58yo M, fell 2m off ladder ?onto his knee, # femur, awaiting | Figure 1

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58yo M, fell 2m off ladder ?onto his knee, # femur, awaiting a plan for OT

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Case Details

• Case 1:
  Otherwise healthy 16 year old male presents with right thigh pain s/p MVA. Slightly weak right pedal pulses compared to left. GCS 15. Vital signs stable. CT head, neck, chest, abdomen/pelvis was notable for intramuscular hematoma in the anterior compartment of the right thigh and a grade II liver laceration. How would you proceed?

• Case 2:
  Follow up to the 65 year old male with the right humeral shaft fracture and ipsilateral subtrochanteric femur fracture. He got a CMN in the femur on hospital day 0. The next day he had ORIF of the humerus. He is WBAT. Humerus images attached. The radial nerve still works.

• Case 3:
  Dermatomyositis (DM) is a rare inflammatory myopathy with an incidence of 9.63 per 1 000 000 people and typically presents with skin rash and muscle weakness. We report a case of DM that presented with proximal muscle weakness, normal creatine phosphokinase (CPK), negative myositis antibody panel, and non-specific histopathological findings on muscle biopsy, without initial skin involvement. A 67-year-old male presented with subacute bilateral proximal lower-extremity weakness and weight loss of 20 pounds over 3 months. Laboratory investigation was significant for elevated erythrocyte sedimentation rate, C-reactive protein, CPK, and aldolase, with negative myositis-specific antibodies. Femur magnetic resonance imaging revealed subcutaneous, fascial, and muscle edema throughout quadriceps and gluteal muscles. Muscle biopsy showed myofiber atrophy with perivascular and endomysial T-lymphocytes and histiocytes, as well as scattered necrotic myofibers. He was diagnosed with inflammatory myositis and started on prednisone and monthly IVIG infusions. At 2-month follow-up, he reported new rashes on the extensor surfaces of the hands consistent with Gottron’s papules, mechanic’s hands, and livedo reticularis of feet and arms. Cases of DM that present with myopathy and later develop skin changes are rare. Our patient had several months of progressive proximal muscle weakness, and skin changes occurred after he was started on treatment. Laboratory findings include elevated CPK, aldolase, and myositis-specific auto-antibodies. Muscle biopsy helps in diagnosis; however, findings may be nonspecific—as was the case in our patient. Corticosteroids are first-line treatment. Long-term follow-up studies are necessary to better understand the incidence of late-onset development of typical skin findings.

• Case 4:
  W56, osteosynthesis of distal femur and apparently untreated tibial fracture 2 years. Now knee pain after falling out of bed. What would you do?

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