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Case 107: Skin Markings

A 44 year old man was brought to the emergency by a concerned motorist who found him walking along a country road. It was early in the morning on a saturday. He was confused, cold and still intoxicated. He had a painful and partially numb right arm and shoulder.

1. What is the cause of the skin markings?

Seat-belt bruising from a high speed motor vehicle accident. In Australia, this gentleman would have been the driver (or possibly the rear, right-hand, back seat passenger)

2. What associated injuries could be present?

Think Trauma.
Not immediately subclavian artery intimal damage.
This is a trauma patient.

Airway - assess and secure if neccessary. (secure cervical spine ! put collar on!)
Breathing - assess, assist, support
Circulation- assess, replace, reduce loss, reassess response to therapy
Disability - consider head / neck injury

Adjuncts to primary survey
ie - Oxygen, ECG monitoring, saturation monitoring, warming blanket

Secondary survey

A head to toe assessment of the entire patient, now consider injuries that would be associated with this characteristic mechanism of injury.

Possible associated injuries:

1. Shoulder region. Fractured clavicle, or first rib, subclavian artery injury, brachial plexus injury.
2. Lap belt injury - Spine (Chance fracture - more common with lap belt only), splenic, liver, small bowel, pancreas, colonic, bladder, major vessel.
3. Chest - Pneumothorax, haemothorax, pulmonary contusion, myocardial contusion.
4. Other - Head, cervical spine, pelvic, long bones

Further Reading
www.trauma.org -- thoracic trauma

wheelessonline.com -Chance fracture

Case Editor:

Mr Russell Gruen - Trauma Surgeon, Royal Melbourne Hospital, Victoria, Australia