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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.

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

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-08-14T14:28:46-07:00Aug 21, 2023|Infectious Disease, Orthopedic, SAEM Clinical Images|
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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.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-08-05T22:35:21-07:00Aug 7, 2023|Orthopedic, SAEM Clinical Images, Sports Medicine|
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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.

 

shoulder pain

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.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

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

By |2023-02-26T18:48:54-08:00Mar 1, 2023|Approved Instructional Resources (AIR series), Expert Peer Reviewed (Clinical), Orthopedic|
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SplintER Series: Patellar Tendon Rupture

A 46-year-old female with a history of diabetes and morbid obesity presents to the emergency department (ED) with difficulty walking after she tripped on a curb and fell onto her right knee. You obtain X-rays (Figure 1). What is your suspected diagnosis? What is your initial workup in the ED? What is your management and disposition?

Figure 1. AP/lateral x-ray of the right knee. Author’s own images.

(more…)

By |2022-12-23T09:52:15-08:00Jan 25, 2023|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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