The chest pain was due to pulmonary emboli.
Small emboli were thrown off from the leading edge of the thrombus through the heart to lodge in the lungs. Small emboli cause typical pleuritic chest pain, which is exacerbated by breathing. In isolation these small pulmonary emboli may affect respiratory function, but they may be the precursor to a large and potentially fatal pulmonary embolus (eFig. 6.143).
Anticoagulation was instituted and the patient had an uneventful delivery.
A 45-year-old man had recently taken up squash. During a game he attempted a forehand shot and noticed severe sudden pain in his heel. He thought his opponent had hit him with his racket. When he turned, though, he realized his opponent was too far away to have hit him.
Within minutes there was marked swelling of the ankle. The patient was unable to plantarflex his foot and had to stop the game. Afterward an appreciable subcutaneous hematoma developed in the ankle.
The diagnostic possibilities include a bone or soft tissue injury.
A bony injury was excluded because there was no bone tenderness.
The patient had a significant soft tissue injury. On examination he had significant swelling of the ankle with a subcutaneous hematoma. He was unable to stand on tiptoe on the right leg, and in the prone position a palpable defect was demonstrated within the calcaneal tendon.
A diagnosis of calcaneal tendon rupture was made.
This patient has a typical history of ruptured calcaneal tendon and the clinical findings support this. Magnetic resonance imaging was carried out and confirmed the diagnosis (eFig. 6.144).
The patient underwent an operative repair.
The tendon healed well, though the patient has not gone back to playing squash.
A 67-year-old man was noted to have a mass at the back of his knee. The mass measured approximately 4 cm in transverse diameter. The patient was otherwise fit and well and had no other history of note.
The mass was arising from one of the structures in the popliteal fossa.
Within the popliteal fossa there is a neurovascular bundle that contains the sciatic nerve (and its two divisions), the popliteal artery and the popliteal vein. There are also numerous small bursae associated with the posterior aspect of the knee joint and the muscles and tendons in this region. It is possible that this mass is arising from the posterior structures of the knee joint, which include synovial outpouchings, the menisci, and the muscles and tendons of this region.
The commonest masses demonstrated within the popliteal fossa are a popliteal cyst, a popliteal aneurysm, and an arterial adventitial cyst.
Further clinical examination revealed that this mass was pulsatile and demonstrated a bruit (an audible rumbling made by turbulent blood flow) on auscultation.
A diagnosis of popliteal artery aneurysm was made.
A popliteal artery aneurysm is an abnormal dilation of the popliteal artery. It is unusual for it to be greater than 5 cm because symptoms usually develop before it reaches this size.
Unlike aneurysms elsewhere in the body, the natural history of popliteal aneurysms is to embolize, with the mural thrombus producing ischemia distal to the lesion, rather than rupture. It is mandatory to examine the rest of the arterial tree in patients with a popliteal aneurysm because aneurysms may be bilateral and there is an association with abdominal aortic aneurysms.
The other diagnostic possibilities include a popliteal cyst and an adventitial cyst.