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A skydiver lost control parachuting and landed in shallow water. At scene the attending doctor noted he was suffering only from a pain in his right knee. The patient denied LOC or any neurological symptoms and was referred to the nearest trauma centre for further management.
At the trauma centre further interrogation revealed the patient had fallen on his right side and twisted his right knee. He had no past medical history, took no medication and was an occassional smoker and consumer of alcohol.
On examination the patient was haemodynamically stable, GCS 15 with a pain score of 4/10. He had a swollen right knee which was tender on the lateral aspect without suggestion of neurovascular injury. A radiograph of the right knee joint was performed showing avulsion of the lateral tibial plateau and fracture of the right head of fibula. These findings were confirmed on CT within 3 hours of injury (Figure 1A-D)
The patient was sent for blood sampling following the CT, at this stage his condition detiriorated. He became irratible and began salivating excessively. A primary survey was repeated showing a patent airway, good bilateral air entry to the chest with saturations of 100% on 10L of oxygen via mask. His blood pressure was 127/82 with a heart rate of 86 BPM. By this point he was GCS 13 with bilateral size 3mm pupils which were reactive to light.
The secondary survey showed a left sided upper motor neuron facial palsy with left sided hemiplegia. The patient was suspected of suffering from an intercranial haemorrhage and was sent for a CT head (Figure 2A-B). On radiologist review a right middle cerebral artery thrombosis was noted and the patient was sent for a CT angiogram.
Following this incident the doctor attending the patient at scene was contacted. They reported that the patient had in fact landed with the parachute twisted around their neck at impact, causing compression of the right side of his neck.
The patient was not thrombolysed and no interventional radioloigst was available to manage this case.
Author: Dr Shihab Ahmed Mahdi, Specialist senior registrar in trauma center Rashid hospital, Dubai, UAE.