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SAEM Clinical Images Series: What’s Coming Out of Your Eye?

open globe

A 32-year-old male with no significant past medical history presented to the emergency department (ED) from an outside hospital for further management of right eye pain and vision loss sustained after he was struck by a metal wire while at work. The patient presented to an outside “eye doctor” and was told to go to the nearest hospital for evaluation. At the outside hospital, he was given analgesia, antiemetics, and a tetanus booster, and transferred to our hospital for ophthalmologic evaluation. On arrival to our emergency department, the patient expressed continued eye pain with bloody discharge as well as blurry vision from his right eye. He had no other complaints and denied any other trauma or loss of consciousness during the event.

 

eye

Right Eye: 12 mm corneoscleral laceration with superior iris prolapse through the laceration at the 12 o’clock position, approximately 6 mm in length. Pupil 3 mm, teardrop shaped, and reactive without relative afferent pupillary defect. Seidel test positive on fluorescein stain. Conjunctival injection superiorly. Visual acuity: able to count fingers. Extraocular movements intact. Ocular pressure deferred. 1 mm superior eyelid laceration.

CT Orbits/Sella w/ IV Contrast: No acute orbital fracture. No evidence of retrobulbar hematoma or emphysema. Intraconal and extraconal fat planes are preserved. Extraocular muscles are symmetric and normal in position. The globes are grossly unremarkable. Absent right lens.

Open Globe Injury

In the photo, you can see the teardrop shape of the pupil, conjunctival injection, corneal laceration, and superior iris prolapse.

Tonometry and ocular ultrasound (US) are generally not recommended as you could squeeze more liquid out of the eye or increase the intraocular pressure even more, pushing the iris further out. An emergent ophthalmology consult is needed to plan for operative repair. The patient should be given an eye shield, IV antibiotics, and tetanus prophylaxis. Avoid increasing intraocular pressure by using anti-emetics, analgesia, and bed elevation. Recommended antibiotics are vancomycin and a third-generation cephalosporin to prevent endophthalmitis. Postoperatively, these patients need IV antibiotics x 48 hours, steroid eye drops, antibiotic ointment, an eyepatch, and recommendations for no heavy lifting, bending, or strenuous activity, and head of bed should be elevated at 45 degrees.

Take-Home Points

  • Open globe injuries present as eye pain, vision loss, teardrop pupil, afferent pupillary defect, and a corneal laceration.
  • Avoid ocular US or tonometry in these patients as these could increase intraocular pressure further and worsen the injury.
  • Management includes an eye shield, head of bed elevation, avoiding ocular manipulation, analgesia, and antiemetics. Update tetanus and start IV antibiotics – vancomycin and a third-generation cephalosporin. Consult ophthalmology emergently.

  • Open globe injury: Assessment and preoperative management. American Academy of Ophthalmology. (2023, March 23). https://www.aao.org/eyenet/article/open- globe-injury
  • Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr. Endophthalmitis following open-globe injuries. Eye (Lond). 2012 Feb;26(2):212-7. doi: 10.1038/eye.2011.313. Epub 2011 Dec 2. PMID: 22134598; PMCID: PMC3272210.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:03:57-07:00Sep 13, 2024|Ophthalmology, SAEM Clinical Images|
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SAEM Clinical Images Series: An Unusual Foreign Body

vp shunt

A 61-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes, and normal pressure hydrocephalus s/p VP shunt (last revision nine months ago) presented to the Emergency Department (ED) for evaluation after noticing a “string” coming out of her anus today. Associated symptoms included nausea and a mild headache for one day, and one episode of vomiting prior to arrival. The patient denied abdominal pain, dizziness, fever, chills, diarrhea, and constipation. She had no other complaints on a complete review of systems. Past surgical history was significant for laparoscopic ventral hernia repair with mesh and lysis of adhesions (three years ago), as well as prior appendectomy, cholecystectomy, c-section, and right nephrectomy.

 

bowel

Vitals: Temp 98.4°F (36.9°C); BP 110/56; HR 64; RR 16; SpO2 100%

General: No acute distress, well appearing.

Neck: Supple, non-tender, no meningismus, full and painless range of motion.

Abdomen: Soft, nontender, nondistended. No peritoneal signs.

Neuro: Awake, alert and oriented x3, no focal neurologic deficits.

Rectum: Narrow lumen tube-like structure protruding from anus. Soft stool present at anus with no blood or melena. Non-tender rectal exam.

Complete Blood Count (CBC): No leukocytosis, no anemia

Comprehensive Metabolic Panel (CMP): Within normal limits

Ventriculoperitoneal shunt erosion into the intestinal tract

Diagnosis can be established with abdominal imaging including VP Shuntogram X-ray series. A CT abdomen/pelvis would also be confirmatory imaging while assisting in ruling out other intra-abdominal complications such as bowel perforation, abscesses or other diseases.

Broad-spectrum empiric antibiotics with CNS coverage should be started for treatment of presumed intra-abdominal, bloodstream, and/or CNS infection. General surgery and neurosurgery should be consulted emergently for evaluation. Bloodwork and a full infectious workup including blood cultures should be done. CSF cultures should be considered as well, in consultation with a neurosurgeon. Patients are at high risk of bacterial spread to the abdomen or retrograde spread up the ventriculoperitoneal shunt leading to peritonitis, peritoneal abscess, ventriculitis, meningitis, or sepsis. Further indicated invasive/surgical interventions should be deferred to general surgery and neurosurgery consultants. Our patient had a confirmatory CT abdomen/pelvis showing the VP shunt catheter perforation into the sigmoid colon and exiting through the rectum. The patient was started on vancomycin, cefepime, and flagyl. General surgery and neurosurgery were consulted and the patient was taken the same day to the OR for laparoscopy and externalization of VP shunt from bowel.

Take-Home Points

  • Bowel perforation is a rare but serious complication of ventriculoperitoneal shunts.
  • Diagnosis should be considered even in patients who present with no meningeal or peritonitic signs.
  • Imaging should be obtained to confirm diagnosis, and broad-spectrum antibiotics with CNS coverage should be started early.
  • General surgery and neurosurgery should be consulted emergently for further operative interventions.

  • Paff, M, Alexandru-Abrams, D, Muhonen, M, Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.
  • Bales J, Morton RP, Airhart N, Flum D, Avellino AM. Transanal presentation of a distal ventriculoperitoneal shunt catheter: Management of bowel perforation without laparotomy. Surg Neurol Int. 2016 Dec 28;7(Suppl 44):S1150-S1153. doi: 10.4103/2152-7806.196930. PMID: 28194303; PMCID: PMC5299151.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:04:47-07:00Sep 9, 2024|Gastrointestinal, Radiology, SAEM Clinical Images|
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SAEM Clinical Images Series: Pediatric Neck Mass

neck mass

A 5-year-old female presented to the emergency department (ED) with a one-year history of gradually increasing anterior neck swelling. The patient had no significant past medical history. She also endorsed three weeks of cough and congestion, and one day of muffled voice. She denied difficulty swallowing, fatigue, cold intolerance, or hair and nail changes.

Vitals: BP 87/62; Pulse 80; Temp 36°C (96.8°F); Resp 21; SpO2 99%

Constitutional: No distress. Able to speak in full sentences

HEENT: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Congestion present. Mucous membranes are moist. Tonsils 4+ bilaterally with no exudate.

Neck: Approximately 3 cm x 4 cm mass on the anterior neck that does not move on protrusion of the tongue. Mass is midline and inferior to the laryngeal prominence. No associated erythema, tenderness to palpation, or drainage. No enlarged surrounding lymph nodes on palpation.

Cardiovascular: Normal rate, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, no stridor, no respiratory distress, no decreased breath sounds, and no wheezes.

Abdominal: Soft. No distention or tenderness.

Neurological: Alert and normal muscle tone.

Thyroid stimulating hormone (TSH): > 100 (ref 0.50 – 4.50 MCU/ML).

Free T4: 0.5 (ref 0.8-2.0 NG/DL)

Ultrasound of the neck revealed an enlarged thyroid gland with lobular contours and diffuse hypoechoic echogenicity, without noticeable nodules, fluid collection, or lymphadenopathy.

Differential diagnosis of a neck mass in a pediatric patient includes branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, laryngocele, dermoid cyst, teratoma, thymic cyst, hemangioma, ranula (mucocele), thyroid mass, enlarged lymph node, lymphoma, rhabdomycosarcoma, neuroblastoma, and melanoma [1]. When evaluating a neck mass, reviewing whether the mass is congenital vs acquired and midline vs lateral will help with narrowing down the differential diagnosis. The photo reveals a prominent anterior lower neck mass with the outline of right lobe of the thyroid gland clearly visible.

The patient was diagnosed with hypothyroidism with goiter, likely Hashimoto’s thyroiditis. She was discharged from the ED on levothyroxine 25 mcg daily with endocrinology outpatient follow-up. Levothyroxine monotherapy is the standard of care in hypothyroidism management [2]. Thyroid peroxidase and thyroglobulin antibodies were found to be positive on subsequent labwork, which confirmed diagnosis.

Take-Home Points

  • Enlarged goiter in the setting of hypothyroidism should be considered in a pediatric patient with a midline lower neck mass.
  • When suspecting hypothyroidism, thyroid stimulating hormone (TSH) and free T4 should be included in the evaluation. An ultrasound and thyroid antibodies may also be helpful to confirm diagnosis.

  • Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck masses. Pediatr Rev. 2013 Mar;34(3):115-24; quiz 125. doi: 10.1542/pir.34-3-115. PMID: 23457198.
  • Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM; American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec;24(12):1670-751. doi: 10.1089/thy.2014.0028. PMID: 25266247; PMCID: PMC4267409.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-08-19T10:18:25-07:00Aug 30, 2024|Endocrine-Metabolic, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: An Interesting Case of Ocular Trauma

ocular trauma

A 27-year-old male with no past medical history presents to the Emergency Department with right eye pain. He states that approximately one week prior, he was working on a wire fence when he lost hold of a wire under tension, and it subsequently hit him in his right eye. He had immediate pain in his affected eye and was unable to see anything but light for the next three days. His vision slowly improved though it never normalized. He continued to have pain, so he presented for evaluation. He also reported seeing floaters and denied pain with eye movement, increased light sensitivity, or eye discharge.

 

iridodialysis

Eyes: Lids without injury. Visual acuity was 20/50 OD, 20/30 OS. Intact visual fields to finger confrontation. Extraocular muscle movements were intact and without pain. Right pupil was oval-shaped and reactive, and an evident defect at the iris from the 9 to 11 o’clock position was noted. On fluorescein stain, there was no uptake, with a negative Seidel sign. Tonometry was normal (13 OD, 12 OS). On slit lamp examination, the patient had a clear cornea, an appropriately deep anterior chamber with no hyphema or hypopyon, and 1+ mixed cells. The lens was clear, with no movement or vibration (phacodonesis) noted. A vitreous hemorrhage OD was also identified on bedside ultrasound.

Non-contributory

Iridodialysis

Traumatic iridodialysis is an uncommon ocular emergency with very distinct findings that we can encounter in the Emergency Department. It is most commonly seen with blunt trauma but can also occur with penetrating injury to the eye. This injury appears as a crescent-shaped defect at the peripheral area of the iris. Blunt trauma causes an acute globe compression, which temporarily increases intraocular pressure. This increased pressure is dissipated throughout the eye, leading to forceful fluid shifts that cause increased tension along the pupillary sphincter muscle. The weaker area of the sphincter muscle can subsequently tear, resulting in separation of the iris from the ciliary body.

Iridodialysis can be managed conservatively if it is asymptomatic and uncomplicated. Complicating factors, which include elevated intraocular pressures refractory to medical therapy, the presence of a large hyphema, rupture from blunt trauma, or the need for exploration secondary to penetrating trauma, require an Ophthalmology consult and may require emergent surgical repair.

Take-Home Points

  • Patients with iridodialysis are at risk for globe rupture, so a fluorescein exam must be performed prior to measuring intraocular pressure.
  • Ophthalmology should be consulted if the patient has complicating factors, which include elevated intraocular pressures refractory to medical therapy, the presence of a large hyphema, rupture from blunt trauma, or the need for exploration secondary to penetrating trauma.

  • Knoop, K. J., Knoop, K. J., & Stack, L. B. (n.d.). Chapter 2: Ophthalmic Conditions. In The Atlas of Emergency Medicine (p. 89). essay, McGraw-Hill Medical.
  • Pujari, A., Agarwal, D., Kumar Behera, A., Bhaskaran, K., & Sharma, N. (2019). Pathomechanism of iris sphincter tear. Medical hypotheses, 122, 147–149. https:// doi.org/10.1016/j.mehy.2018.11.013

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-08-19T10:01:53-07:00Aug 26, 2024|Ophthalmology, SAEM Clinical Images|
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SAEM Clinical Images Series: Red Rash on My Legs

milaria

A 23-year-old female with no known past medical history presented with a rash concentrated on her legs, with a few areas on her arms and chest. The rash began the day before presentation when she became overheated while wearing sweatpants in 104°F weather. The rash was mildly pruritic but not painful. She denied any prior reaction to her sweatpants that she has had for several months. She denied any new soap or cosmetic use, prior rash, allergy, or medication use. Her review of systems and past medical history were negative.

rash

Vitals: Normal

Skin: An erythematous papular rash is concentrated and symmetric on her lower extremities. There are a few sparse lesions on her arms, thorax, and abdomen with sparing of the palms, soles, and face. No pustules or vesicles are noted. There is no scale or crust. No other skin lesions are present. The rest of the examination is normal.

Non-contributory

Miliaria, or prickly heat (heat rash).

Miliaria, also known as prickly heat or heat rash, is caused by blocked eccrine sweat glands and ducts. Exposure to heat with sweating causes eccrine sweat to pass into the dermis or epidermis causing a rash. It is common in warm and humid climates during the summer months. It can affect up to 30% of adults living in hot and humid conditions. It may present as vesicles, papules, or pustules depending on the depth of the eccrine gland obstruction. In adults the rash is most likely seen where clothes rub on the skin. Infants and children typically have lesions on the upper trunk, neck, and head. Miliaria is a clinical diagnosis. Treatment involves measures to reduce sweating and exposure to hot and humid conditions. Air conditioning and the reduced humidity of indoor environments are helpful. If significant inflammation is present with pruritis, some improvement can be seen with 0.1% triamcinolone topically, though ointment should be avoided and only cream or lotion applied.

Take-Home Points

  • Miliaria, or prickly heat, is caused by sweating and blocked eccrine sweat glands.
  • Treatment involves retreating to cool, indoor environments.
  • Triamcinolone 0.1% cream or lotion may reduce pruritis.

  • Guerra KC, Toncar A, Krishnamurthy K. Miliaria. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30725861.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-03-26T10:26:51-07:00Apr 1, 2024|Dermatology, SAEM Clinical Images|
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SAEM Clinical Images Series: Seeing Double

ophthalmoplegia

A 53-year-old woman with no significant past medical history presented to the emergency department with a 3-day history of double vision on leftward gaze. She initially presented to urgent care with a chief complaint of chest heaviness and concern that her blood pressure was too high, but was sent to the emergency department for further cardiac and neurological evaluation after her urgent care provider noticed abnormal eye movement. She endorsed mild, intermittent headaches associated with diplopia when looking to the left. However, she denied any blurry vision when looking forward. She denied any trauma or falls.

Vitals: Temp 36.7°C; Heart rate 86 beats/min; Respirations 18 breaths/min; BP 150/82 mmHg; O2 Saturation: 100%

General: No acute distress and appears comfortable. She is alert and oriented.

Eyes: Equal, round and reactive pupils and severely limited adduction of the right eye, all other extraocular movements are normal.

Neuro: All other cranial nerves are intact, normal tone in bilateral upper and lower extremities, normal sensation bilaterally to light touch and pinprick except for mildly decreased sensation to pinprick over right ulnar distribution.

CBC, CMP, EKG, and Troponins were normal.

Lipid panel: Cholesterol 241 (H)

CSF: No oligoclonal bands, Protein 197 (H), Albumin 57 (H), IgG 16.3 (H)

Internuclear ophthalmoplegia (INO) is defined as the inability to adduct the eye due to a lesion in the medial longitudinal fasciculus (MLF) and can be accompanied by nystagmus in the same eye. The two main causes of internuclear ophthalmoplegia are demyelination of the medial longitudinal fasciculus (MLF) from multiple sclerosis (MS) and ischemic cranial nerve damage from stroke. However, a comprehensive list of causes of INO includes: infarction (ischemic stroke), demyelination (MS), tumor, encephalitis, hemorrhage, hydrocephalus, Chiari malformation, infection (Lyme Disease), and trauma. Usually, MS is seen in younger patients where both eyes are affected whereas strokes occur more often in older patients and only one eye is affected.

The therapeutic approach focuses on treating the underlying cause and hence determining the etiology is of immense importance. A brain MRI should be ordered to evaluate for ischemia and demyelination. Proton density imaging is beneficial in identifying MLF lesions in multiple sclerosis. A lumbar puncture can also help rule out infections. A kappa-free light chain antibody test is a faster and less expensive way to test for multiple sclerosis than looking for oligoclonal bands in the CSF.

Given this patient’s relatively young age and vascular risk factors, stroke is highest on the differential. Her brain MRI showed areas of restricted diffusion in the right dorsal medial pons correlating with her exam. It also showed periventricular and subcortical white matter changes which is a non-specific finding in chronic small vessel ischemic changes vs underlying demyelinating disease. This was followed up with an MRI of her spine that demonstrated C5-6 stenosis with associated cord edema and an additional enhancing C3-4 lesion concerning for demyelinating disease. Her lumbar puncture revealed 3 nucleated cells and a protein of 197 but was deemed a traumatic tap. There were no oligoclonal bands. The initial brain MRI findings favored stroke for which she underwent a stroke work-up and was ultimately discharged on aspirin and atorvastatin for secondary prevention. However, due to concern for demyelinating disease, she was also treated with a 3-day course of IV methylprednisolone. Ultimately, she was discharged and asked to come back for a follow-up for repeat brain imaging and evaluation. A recent study showed that patients with unilateral or bilateral INO who experienced symptomatic diplopia were commonly managed by uniocular occlusion. Another case report showed that a young man who presented with acute INO responded rapidly to treatment with IV alteplase when administered within 2 hours of the onset of symptoms and resolution within 15 minutes. A case series revealed that 1 in 5 patients failed to recover from an INO. Hence, it is critical that a definitive workup is carried out to determine the etiology of the INO.

Take-Home Points

  • Brain MRI including DWI is a useful diagnostic tool for INO.
  • Unilateral INO is more frequently related to ischemic/vascular causes whereas bilateral INO is associated with MS.

  • Kim SS, Lee MH, Ji C. Unilateral Internuclear Ophthalmoplegia Following Minor Head Injury. Korean J Neurotrauma. 2022 Oct 24;18(2):329-334. doi: 10.13004/kjnt.2022.18.e64. PMID: 36381451; PMCID: PMC9634317.
  • Mahawish KM, Aravind A. Acute onset internuclear ophthalmoplegia responsive to treatment with intravenous alteplase. N Z Med J. 2020 May 22;133(1515):119-121. PMID: 32438384.
  • Simmons J, Rhodes M. Conservative and Surgical Management of Unilateral and Bilateral Internuclear Ophthalmoplegia (INO)-A Retrospective Analysis. Br Ir Orthopt J. 2022 Nov 7;18(1):152-158. doi: 10.22599/bioj.280. PMID: 36420121; PMCID: PMC9650975.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-03-16T21:53:50-07:00Mar 22, 2024|Neurology, Ophthalmology, SAEM Clinical Images|
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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.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-04-01T09:11:49-07:00Mar 18, 2024|Orthopedic, SAEM Clinical Images|
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