovascular compromise (Doppler and CT angiogram) was found to be negative. Radiological investigations (X-rays (figure 2) and MRI ( figure 3A,B)) Figure 1 (A and B) Clinical photograph showing the medial aspect of right knee joint. The medial femoral condyle has button holed through the medial capsuloligamentous structures and lies subcutaneously. We can also see the skin and medial subcutaneous tissues being entrapped between the medial femoral condyle and the joint cavity producing the 'pucker sign'.
A 29-year-old man had a head-on collision with an oncoming truck while riding a bike. He sustained a fracture of the left first rib, fracture of the left talar neck with ankle dislocation and fracture dislocation of the right wrist. The patient was haemodynamically stable and underwent an emergency open reduction and internal fixation of the fractured talar neck to prevent further vascular compromise of the lower limb. Postoperatively, the patient deteriorated haemodynamically with persistent tachycardia and respiratory distress and died after 3 days despite ventilator support. The postmortem examination revealed a contused heart with dissection of the coronary arteries. Our case demonstrates that a first rib fracture may be associated with severe thoracic and cardiac injuries which may be masked by less severe but more obvious skeletal injuries.
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