Erythema Multiforme (minor)

• Acute, self-limited rash affecting the skin; mucus membranes are spared in the minor variant although EM major involves one mucus membrane.
• Erythematous, macupapular, and blanching with central clearing; it is often puritic
• Several etiologic factors that have been identified. Most commonly:
  • Infections: viral (e.g., HSV), bacterial (e.g., strep), fungal (e.g., histoplasmosis)
  • Drugs: antibiotics (e.g., sulfa drugs, PCN, etc.), NSAIDs
  • Miscellaneous: collagen vascular diseases, pregnancy, and malignancy
• It is self-limiting and will resolve in 2-6 weeks.
• Treat by stopping offending agent and supportive care (e.g., diphenhydramine for purtitis)

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Answer: Infectious Flexor Tenosynovitis

Infectious Flexor Tenosynovitis

• Closed space infection of the flexor tendon sheath; an orthopedic emergency
• Typically an infection with skin flora secondary to penetrating trauma
• Remember Kanavel's cardinal signs via mnemonic B.E.S.T. (the "BEST" mnemonic):
  • B: Bend finger (i.e., finger held in slight flexion)
  • E: Extension pain (i.e., pain on passive extension)
  • S: Sausage-like digit (i.e., fusiform swelling
  • T: Tenderness along tendon sheath
• If early and not severe a course of IV antibiotics covering skin flora may be tried. Surgical intervention, however, is often necessary so early consultation with a hand surgeon is highly recommended

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Free intra-abdominal fluid.

• The patient had ascites in this case, with spontaneous bacterial peritonitis; this was initially thought to be pericholecystic fluid secondary to acute cholecystitis.
• Another mimic of acute cholecystitis includes conditions with gallbladder wall thickening such as a contracted GB (e.g, post-prandial) or GB wall edema from fluid overload (e.g., CHF, renal failure, etc.)

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Diaphragmatic hernia

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Ring-enhancing lesion

Differential diagnosis of a ring-enhancing lesion

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Scaphoid fracture

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This is the right ventricular inflow view

• RV inflow view obtained by obtaining a parasternal long-axis view and then tilting the tail of the transducer cephalad; eventually you'll see the heart as detailed below
• It's a great view for Doppler measurements through the tricuspid valve because the flow of blood is parallel to the ultrasound beam, useful when estimating things like the pulmonary artery systolic pressure
• Want to learn more about the RV? Click here for a whole podcast on it!

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• Ascending aortic aneurysm resulting in secondary aortic reguritation

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Sclerotic bone (osteoblastic) metastasis secondary to prostate cancer. The patient's CXR from 2 years prior is shown below for comparison.

Other malignancies associated with osteoblastic metastasis:

• Breast cancer
• Colon cancer (i.e., mucinous adenocarcinoma)
• Lymphoma
• Carcinoid
• Neuroblastoma
• Prostate cancer (#1 cause)

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Biceps tendon rupture (BTR) aka Popeye's Sign

• BTR can be related to degenerative issues in the elderly or acute injuries associated vigorous bicep use (e.g., weight lifting). Patients report a "popping" sound followed by sharp, sudden pain, ecchymosis and swelling.
• Diagnosis is clinical; a palpable mass is seen between the shoulder and the elbow. The tendon typically ruptures on the proximal end, causing coiling of the muscle distally. ROM is maintained because only one bicep tendon ruptures, the remaining one functions normally.
• Medical management is appropriate and emergency surgery is unnecessary (except for athletes or patient who rely on muscle strength for occupational purposes) Rupture of the distal bicep tendon ruptures requires surgical referral. 

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Salter-Harris fracture (type II): 

Salter-Harris Fracture (remember mnemonic SALTR)

• Slipped (i.e., through growth plate and not involving bone) / Type I
• Above growth plate (i.e., through metaphysis) / Type II (most common)
• Lower growth plate (i.e., through epiphysis) / Type III
• Through (i.e., through metaphysis growth plate and epiphysis) / Type IV
• Rammed (i.e., Crush injury) / Type V (worst prognosis)

For more on Salter-Harris fractures, check out this and that

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Mediastinal mass (lymphoma confirmed on biopsy)

• There was no bony abnormality of the shoulder but the mediastinal mass was nearly missed because the focus was on the shoulder
• Below is Xray after patient started receiving chemotherapy.
• Bottom Line: always be sure to evaluate the entire Xray because sometimes you'll discover unrelated, but important findings 

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Yes, the shoulder is dislocated...but did you notice anything else (see below)?

Bankart lesion (a.k.a. fracture of the glenoid fossa)

• Fractures of the glenoid fossa occur when the humeral head collides with the glenoid margin by a laterally directed force.
• Although less than 10% of glenoid fossa fractures result in significant displacement, surgical repair is indicated if:
  • Fracture displacement >10mm
  • >33% involvement of posterior glenoid fossa
  • >25% involvement of anterior glenoid fossa
  • Persistent humeral head subluxation

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This was SVT and adenosine was given; notice how the heart pauses in the echo and in the rhythm strip.

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Hydrocephalus secondary to malfunctioning VP shunt. 

The patient went to the operating room for a shunt repair and the CT after the repair is shown; although not dramatically different it does show an improvement of the hydrocephalus.  

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• Beck's triad
  • Jugular venous distention
  • Muffled (or distant) heart sounds
  • Low blood pressure
• None of these findings is sensitive or specific for the diagnosis of pericardial tamponade
• Only 10-40% of patients with pericardial tampaonde will have all three signs present

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Spodick, D. Cardiac Tamponade Revisited: A Postmortem Look at a Cautionary Case: Tex Heart Inst J. 2007; 34(3): 347–351.

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Brodie's abscess a.k.a subacute osteomyelitis

• Form of osteomyelitis, which is difficult to diagnose, and is often mistaken for a tumor.
• Males are affected more than females and the range of presentation is 2-15 years.
• Work up is difficult as CBC, ESR, CRP, and blood cultures are inconclusive. Xrays may mimic tumors.
• Treatment is antibiotics if the diagnosis is obvious; if not, biopsy to make the diagnosis. Surgery an option if either the lesion is aggressive or there is pus extending into the synovial fluid. 

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40 year-old male sustains a blunt force injury the left side of his lead. What's the diagnosis and what structure was injured?

Epidural Hematoma with mid-line shift from middle meningeal artery injury; see image below for comparison of subdural and epidural

Epidural hematoma

• Blood accumulates between dura and calvarium secondary to trauma; concurrent skull fractures are common
• Middle menial artery is usually involved in the temporal region; other arteries may be involved depending on which area of the skull receives the impact
• Up to one-third of cases present with the "classic" lucid interval from injury and loss of consciousness to a decline in mental status. Diagnosis should be suspected, however, based on mechanism
• Treatment is surgical evacuation, however aggressive medical management of increased intracranial pressure should not be delayed:
  • Head of bed elevated and keep neck mid-line
  • Anti-emetics and analgesics
  • Osmotic agents such as mannitol or hypertonic saline
  • Avoid hypoxia, hypotension, and hyperthermia

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• Aggressive fluid and vasopressor support
• Early intubation and airway protection should be considered in severe cases; minimize BVM given the risk of gastric distention.
• NG tube decompressing of the stomach will help the ventilation/oxygenation process.
• ECMO may be considered if conventional therapy has failed and any one of the following criteria is met:

1. Inability to maintain pre-ductal PaO2 saturations >85 percent or post-ductal PaO2 >30 mmHg
2. Peak inspiratory pressure >28 cm H2O or mean airway pressure >15 cm H2O
3. Hypotension that is resistant to fluid and inotropic support
4. Inadequate oxygen delivery with persistent metabolic acidosis

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