SAEM Clinical Images Series: Purple Finger

bruising

A 30-year-old female with a past medical history of Crohn’s Disease presented to the ED for evaluation of an acutely bruised right 4th finger. She stated she was typing on a computer keyboard approximately 10 minutes prior to presentation and she noticed a sudden popping sensation at the base of her right ring finger. After the popping sensation, she noticed a cool sensation of the finger and numbness to the entire finger. Shortly after that, the finger turned purple, so she came to the Emergency Department for evaluation. She denied pain in the hand and has had no problems moving the finger. She denied trauma to the hand or finger. No other complaints or issues. She noted that she has had this once in the past, which self-resolved on its own in 10 days a few months ago in the same situation.

General: No acute distress

Right hand: Right 4th finger with diffuse ecchymosis across the palmar surface of the finger with swelling, no tenderness, ecchymosis does not extend to the palmar surface of the hand. FROM of all 5 digits at both the DIP and PIP joints. Sensation to the right 4th finger is decreased to light touch.

Left hand: Normal

Extremities: Normal other than the right ring finger

Pulses: Radial pulses 2+ bilaterally

Remainder of the physical exam is normal.

Non-contributory

Achenbach Syndrome, also known as paroxysmal finger hematomas, is a self-limited condition. It typically afflicts middle-aged women and presents as spontaneous subcutaneous bleeding of the palmar surface of the middle and index fingers of the hand. Patients usually present with pain, swelling, tingling, numbness, and ecchymosis. Many report a burning sensation to the finger. Diagnosis is based on presentation and exam. Laboratory testing and imaging do not show pathologic findings in this disorder. There is no known treatment and symptoms usually resolve on their own in a few days, but can last up to months. It has been shown to be recurrent, but without a known cause. Given the dramatic presentation of Achenbach Syndrome, it is important to be aware of this benign process to prevent unnecessary testing and workup, as it is a self-limited process.

Take-Home Points

  • Achenbach Syndrome is a benign, self-limited condition that does not require treatment
  • Relapses may occur.
  • No testing is indicated, but if sent will be normal including laboratory studies and arterial dopplers of the extremity.
  • Ahmed Z, Elmallah A, Elnagar M, Dowdall J, Barry M, Sheehan SJ. Painful Blue Finger-Achenbach’s Syndrome: Two Case Reports. EJVES Short Rep. 2018 Jun 27;40:1-2. doi: 10.1016/j.ejvssr.2018.05.008. PMID: 30094355; PMCID: PMC6070693.
  • van Twist DJL, Hermans W, Mostard GJM. Paroxysmal finger hematoma. Cleve Clin J Med. 2020 Apr;87(4):194. doi: 10.3949/ccjm.87a.19122. PMID: 32238371.

By |2024-03-16T21:44:45-07:00Mar 18, 2024|Orthopedic, SAEM Clinical Images|

SAEM Clinical Images Series: Enigmatic Traumatic Hip Pain

hip

An 84-year-old female presented with a chief complaint of right hip pain after a fall 12 hours prior to presentation. The patient reported a history of falls resulting in shoulder, rib, and left hip fractures in the past. The patient stated that upon getting out of bed, she took 4-5 steps, lost her balance, and fell backward onto the bedroom floor. She denied loss of consciousness. She denied syncope or vertigo before the fall. She was unable to bear weight due to a 7/10 intensity pain on the anterior medial aspect of her right thigh that was worse with movement.

Vitals: 37.8°C; BP 138/92; HR 94; RR 18; SpO2 98% on room air; BMI 24

General: A&Ox4, anxious, in moderate distress.

HEENT: Normocephalic, atraumatic, PERRLA, EOM’s intact.

Cardiac: RRR w/out m/r/g, pulses 2+ in all extremities.

Respiratory: BBS, CTA.

Abdomen: BS+, nondistended, nontender.

MSK: No gross deformities appreciated, right hip with limited flexion and extension due to pain. Tender to palpation superior, anterior medial aspect of the right thigh. Full range of motion of the right knee, ankle, and left lower extremity.

Complete blood count (CBC): Within normal limits

Comprehensive metabolic panel (CMP): Within normal limits

AP Pelvis Radiograph (Figure 1): “Osteopenia with no acute fractures or dislocation”

Occult femur fracture

Occult fractures are defined as fractures that cannot be detected by standard radiographic examination until weeks after the injury either due to lack of displacement or limitations of the imaging study. Occult femur fractures account for 2-10% of total hip fractures and have an associated one-year mortality of 14-16% even when surgically repaired within two days. Delayed recognition coupled with patient immobility may lead to complications such as pulmonary emboli that have been shown to increase one-year mortality by up to 30%.

Magnetic Resonance Imaging

In our case, computed tomography with 3D reconstruction (Figures 2,3) revealed a non-displaced intertrochanteric fracture with involvement of the greater and lesser trochanters. As CT scanning is usually more readily available than MRI, it may be the first additional imaging choice when radiographs are normal. A normal CT scan, however, especially in patients with osteopenia is considered insufficient to rule out an occult fracture. In a 7-year retrospective analysis at a regional trauma center, 57.4% of cases were diagnosed by MRI and 14.6% were diagnosed by CT scan within the first 24 hours. Of the remaining portion, a final diagnosis was made 72 hours after presentation with CT scan (39% of false negative cases) or MRI (61% of false negative cases).

Take-Home Points

  • Occult fractures are an important differential when standard imaging modalities do not correlate with physical exam findings.
  • Occult fractures can be missed on X-rays and CT scans, delaying definitive treatment. Delayed diagnosis can result in further complications and increased mortality and morbidity.
  • MRI is considered the gold standard for identifying occult fractures.
  • Deleanu B, Prejbeanu R, Tsiridis E, Vermesan D, Crisan D, Haragus H, Predescu V, Birsasteanu F. Occult fractures of the proximal femur: imaging diagnosis and management of 82 cases in a regional trauma center. World J Emerg Surg. 2015 Nov 18;10:55. doi: 10.1186/s13017-015-0049-y. PMID: 26587053; PMCID: PMC4652353.
  • Jonathan Grammer, Michael Sternberg. Occult femur fracture. Visual Journal of Emergency Medicine. Volume 14, 2019, Pages 15-16, ISSN 2405-4690

By |2023-12-23T10:25:21-08:00Dec 22, 2023|Orthopedic, Radiology, SAEM Clinical Images|

SAEM Clinical Images Series: Insidiously Contracted Hand

contracture

A 64-year-old Caucasian male with a history of alcohol use disorder and tobacco use disorder presents with painless bilateral hand contractures that have been worsening for the past several months. He denies any recent trauma, fever, chills, or decreased sensation. The patient works as a construction worker.

Vitals: BP 143/83 ; HR 94; RR 18; T 98.6°F; O2 saturation 98% on room air

Musculoskeletal: He has bilateral palmar contractures proximal to the fourth digits. No tenderness to palpation along digits. Passive extension of the digits is limited bilaterally but does not elicit pain. When asked to place his palm flat on the table, there is notable contracture of the bilateral fourth metacarpophalangeal (MCP) joint (a positive Hueston’s tabletop test). No erythema or cellulitic changes are appreciated.

Non-contributory

Dupuytren’s Contracture is a clinical diagnosis that most commonly presents as painless loss of extension of the fourth and fifth phalanx. Collagen deposition and subsequent fibrosis within the palmar fascia cause nodule formation along the flexor tendons near the distal palmar crease. Clinically this appears as puckering, tethering, and/or dimpling of the skin of the palm (as shown in the photograph). Accompanying joint rigidity and loss of full extension of the digit typically can take years to fully develop. Pain or inflammatory findings are not commonly seen unless there is an underlying tenosynovitis. Without signs of infection, outpatient management with Hand Surgery is the appropriate initial management.

Risk factors for the development of Dupuytren’s contracture include northern European descent, age greater than 50 years, and diabetes. The condition has been associated with tobacco use disorder, alcohol use disorder, jobs that require repetitive handling tasks or vibration, and localized fibrotic pathologies including Peyronie’s disease.

Take-Home Points

  • Dupuytren’s contracture presents as a painless palmar contraction (typically proximal to the 4th or 5th digit) that impedes finger extension.
  • A progressive condition, Dupuytren’s is best managed through Hand Surgery referral provided there is no evidence of superinfection.
  • Repetitive motion occupations, tobacco use, alcohol use, and diabetes are key risk factors.

  • Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol 2010; 6:715.   Trojian TH, Chu SM. Dupuytren’s disease: diagnosis and treatment. Am Fam Physician 2007; 76:86.

By |2023-09-14T12:40:35-07:00Sep 15, 2023|Orthopedic, SAEM Clinical Images|

SAEM Clinical Images Series: A Painful Swollen Digit

finger

A 50-year-old male with a history of polysubstance use disorder and poorly-controlled type 2 diabetes mellitus presents with left hand pain. One week ago, the patient sustained a macerating injury of the left distal middle digit. Since that time he has experienced worsening pain throughout the digit, now associated with diffuse swelling and discoloration. The patient also reports reduction in range of motion.

Vitals: Temp 97.6°F (36.4°C); BP 134/89; HR 87; Resp 16

General: Uncomfortable appearing male.

Musculoskeletal: Left hand third digit with fusiform edema, diffuse erythema, and warmth. Held in passive flexion at rest. Skin breakdown noted at distal fingertip with scant serous drainage. Tender to palpation, most markedly over the volar surface of the PIP joint. Patient reports severe pain with passive extension at the MCP, PIP, and DIP joints.

Glucose: 296

White Blood Cell (WBC) Count: 8,000/μl

ESR: 54 mm/hr

Infectious flexor tenosynovitis is an infection of the flexor tendon and synovial sheath with a significant risk of complications (e.g., tendon rupture, loss of function, amputation) if not promptly treated. Patients classically present 2-4 days after penetrating trauma to the hand (e.g., bite/scratch, puncture wound, laceration, injection).

This diagnosis is suggested clinically by four cardinal findings, the Kanavel signs:

1) diffuse “fusiform” swelling of the digit (most common)

2) digit held in passive flexion

3) tenderness to percussion over the flexor sheath

4) pain with passive extension

Although fundamentally a clinical diagnosis, the initial evaluation for infectious flexor tenosynovitis should include laboratory studies including complete blood count (CBC) and inflammatory markers (ESR/CRP). Radiographs may be performed to evaluate for occult traumatic injury or foreign body. Treatment includes emergent consultation of orthopedics or hand surgery, initiation of intravenous (IV) antibiotics, and hospital admission. Antibiotics should target gram-positive organisms (Staphylococcus, including MRSA, and Streptococcus). In immunocompromised patients, additional coverage against gram-negative organisms and anaerobes may be needed. Risk factors for poor outcomes include immunocompromise (HIV, diabetes, immunosuppression), intravenous drug use, peripheral vascular disease, and polymicrobial infection.

Take-Home Points

  • Infectious flexor tenosynovitis is a surgical emergency that is diagnosed clinically by the presence of one or more of the four Kanavel signs on physical exam.
  • History of trauma or penetrating injury and immunocompromised status should raise suspicion for infectious flexor tenosynovitis; common pathogens include Staphylococcus and Streptococcus species.
  • Treatment includes emergent consultation with orthopedics or hand surgery as well as early initiation of IV antibiotics.

  • Ritter K, Fitch R. Tenosynovitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. Accessed November 30, 2022. https://accessmedicine-mhmedical-com.ezproxy.bu.edu/content.aspx?bookid=2969&sectionid=250459435.
  • Hyatt MT, Bagg MR. Flexor Tenosynovitis. OrthopClin N Am 2017;48:217-27.
  • Pang HN, Teoh LC, Yam AKT, Lee JYL, Puhaindran ME, Tan ABH. Factors affecting the prognosis of pyogenic flexor tenosynovitis. Journal of Bone and Joint Surgery. 2007;89(8):1742-1748.

SAEM Clinical Images Series: Back Yard Football Injury

sternoclavicular

A 10-year-old male with no past medical history presents to the Emergency Department (ED) by EMS for evaluation of an injury sustained while playing tackle football. The patient was forcibly hit by another child against a tree. He complains of sharp right shoulder and chest pain that worsens with movement of his right upper extremity and he arrives wearing a sling to immobilize the arm.

Vitals: BP 123/86; HR 121; RR 25; T 37°C

General: Alert and oriented, in moderate distress

Cardiovascular: RRR without murmurs, rubs, or gallops, peripheral pulses 2+ throughout

Pulmonary:  Bilateral breath sounds, clear to auscultation

Chest: Inability to visualize the right medial clavicular notch or clavicular ridge along with palpable tenderness at the right upper sternoclavicular joint

MSK: The shoulders are asymmetric with the right slightly higher than the left. The right arm is held adducted and internally rotated in a sling. The patient is reluctant to abduct the right arm secondary to pain.

Neuro: No gross motor or sensory deficits were appreciated

Non-contributory

Sternoclavicular (SC) joint dislocation

SC joint dislocation can occur with anterior or posterior displacement of the medial clavicular head. Anterior dislocations are mostly caused by medial impact to the lateral shoulder. Anterior dislocations are more common and generally regarded as less serious. Conversely, posterior dislocations are more serious but less common. Posterior dislocations usually result from impact directly to the anterior chest wall. High-speed motor vehicle accidents or high-impact sports are common causes of posterior dislocations.

Subclavian vascular injury, pneumothorax, esophageal injury, cardiac arrhythmias, brachial plexus injury, tracheal injury, and thoracic outlet syndrome are all potential complications of an SC joint dislocation. When the medial head of the clavicle is forced posteriorly into the superior mediastinum several structures are at risk of impingement which could cause serious complications. In patients with suspicion of clavicular fracture or dislocation, the presence of dyspnea, stridor, dysphagia, or hoarseness should raise genuine concern for a compressive mediastinal syndrome that may require emergent closed or surgical relocation attempts.

Take-Home Points

  • An anterior medial head sternoclavicular dislocation is generally apparent and easily palpable on physical examination, while a posterior dislocation may be difficult to appreciate.
  • A posterior medial head sternoclavicular dislocation may require computed tomography to diagnose and requires computed tomography angiography to fully assess all mediastinal structures.
  • Closed reduction is the gold standard for the treatment of non-complicated posterior dislocations. Surgical fixation may be required when compressive complications such as vascular injury are confirmed or when closed reduction is unsuccessful.
  • Patients with a previous history of sternoclavicular dislocation are at higher risk of developing thoracic outlet syndrome.

SAEM Clinical Images Series: My Shoulder Hurts

An 18-year-old male presents to the Emergency Department (ED) with right shoulder pain after wrestling with his brother. He heard a “pop,” and has been having pain along his right clavicle and shoulder since. He is unable to move his right shoulder. No numbness, tingling, or weakness in his arm or hand. No dysphagia, stridor, or shortness of breath. No medical or surgical history. He has no history of shoulder dislocation or fractures.

Vitals: HR 71; BP 139/77; RR 18; O2 sat 98% on RA

General: Uncomfortable appearing young man with his right arm held in adduction and internal rotation.

Respiratory: Clear breath sounds without stridor or shortness of breath.

CV: Heart is regular rate and rhythm without murmur, rub or gallop. Radial pulses are 2+ bilaterally, with brisk capillary refill.

MSK: Right shoulder without gross deformity. Right sternoclavicular joint is boggy, tender to palpation, and asymmetric when compared to the left. Limited active range of motion due to pain.

Neuro: Grip strength is 5/5 bilaterally, with intact motor and sensation demonstrated in the radial, median and ulnar distributions.

Shoulder and clavicular x-ray: No fracture or dislocation.

Point-of-care ultrasound: Clavicle (blue circle) posterior to the sternum (red square) at the sternoclavicular joint.

This is a posterior sternoclavicular dislocation. These dislocations are rare and are often the result of indirect lateral shoulder compression. It takes a high level of suspicion to diagnose as the physical exam and initial x-ray may be unrevealing. These patients require admission with emergent orthopedic consultation as there is a 30% chance of developing life-threatening complications due to damage of underlying structures including the trachea, esophagus, innominate artery and vein, and thoracic duct. Closed reduction in the operating room (OR) is typically the first line of treatment, with open reduction and internal fixation with cardiothoracic surgery consult available as the secondary treatment option.

CT with contrast is the imaging modality of choice, showing the sternoclavicular relationship in detail and allowing for evaluation of the underlying vascular and mediastinal structures. If unavailable, an oblique “serendipity view” x-ray may allow for better evaluation of the sternoclavicular joint than a standard shoulder or clavicle series. Additionally, point-of-care ultrasound can be an imaging modality that allows for quick and reliable bedside evaluation and diagnosis of sternoclavicular dislocation.

Take-Home Points

  •  Consider posterior sternoclavicular dislocation for those with traumatic shoulder or clavicular pain, particularly when the initial x-ray is unrevealing.
  • Posterior sternoclavicular dislocation can have subtle exam findings that are easily missed if a high level of suspicion is not maintained.
  • Posterior sternoclavicular dislocations can result in damage to underlying structures and require emergent orthopedic consultation for reduction in the OR with cardiothoracic backup available.

  • Bengtzen RR, Petering RC.Point-of-Care Ultrasound Diagnosis of Posterior Sternoclavicular Joint Dislocation. The Journal of Emergency Medicine. (2017) Volume 52,(4) 513-515. https://https://doi.org/10.1016/j.jemermed.2016.11.001.
  • Deren ME, Behrens SB, Vopat BG, Blaine TA. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthop Rev (Pavia). 2014 Mar 12;6(1):5245. doi: 10.4081/or.2014.5245. PMID: 24744842; PMCID: PMC3980158.
  • Grantier III RL, Craddock P. Recanting Impressions: Posterior Sternoclavicular Joint Dislocation. EMResident, Published 2018 June 6.
  • Roepke C, Kleiner M, Jhun P, Bright A, Herbert M. Chest Pain Bounce-Back: Posterior Sternoclavicular Dislocation. Ann Emerg Med. 2015 Nov;66(5):559-61. doi: 10.1016/j.annemergmed.2015.09.015. PMID: 26497437.

By |2023-03-18T23:11:47-07:00Mar 20, 2023|Orthopedic, SAEM Clinical Images|

ALiEM AIR Series | Orthopedics Lower Extremity Module

AIR Orthopedics Lower Extremity badge module

 

Welcome to the AIR Orthopedics Lower Extremity Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to neurologic emergencies in the Emergency Department. 4 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 3 Honorable Mentions. We recommend programs give 2 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Orthopedics Lower Extremity Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Orthopedic Lower Extremity Emergencies

SiteArticleAuthorDateLabel
PedEM MorselsLisfranc Injuries in Pediatric PatientsChristyn Magill, MD3/18/22AIR
Rebel EMCompartment SyndromeAnand Swaminathan, MD5/4/22HM
EM CasesEmergency Orthopedics Differential: SCARED OF Mnemonic – When X-rays LieArun Sayal, MD and Yatin Chadha, MD10/25/22HM
PedEM MorselsTibial Shaft Fractures in ChildrenSean Fox, MD5/6/22HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

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