HPI:
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.

Physical Examination:
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.

Radiology:
AP, lateral and oblique views of left 2nd phalanx – no fracture or dislocation identified

Management:
Nail removal and bedside repair of nail bed laceration, tetanus updated, discharged home with 48 hour follow up for reevaluation

Discussion:
Fingertip injuries = most common hand injuries seen in the ED
Most common mechanisms:

• Crush between two objects
  
• Catching finger in a door
  
• Power/home tools
  
• Direct blows (hammer injury)
  

Evaluate for:

• Subungual hematoma
  
• Laceration to the nail bed
  
• Avulsion of the nail bed
  
• DIP fractures or dislocations

Complications of injury:

• Nail loss
  
• Abnormal growth
  
• Nonadherence of new nail
  
• Splitting of the nail
  
• Soft tissue infection
  
• Osteomyelitis of the underlying distal tuft

HPI:
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.

Physical Examination:
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. 

Radiology:
AP/Lateral/Sunrise/Oblique views of R knee:
Transverse fracture of the patella with 3mm of displacement present and surrounding soft tissue edema

Management:

• Bedside washout of wound with copious saline and with wet gauze placement
  
• Tetanus updated
  
• 2g IV Ancef administered
  
• Admission for ORIF of R patella with tension band construction
  

Discussion:

• Patella = largest sesamoid bone in the body with the thickest articular cartilage 
  
• Patella fractures = 1% of all bony injuries
  
• Injury usually by direct impact or indirect eccentric contraction of quadriceps with hyperextension of the knee
  
• Usually seen in younger adult population (20-50 years old)
  

 Types of fracture:

Obtain Radiographs
Fracture displacement best viewed on lateral films, but obtain AP/Lat/Oblique/Sunrise to fully evaluate
Degree of displacement =  degree of retinacular disruption

Treatment:
Nonoperative:

• If intact extensor mechanism
  
• Nondisplaced or minimally displaced fracture
  
• Vertical fracture
  

Knee immobilized in extension with brace or cylinder cast with early WBAT
Early active ROM with hinged knee brace after 2-3 weeks

Operative:

• Open fractures
  
• Extensor mechanism failure
  
• Fracture with articular displacement of >2mm
  
• Displaced patella fracture >3mm
  
• Patella sleeve fractures in children
  

Usually managed by ORIF with tension band construction

Pearls:
Watch out for patella sleeve fractures in peds – need high index of suspicion to diagnose

• Small avulsion fractures that occur between cartilage “sleeve” and main bony patella usually in kids 8-12 yrs old when patellar ossification is nearly complete

Consider obtaining MRI in a child with normal x-rays but who is unable to straight leg raise

Bipartite patella = failure of bony fusion

• Anatomic anomaly seen in up to 8% of population and may be mistaken for fracture
  
• May be bilateral in up to 50% of people with this variation

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

HPI:
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.

Physical Exam:
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.

Radiology:
No fracture or acute changes. No foreign body present.

Management:
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.

Discussion:
Pyogenic flexor tenosynovitis = infection of synovial sheath surrounding the flexor tendon

• Staph aureus = most common
  
• Eikenella = human bites
  
• Pasteurella multocida = animal bites
  

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

• Flexed posturing of the digit
  
• Tenderness to palpation over tendon sheath
  
• Significant pain with passive extension of digit
  
• Fusiform swelling of the digit
  

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

Treatment:
If early presentation:   

• Admission
• IV abx
• Immobilization
• Observation
  

If late presentation or if no improvement after 24 hours of conservative treatment:

• Operative I&D with IV antibiotics
  

Empiric Abx to consider:
Otherwise healthy individuals--

• Cefazolin 1-2 g IV q6-8h
• Clindamycin 600 mg IV q8h 
  
• Erythromycin 500-1000 mg IV q6h 
  

Immunocompromised individuals or bite involvement:

• Ampicillin-sulbactam 1.5-3 g IV q6h
  
• Cefoxitin 2 g IV q6-8h
  
• Clindamycin 600 mg IV q8h PLUS levofloxacin 500 mg IV q24h 
  

 Consider with dog bites-- most are polymicrobial:

• Staph
  
• Strep
  
• Pasteurella multocida
• Anerobes

Key Points:
History and physical examination is key to diagnosis
Start antibiotics early 
Consider surgical intervention when there is:

• crushed tissue
  
• bite to pulp space
  
• involvement of:
  

                o   nail bed 
                o   flexor tendon sheath
                o   deep spaces of the palm
                o   joint spaces

Kanavel signs may not be seen if patient has:

• Early presentation
  
• Antibiotics recently administered
  
• Immunocompromised state/Chronic infection/Diabetes