Metacarpal fracture; emergent surgical consult is required

High-Pressure Injection Injuries (HPI) injuries

HPI devices (e.g., grease, paint guns, etc.) may cause injury when the device accidently discharges, typically into the operator’s dominant hand during attempts to clean the nozzle.

Injuries may initially appear benign, however injuries should be considered surgical emergencies because they often require debridement / washout of materials injected into deeper tissues.

Tissue damage is multi-factorial and includes direct injury (e.g., high-pressure tissue damage, vascular compression, etc.) and indirect injury from material injected into tissues (e.g., chemical inflammation / injury, granuloma formation, deep-tissue infections, etc.).

Radiographs may assist surgical planning by identifying subcutaneous air, debris, or unanticipated fractures.

Treatment:

• High-potential for disability and amputation so prompt aggressive therapy and surgical consult is crucial.
• Broad-spectrum prophylactic antibiotics and update tetanus
• Splint the extremity and keep it elevated while awaiting disposition

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"Cobblestoning" of subcutaneous tissue consistent with cellulitis. There are also areas of subcutaneous air raising the concern for necrotizing fasciitis.

Special thanks to Dr. Mike Mallin from the Ultrasound Podcast for the clip. Want to see more amazing ultrasound clips? Check out Sonocloud

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Right main-stem intubation as demonstrated by presence of lung-pulse on the left side

Lung-Pulse

• Normal lung sliding creates an artifact at the pleural line, as the visceral and parietal pleura slide against one another; this is seen in the M-mode image below for the right lung
• When a pneumothorax occurs the two pleural become separated and there is loss of this artifact; this is called the stratosphere sign (not shown here)
• However, when the two pleura are in contact but there is no movement of the pleura (e.g. main-stem intubation on the non-ventilated side) lung-pulse is observed (seen below with arrows)
• Although there is no ventilation of the affected lung, the lung pulse occurs because there is still cardiac activity that "pushes" the lung into the chest wall from underneath. This creates small periodic movements of the visceral and parietal pleura, creating small amounts of artifact
• Lung pulse can differentiate pneumothorax from other causes of lung hypoventilation:
  • Mucus plug in main-stem bronchus
  • Foreign body in main-stem bronchus
  • Main-stem intubation

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• Retrobulbar hematoma (a compartment syndrome of the eye) with proptosis.
• Treatment is emergent lateral canthotomy; lowering intraocular pressure with medical therapy (e.g., steroids, mannitol, etc.) is a temporizing option but should never delay canthotomy. 
• Here's a video narrated by our own Dr. Mak Moayedi demonstrating the procedure.

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A non-circumferential, superficial partial-thickness burn; it was treated with Silvadene (silver sulfadiazine)

Burn Classification:

• The traditional 1st, 2nd, 3rd degree classification-system was replaced by:
  • Superficial: skin is dry, red, and blanches with pressure; painful sensation (e.g. sunburn)
  • Superficial partial-thickness: skin has blisters, red, moist, weeping, and blanches with pressure; painful sensation
  • Deep partial-thickness: skin has blisters, wet/waxy dry, variable color (patchy to yellow-white to red), and does not blanch with pressure; pressure-like sensation
  • Full-thickness: skin is waxy-white to leathery-gray to charred and black; dry, elastic, and does not blanch with pressure; deep-pressure sensation
  • Fourth-degree: Burn extends into fascia, muscle, bone; deep-pressure sensation
• Always be concerned with extremity burns because they can become edematous, causing superficial/deep partial-thickness to convert to full-thickness burns 
• Treat with:
  • Extremity elevation 
  • Topical antibiotic creams/ointments
  • Blister debridement is controversial
  • Observation for compartment syndrome if circumferential
  • Consult with burn center as necessary
• See image below demonstrating blisters after debridement

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Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine). New York: McGraw-Hill Companies. pp. 1374–1386.

Grey-Turner and Fox's sign; these signs indicate retroperitoneal hemorrhage.

There are five signs suggesting retroperitoneal bleeding. They generally appear 24 hours after bleeding starts, occurring when blood extravasates along ligamentous connections between the retroperitoneal space and skin surface.

1. Grey-Turner Sign: Named for the surgeon who identified it in 1920; a bluish hematoma across the lateral abdominal wall when blood from the pararenal space leaks along the quadratus lumborum.

2. Fox’s Sign: Described by Dr. Fox in 1966 in two patients, (ruptured AAA and pancreatitis); ecchymosis over anteromedial thigh secondary to blood seeping along the fascia of psoas and iliacus.

3. Cullen’s Sign: Dr. Cullen (gynecologist), described this in 1918 as a sign of a ruptured ectopic pregnancy; bruise around the umbilicus from retroperitoneal blood tracking along falciform ligament.

4. Bryant’s Sign: Dr. Bryant initially described this sign; ecchymosis of the scrotum from blood tracking down the spermatic cord.

5. Stabler’s sign: Ecchymosis over the inguinal ligament

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• Turner GG. Local discoloration of the abdominal wall as a sign of acute pancreatitis. Br J Surg, 1920;7:394–395
• Fox JA. A diagnostic sign of extraperitoneal hemorrhage. Br J Surg 1966;53:193–195
• Cullen TS. A new Sign in Ruptured Extrauterine Pregnancy, Amer J Obstet, 1918,78:457
• James M. Dargin, Robert A. Lowenstein, Ruptured Abdominal Aortic Aneurysm Presenting as Painless Testicular Ecchymosis: The Scrotal Sign of Bryant Revisited, The Journal of Emergency Medicine, Volume 40, Issue 3, March 2011, Pages e45-e48
• Stijn, Heyman, and Vervloessem, Bryant's and Stabler's Signs after a Difficult Delivery,N Engl J Med 2011; 365:1824

Rib fracture

• Rib fractures may be missed on traditional diagnostics such as chest X-ray.
• Ultrasound can be used to not only detect rib fractures but more importantly to detect co-existing injury such as pneumothorax or pulmonary contusion.
• The ultrasound exam is easy and fast to perform:
  • The linear probe is used to evaluate
  • Ask the patient to place the probe on the point of maximal tenderness.
  • Evaluate the bright cortex of the bone in either cross-section or longitudinal plane (as is shown in case)
• Look for other pathologies (e.g., pneumothorax) if rib fracture is discovered
• Watch this video for a demonstration of the technique http://vimeo.com/1086731

Turk F. et al. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol. 2010 Nov;17(6):473-7. doi: 10.1007/s10140-010-0892-9

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Hemopericardium

The heterogeneous appearance of the pericardial fluid indicates that is likely a complex pericardial effusion; the fluid could be blood, pus, or a malignant effusion.

Differential diagnosis of hemopericardium includes:

• Ascending aortic dissection
• Cardiac free-wall rupture
• Blunt / penetrating trauma
• Coagulopathies
• Metastasis to the pericardium

Based on this initial ECHO, a pericardiocentesis was performed and blood was aspirated.

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Answer: Lung Abscesses

Lung Abscess

• Necrosis of lung parenchyma with pus and debris-filled cavities
• Caused by
  • direct injury (e.g., aspiration pneumonia)
  • secondary causes (e.g., tricuspid  endocarditis, bacteremia, etc.)
• Risk factors for disease:
  • Loss of airway reflexes (e.g., CVA, seizures, alcohol / narcotic abuse, etc)
  • Poor dentition
  • Immunosuppression (Diabetes, chronic steroids, etc.)
  • IVDA
• Gram positives (especially Staph), negatives, and anaerobic bacteria have been implicated.
• CXR may suggest, but CT scan better identifies abscess, necrotic tissue, empyema, or other pathology
• Start broad-spectrum antibiotics and address potential underlying cause 

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1. Subcostal or Subxiphoid view; this view is obtained by placing the probe under the ribs with the patient supine. The liver is used as an acoutic window to image the heart.

2. Name the items labeled A-G:

• A = Liver
• B = Right ventricle
• C= Tricuspid valve
• D= Right atrium
• E = Left atrium
• F = Mitral valve
• G = Left ventricle

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1. Apical-four chamber view; this view is obtained by placing the probe in the 4-5th intercostal space at the anterior axillary-line. The patient can be placed in left lateral decubitus to improve imaging.

2. Name the items labeled A-G:

• A = Right ventricle
• B = Tricuspid valve
• C= Right atrium
• D= Interventricular septum
• E = Left ventricle
• F = Mitral valve
• G = Left atrium

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Calcaneus fracture

Answer to Bonus Question: Historically called a “Lover’s Fracture” for “lovers” jumping out of bedroom windows (to evade suspicious spouses) who then land directly on their feet.

Calcaneus fractures

• Most commonly fractured tarsal bone
• 2 types:
  • Extra-articular fracture (direct blow), twisting, and repetitive forces 
  • Intra-articular fracture from axial loading secondary to fall >6 feet, motor vehicle crash, etc.; (classic “lover’s fracture”)
• 10% of axial loaded intra-articular fractures associated with:
  • Bilateral calcaneus fractures and/or,
  • Thoracic or lumbar compression fractures and/or,
  • Proximal femur or tibial plateau fractures
• Ankle Xray is diagnostic and to measure Bohler’s angle (see figure below)
  • Normally 20-40 degrees
  • <20 degrees increases suspicion for intra-articular fracture
• Ankle CT in select cases as Xray may underestimate some injuries
• Extra-articular fractures treated with closed reduction and casting and intra-articular fractures treated by open reduction and internal fixation (closed reduction in select cases)

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Pneumothorax with mediastinal shift

Differential Diagnosis

• Atypical bacterial PNA
• Acute Respiratory Distress Syndrome
• Interstitial lung disease
• Pneumocystis Jirovecii PNA (PJP)

The patient in this case had undiagnosed HIV/AIDS and presented with PTX secondary to PJP. The lifetime risk of PTX with HIV is 6% and 85% of those cases are secondary to PJP.

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The parasternal long-axis is obtained by scanning to the left (patient's left) of the sternum through the 2nd-5th intercostal space. Click here for a tutorial on the technique. 

• A - Left Ventricle
• B - Right Ventricular Outflow Tract (RVOT)
• C - Left atrium
• D - Ascending Aorta
• E - Mitral Valve
• F - Aortic Valve
• G - Descending Aorta

Answer to Bonus Question: Dilation of the RVOT

• Quick tip for evaluating the RVOT; use the left atrium as a size reference (assuming normal atrial size) for the RVOT
• Normally, the RVOT and left atrium should be approximately equal in size

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Monteggia Fracture

• Ulnar fracture with dislocation of proximal radio-ulnar joint; typically secondary to fall on outstretched hand (with arm in hyper-pronation) or with direct trauma to forearm as in a defensive injury (e.g., "Nightstick" injury).
• Should not be confused with a Galeazzi fracture, a fracture of the radius with distal radio-ulnar dislocation
• Remember the mnemonic GRUM; Galeazzi = Radius fracture / Ulnar fracture = Monteggia
• Children may be treated with closed reduction and immobilization; adults usually require open reduction and internal fixation.
• Radial head dislocations should be reduced within 6-8 hours because they can lead to articular damage and/or nerve injury

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• Automatic Implantable Cardioverter-Defibrillator (AICD); Pacemaker could also be the answer as it is difficult to distinguish on ECHO.
• It was placed in this patient for primary prevention of VT/VF secondary to a chronically low left-ventricular ejection fraction. 

AICD

• Placed for patients at risk for sudden cardiac death secondary to malignant arrhythmias (e.g., ventricular tachycardia / fibrillation)
• Shown to improve mortality for patients with severe left ventricular dysfunction (EF<30%) and has been shown to improve mortality (as in this case)
• Tricuspid regurgitation is caused by the intra-cardiac lead preventing complete closure of tricuspid valve leaflets.

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Rash secondary to Epstein-Barr pharyngitis treated with amoxicillin

• Morbilliform rash occuring in up to 95% of patients given amoxicillin for EBV pharyngitis; the rash typically spreads to the trunk 
• Other types of beta-lactams, cephalosporins, and macrolides may also cause this rash 
• The exact mechanism is unknown but it is non-allergic; researchers have demonstrated that patients may receive amoxicilin after the rash resolves without adverse events.  
• The rash spontaneously resolves in 1-2 weeks

Luzuriaga, K., Sullivan, J. Infectious Mononucleosis. N Engl J Med 2010; 362:1993-2000

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Dorsal Metacarpophalangeal (MCP) Dislocation

• MCP dislocations typically occur secondary to a hyperextension injury
• Two categories of dislocations
  • Simple; joint spaces closely opposed and treated by closed reduction
  • Complex; volar plate is entrapped dorsal to metacarpal head with lumbricals and tendons interposed between joint surfaces; treated by operative reduction
• To reduce a simple dislocation:
  • Provide a digital ring-block for analgesia
  • Maximally hyperextend the proximal phalanx with wrist in flexion
  • Push base of proximal phalanx distally while bending the joint into flexion
  • Test neurovascular integrity and joint-stability post-reduction by ranging the joint through a full range of motions
  • Place in thumb spica splint and refer to hand specialist

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Emphysematous Cholecystitis

Emphysematous Cholecystitis

• More common in elderly patients, especially with diabetes
• Usually due to ischemia secondary to systemic hypoperfusion, atherosclerosis, embolism, or vasculitis
• Common organisms causing infection include Clostridium, E. Coli, Klebsiella, and anaerobic streptococci.
• Early antibiotic treatment is mandatory, but definitive surgery is typically required
• Air-fluid level and distended gallbladder may be seen on upright plain abdominal radiographs; CT scan demonstrates air in the GB wall and sometimes throughout the biliary tree

Carrascosa MF, et al.  Emphysematous Cholecystitis. CMAJ.10 Jan 2012; 184(1): E81

Large left-sided ureterolithiasis with hydronephrosis