A 21-year-old male bicyclist is brought to the ED, fully immobilized by EMS, after being struck by a car at moderate speed. The patient was found on the ground a few feet from the road with an obvious deformity to his right lower extremity (RLE). He reports that he was struck on the right side, which caused him to go over the handlebars. He was not wearing a helmet but he denies any headache or loss of consciousness. He states that his only significant pain is to his right leg. He has no significant past medical history except for the fact that he was assaulted two weeks prior and had jaw wiring at that time for a mandibular fracture.

Physical examination reveals a young adult male in moderate distress secondary to leg pain, with obvious shortening and deformity to the right femur. There is no evidence of trauma to the head, neck, chest, abdomen or upper back. The jaw is wired shut. Breath sounds are equal bilaterally and the cardiac exam is also normal. The abdomen is non-distended, non-tender and normal bowel sounds are heard. The pelvis is stable, but pain is elicited with gentle pelvic manipulation. The right leg has a notable deformity at the mid-thigh, with shortening and swelling, but no laceration. There are palpable dorsalis pedis and posterior tibial pulses, which are symmetric with the uninjured contralateral leg. The motor and sensory exam distal to the injury is normal bilaterally except as limited by pain. The GU exam is also normal.


A FAST (Focused Assessment with Sonography in Trauma) exam is done during the initial evaluation. The left-upper-quadrant image is shown above. What are the notable findings? What additional imaging studies would you order on this patient or should he instead go straight to the OR?

Conclusion on next page


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