FacebookRssXInstagramSoundCloud
Generic filters
Exact matches only

SAEM Clinical Images Series: Pain and Swelling in a Roofer’s Right Wrist

A 27-year-old male with no significant past medical history presented to the ED due to right hand pain and swelling. The patient reported that he works as a roofer and felt severe, sharp pain in his right hand immediately after using a nail gun this morning. The pain was followed by gradual swelling of the right wrist and hand. There was no loss of sensation or bleeding from the injury site. He additionally denied any injury from the nail itself. The patient was in moderate pain but hemodynamically stable while in the ED.

 

lunate

Vitals: Temp 36.6 °C; BP 155/99; HR 71; RR 18; SpO2 99%

General: Alert, mild distress.

Musculoskeletal: No gross deformities to right hand, reduced right hand flexion/extension due to pain, normal ROM of right shoulder and elbow, pain with right forearm supination/pronation, swelling of right hand and fingers and diffusely tender carpal bones.

Non-contributory

Comminuted lunate fracture. Lunate fractures, especially comminuted lunate fractures, usually result from high-energy trauma, with an incidence ranging from only 0.5% to 6.5% of carpal fractures. Up to one-third of wrist fractures appear to be overlooked on traditional radiography. Further imaging should be warranted for patients who are clinically suspicious of wrist fractures in the ED. Multidetector Computed Tomography (MDCT) with multiplanar reformat capability is a useful method to identify occult wrist fractures.

The blood supply of the lunate bone comes from the palmar and medial arteries of the carpometacarpal branch of the radial artery. Damage to the artery may lead to avascular necrosis (Kienböck disease). Comminuted lunate fractures may result in severe intraosseous destruction of vasculature, increasing the risk of lunate bone necrosis. An at-risk nerve is the median nerve, which runs through the carpal tunnel. If the lunate is fractured or displaced, it may compress or damage the median nerve, resulting in pain, paresthesia, or sensory loss in the palmar surface of the thumb, index, and middle fingers and radial half of the ring finger.

Take-Home Points

  • Associated risk factors for a lunate fracture include occupations or sports involving repetitive pressure to the base of the hand with the wrist in extension (eg, roofer, gymnast, jack-hammer operator).

  • Due to complex carpal anatomy, traditional radiography may not be sufficient to detect lunate fractures.

  • At-risk structures that require evaluation in the case of lunate fracture include the palmar and medial branches of the radial artery and the median nerve.

  • Li, Jun, et al. “Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report.” Medicine, vol. 102, no. 29, 2023, https://doi.org/10.1097/md.0000000000034393.

  • Balci, Ali, et al. “Wrist fractures: Sensitivity of radiography, prevalence, and patterns in MDCT.” Emergency Radiology, vol. 22, no. 3, 2014, pp. 251–256, https://doi.org/10.1007/s10140-014-1278-1.

  • Geissler, William B. “Carpal fractures in athletes.” Clinics in Sports Medicine, vol. 20, no. 1, 2001, pp. 167–188, https://doi.org/10.1016/s0278-5919(05)70254-4.

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 |2025-04-28T14:39:34-07:00May 2, 2025|Orthopedic, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: Weird Flex

tenosynovitis

A 29-year-old female with a history of depression, anxiety, and tobacco use disorder presented with worsening right index finger pain, swelling, and redness for the previous three days. Additionally, she reported that she was unable to further flex or extend her finger. She denied fevers, chills, rashes, or recent illness. There was no history of trauma, aquatic or other environmental exposures, insect bites, or intravenous drug use. She did note that she uses a copper brillo pad to clean her dishes at home which often causes small abrasions to her fingers.

Vitals: BP 160/112; PR 73; Temp 36.4°C; RR 18; SpO2 100% on RA

General: Well-appearing, no acute distress.

Cardiovascular: Right index finger capillary refill <2 sec.

Skin: Right index finger uniformly edematous and erythematous with tenderness to palpation along the tendon sheath; small healed abrasions over distal palmar aspect of the digit; no focal area of fluctuance.

MSK: right index finger held in flexion, pain with passive extension.

WBC: 8.6

ESR: 129

CRP: 105.5

This patient has flexor tenosynovitis, an infection of the synovial sheath surrounding the flexor tendon of the hand. The condition is usually caused by local inoculation from penetrating trauma although can also result from hematogenous spread. Flexor tenosynovitis is considered a surgical emergency, as delayed intervention can lead to significant morbidity including tendon rupture, deep space infection, abscess development, soft tissue necrosis, amputation, and/or chronically compromised hand function. Diagnosis is usually clinical, based on history and physical exam findings; however, laboratory evaluation may reveal leukocytosis and/or elevated inflammatory markers. If there is a history of penetrating trauma, x-rays of the affected digit are recommended to rule out retained foreign body. Management in the ED includes prompt surgical consultation and broad-spectrum antibiotics against common cutaneous pathogens. Antibiotic coverage should be broadened in patients with a history of marine exposure or Pseudomonal risk factors including immunocompromised status.

Flexor tenosynovitis presents with four classic exam findings called “Kanavel Signs.” Kanavel Signs include (1) flexion of the involved digit, (2) tenderness to palpation over the tendon sheath, (3) pain with passive extension, and (4) uniform swelling of the finger. The presence of all four Signs has a sensitivity for flexor tenosynovitis as high as 97.1%, although early in the course of infection, pain with passive extension may be the only finding.

Take-Home Points

  • Flexor tenosynovitis is an infection of the flexor tendon sheath of the hand and a history of trauma or penetrating injury to the area should raise suspicion.

  • Flexor tenosynovitis is a “can’t miss” clinical diagnosis in the ED as there is a risk of significant complications with delayed antibiotics and surgical intervention.

  • Infection can reliably be identified by the presence of the four Kanavel Signs on physical exam.

  • Chan E, Robertson BF, Johnson SM. Kanavel signs of flexor sheath infection: a cautionary tale. Br J Gen Pract. 2019 Jun;69(683):315-316. doi: 10.3399/bjgp19X704081. PMID: 31147342; PMCID: PMC6532803.

  • Chapman T, Ilyas AM. Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. J Hand Microsurg. 2019 Dec;11(3):121-126. doi: 10.1055/s-0039-1700370. Epub 2019 Nov 2. PMID: 31814662; PMCID: PMC6894957.

  • Hermena S, Tiwari V. Pyogenic Flexor Tenosynovitis. In: StatPearls. StatPearls Publishing; 2022.

  • Kennedy CD, Huang JI, Hanel DP. In Brief: Kanavel’s Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016 Jan;474(1):280-4. doi: 10.1007/s11999-015-4367-x. Epub 2015 May 29. PMID: 26022113; PMCID: PMC4686527.

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 |2025-03-30T20:30:57-07:00Apr 7, 2025|Orthopedic, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: An Unusual Arm Conundrum

shoulder

A 58-year-old female with a past medical history significant for osteoporosis presented with right shoulder pain after a witnessed mechanical fall down two stairs. She sustained no headstrike or loss of consciousness. She endorses severe right shoulder pain without numbness/tingling over any part of her arm. Since the fall, she has been unable to move her arm, which remains abducted overhead.

 

dislocation

General: Right arm fixed, abducted position and elevated over her head.

Vascular: 2-second capillary refill in all nail beds, strong palpable radial pulse.

Neuro: Sensation intact to light touch on medial and lateral aspects of all distal digits, and throughout entire axillary, radial, ulnar and median nerve distribution.

Motor: Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) intact in digits 2 through 5. Extensor digitorum communis (EDC) and extensor indicis proprius (EIP) intact. Normal finger abduction and adduction. Normal thumb opposition. Normal OK sign. Wrist flexors and extensors intact.

None

Luxatio erecta (inferior shoulder dislocation) is a rare type of shoulder dislocation. The majority of shoulder dislocations are anterior (over 95%), with a smaller number being posterior (2-4%). Inferior dislocations are the least common injury pattern (0.5%), but prompt identification and treatment are crucial due to the high risk of neurovascular damage.  Radiographs will typically demonstrate the humeral head lying inferior to the glenoid fossa, with the humeral shaft parallel to the spine of the scapula. Classically, the entire arm is held in abduction.

Inferior shoulder dislocation most commonly occurs either due to hyperabduction of the shoulder (such as when grasping at a tree branch above while falling) or through an axial load from above on a hyperabducted arm (as seen in falls or motor vehicle accidents). Patients presenting with inferior shoulder dislocation are at substantial risk for neurovascular compromise, particularly of the axillary nerve, leading to impaired upper extremity movement and sensation. Due to the substantial injury mechanism, patients with inferior shoulder dislocations are also at increased risk for rotator cuff pathology. Treatment of inferior shoulder dislocation is immediate closed reduction to reduce the risk of neurovascular complications. Once reduced, the arm should be placed in an immobilizer to prevent recurrent dislocation.

Take-Home Points

  • Patients with inferior shoulder dislocations often present holding their arm above their head. Often, patients cannot adduct their arm.

  • Axillary nerve injuries occur in about 60% of inferior dislocations. Compared to other dislocations, inferior dislocations have the highest incidence of axillary nerve injuries.

  • Patients with inferior dislocations often present with neurovascular compromise of the affected arm, so be sure to do a thorough exam after reduction.

  • Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med. 2000 May;18(3):317-21. doi: 10.1016/s0735-6757(00)90127-x. PMID: 10830689.

  • Nambiar M, Owen D, Moore P, Carr A, Thomas M. Traumatic inferior shoulder dislocation: a review of management and outcome. Eur J Trauma Emerg Surg. 2018 Feb;44(1):45-51. doi: 10.1007/s00068-017-0854-y. Epub 2017 Oct 3. Erratum in: Eur J Trauma Emerg Surg. 2018 Feb;44(1):53. doi: 10.1007/s00068-017-0878-3. PMID: 28975397.

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 |2025-03-09T21:48:15-07:00Mar 10, 2025|Orthopedic, SAEM Clinical Images|
Read More

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|
Read More

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.

 

occult

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

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

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|
Read More

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|
Read More
Go to Top
OSZAR »