Don't Swing A Hammer At This Nail!
Right hand dominant middle aged female with history of HTN presents to the ED after accidentally hitting her left index finger with a hammer while working on a home improvement project. Finger is painful and swollen but she has no other injuries and reports she is otherwise feeling well.
Erythematous, swollen, and tender left 2nd distal phalanx. There is a subungual hematoma present over approx. 75% of the nail but the nail is intact. Motor and sensation intact, full ROM of PIP and DIP, 2+ radial pulse, no other injuries identified.
AP, lateral and oblique views of left 2nd phalanx – no fracture or dislocation identified
Nail removal and bedside repair of nail bed laceration, tetanus updated, discharged home with 48 hour follow up for reevaluation
Fingertip injuries = most common hand injuries seen in the ED
Most common mechanisms:
Complications of injury:
Blood Supply and Innervation:
Obtain radiographs to rule out distal phalanx fracture
Evaluate for subunginal hematoma and nail bed lacerations
Drain hematoma if <50% nail involved
Nail removal, I&D, repair of nail bed if >50% of nail involved
20ish year old and otherwise healthy male presents as the restrained driver in head-on MVC at low speed just prior to arrival. He has a large linear laceration to anterior aspect of R knee and is unable to fully extend the knee. Wound is hemostatic. No other injuries or complaints.
10cm linear, horizontal laceration to the anterior aspect of the patient’s R knee. Knee is held in slightly flexed positioning. Decreased ROM of the knee secondary to pain and injury, patient unable to actively extend extremity in straight leg raise. FROM of ankle. 2+ DP and PT pulses present. Sensation intact to light touch throughout. No erythema, swelling or significant tenderness present over RLE.
AP/Lateral/Sunrise/Oblique views of R knee:
Transverse fracture of the patella with 3mm of displacement present and surrounding soft tissue edema
Types of fracture:
C) Pole or sleeve (upper or lower)
D) Comminuted nondisplaced
E) Comminuted displaced
Evaluate with physical examination first
Severe knee pain and soft tissue swelling should raise suspicion for injury
Fracture displacement best viewed on lateral films, but obtain AP/Lat/Oblique/Sunrise to fully evaluate
Degree of displacement = degree of retinacular disruption
Early active ROM with hinged knee brace after 2-3 weeks
Watch out for patella sleeve fractures in peds – need high index of suspicion to diagnose
Bipartite patella = failure of bony fusion
Any lacerations present must be assumed to communicate with the knee joint until this assumption is disproved by a saline load joint challenge
A patellar fracture is problematic and requires intervention if extensor mechanism of knee is nonfunctional = unable to perform straight leg raise test
Pre-teen male with no PMH presents to the ED after a dog bite the night before. Patient was bit on the palm of his left hand by a relative’s pit bull known to be fully vaccinated. Wound had been becoming more painful and 3rd digit is more swollen, painful, and difficult to range. No other injuries or complaints.
Two sub-centimeter puncture wounds to the center of the palm of the left hand, hemostatic with small amount of surrounding erythema present. 3rd digit with fusiform soft tissue swelling, increased warmth, and significant tenderness to palpation. Finger in slightly flexed positioning. Decreased ROM of the 3rd digit with flexion and significant pain with passive extension. Sensation intact to light touch throughout digits and hand. No other erythema, swelling, or significant tenderness present over LUE. 2+ palpable radial and ulnar pulses present.
No fracture or acute changes. No foreign body present.
Patient was admitted and was started on IV antibiotics for suspected pyogenic flexor tenosynovitis. Wound was rechecked in the morning with minimal improvement in symptoms and patient underwent I&D of digit and hand with continued IV antibiotics.
Pyogenic flexor tenosynovitis = infection of synovial sheath surrounding the flexor tendon
Pain/swelling usually delayed 24-48 hours, usually localized to the palmar aspect of one digit of the hand
Kanavel signs – key physical exam findings for diagnosis
Obtain x-rays to rule out bony involvement or foreign body
MRI can help diagnose but is expensive and generally unnecessary since clinical exam usually is sufficient
If early presentation:
If late presentation or if no improvement after 24 hours of conservative treatment:
Empiric Abx to consider:
Otherwise healthy individuals--
Consider with dog bites-- most are polymicrobial:
History and physical examination is key to diagnosis
Start antibiotics early
Consider surgical intervention when there is:
o flexor tendon sheath
o deep spaces of the palm
o joint spaces
Kanavel signs may not be seen if patient has:
CMC ER Residents
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