sis. Splenic vein thrombosis can follow a single mild episode of pancreati t is as well as chronic severe cases, and pseudo- cysts are not necessarily associated. Some pat ients may have jaundice and a pancreatic mass which has been shown to be inflammatory. The key to diagnosis is angiography, in which the venous phase of the study demonstrates the pathology. Some pat ients may have splenomegaly. Treatment depends on the presence or absence of bleeding and its severity. In cases unresponsive to medical therapy, splenectomy is indi- cated. Risk of bleeding in pat ients with splenic vein thrombo- sis and varices is not known. This study suggests the inci- dence may be as h igh as 70%. (Edi tor ' s note: It is curious that more cases of this entity have not been encountered since pancreatitis is so common in the alcoholic population. We will certainly look for it, especially in the bleeding alcoholic who lacks ascites or jaundice.)

Nancy Bodelson, MD

splenic vein thrombosis

Fractures of the scapula. McGahan JP, Rab GT, Dub- lin A, J Trauma 20:880-883, (Oct) 1980.

A retrospective study of 121 pa t ien ts sus ta in ing scapular fractures over an eight-year period was performed. The aver- age age of pat ients with such fractures was 35 years; two- thirds of those injured were men. A great deal of force was necessary to break the scapula, as is evident in tha t 81% of patients were involved in some type of vehicular accident. A significant number of pat ients had the i r fractures overlooked initially, which reflects the fact tha t a high percentage (88%) had associated injuries tha t detracted from careful evalua- tion of the scapula. Forty-four percent had rib fractures; 26%, clavicle fractures; 13%, neurologic deficit; and 16%, pulmo- nary complications. Per ipheral nerve injuries were uncom- mon, and were almost always associated with fractures of the acromion process. The most common injured regions of the scapula were the body and neck, being injured in 43% and 26% of patients, respectively. Treatment of these injuries con- sisted of immobilization for three weeks with emphasis on early ROM. Most pat ients were able to re tu rn to work in four to six weeks and ra re ly were there l a t e r complicat ions. (Edi tor ' s note: Another fracture along with rib number 1, 2 or 11, 12 in which the significance of bone injury is of lesser importance than associated or underlying damage.)

Ken Jackimczyk, MD

fracture, scapula

Acute nerve injury as a complication of closed frac- tures or dislocations of the elbow. Galbraith K, McCul- Iough C, Injury 11:159, (Oct) 1980.

A retrospective review of 1,540 pa t ien ts sus ta in ing closed fractures or dislocations of the elbow was performed. Among these pat ients , 21 cases with objective neurologic deficits were found and analyzed. Those cases with t rans ien t paras- thes ias were not considered. Nerves involved were u lna r (nine cases), median (five cases), radial (three cases), anter ior interosseous (two cases), and poster ior interosseous (two cases). Nine of the 21 cases had persis tent nerve damage. Ul- na r nerve palsy was seen most commonly wi th posterior

elbow dislocations (six), bu t also wi th h u m e r u s fractures (two) and medial epicondyle fracture (One). Only two pat ients with u lnar deficits had full recovery. Radial nerve deficit was seen in three patients, two with Monteggia fractures and one wi th a f ractured capitellum. One had a pers is tent defect. Four hundred sixty-five supracondylar f ractures produced five median nerve palsies. Anter ior interosseus involvement

was seen in two patients, one with a supracondylar fracture and one with an olecrannon fracture. Both pat ients had full recovery. Two pat ients sustained posterior interosseus deficits secondary to Monteggia injuries and both showed full recov- ery. (Ed i tor ' s note: While these troublesome complications are rare, early recognition in the emergency department per- mits appropriate foUowup and early therapy.)

Ken Jackimczyk, MD fracture, elbow, compfications; injury, nerve

Clinical setting and prognostic significance of high degree atrioventricular block in acute inferior myo- cardial infarction: A study of 144 patients. Tans AC, Lie KL, Durrer D., Am Heart J 99:4-8, (Jan) 1980.

Of 843 pat ients with acute inferior infarction, 144 (17%) de- veloped high degree A-V block. The hospital mortal i ty rate of the cases complicated by high degree A-V block was 22~ compared to 9% in the pa t ient group without high degree A-V block. Seventy-five percent of in-hospital deaths were due to pump failure. The maximal degree of A-V block did not influence the immediate prognosis. Forty-eight percent of cases of high degree A-V block were present on admission and 92% within 72 hours of admission. Fifty-nine percent of pat ients with h igh degree A-V block were temporari ly paced and 41% were successfully managed without pacing. There was no significant difference in mortal i ty between those who were paced and those who were not. However, of the 42 pa- t ients who demonstrated shock, 31 had ventr icular rates less than 50, and in 24 of 29 of these pat ients who were paced, the shock was reversed. In pat ients with ventr icular rates great- er than 50, pacemaker insert ion did not affect the immediate prognosis. (Edi tor ' s note: High degree block was defined as 2 ° A - V block occurring via a Type I mechanism + 2:1 block, atrial fibrillation with ventricular response less than 60 min- utes in the absence of digitalis, and 30 A - V block. I t is in- teresting that in most instances pump failure, rather than block, caused the death.) Brian Allen, MD myocardial infarction

Use of intraperitoneal Xenon-133 for imaging of in- testinal strangulation in small bowel obstruction. Bulkley GB, et al, Am J Surg 141:128-135, (Jan) 1980.

Clinically and diagnostically, identification of small bowel ischemia by radionuclide imaging previously has been very difficult. Based on the principle of reduced radionuclide clear- ance, or delay in external ly detected isotope washout seen with decreased blood flow in ischemic tissue, a new method of detection was accidentally discovered. Rat and dog models were used to demonst ra te tha t intraperi toneal injection of Xenon-133 dissolved in normal saline could accurately detect small bowel ischemia at one hour post injection, using exter- nal gamma ray counting. This new method overcomes the usual drawbacks found in conventional intravenous radio- nuclide imaging and, more important , allows identification of mechanical in tes t ina l obstruct ion at a t ime w h e n sur- gical correction and bowel t issue salvage is still possible. (Edi tor ' s note: This promising work is still experimental and its validity in man is as yet untested. To be answered is whether this would identify early post-operative bowel ische- mia, mesenteric vascular impairments, and bowel compromise in the face of intraperitoneal adhesions. I t would also be help- ful i f the radionuclide could be instilled intraluminally rather than intraperitoneally.) Nancy Bodelson, MD

bowel , obstruct ion, imag ing

108/558 Ann Emerg Med 10:10 (October) 1981