50-year-old with a history of T2DM, hypertension, hyperlipidemia, substance use, and asthma who presents with 4 weeks of progressive left index finger pain. The patient had some swelling from the fall, but now has had one week of swelling worsening, pain, redness. Physical exam reveals digit red, swollen, fusiform, very tender, and unable to flex or extend DIP and PIP. A POCUS is obtained and shown below. What’s the diagnosis?

Answer: Necrotizing Fasciitis

POCUS is very quick to evaluate for many of differentials but would be painful to press directly on the digit with gel. There is an excellent alternative here: waterbath technique.

Water is an excellent medium for ultrasound. In this instance, we submerged the patient’s hand in water, and we are able to submerge the probe and hover above the affect area without concern for the amount of gel we displace in assessing the area or the pressure we apply to get clear images. Also, the high transmissibility of ultrasound through water allows for excellent visibility of superficial structures of body parts like fingers when direct contouring with gel would be virtually impossible. With this technique, we can look for fractures, abscesses, air, and cobble-stoning quickly, easily and with a high degree of accuracy.

So, in this patient as it turns out, air and cellulitis are visible, likely being a necrotizing infection. POCUS with a waterbath was the quickest way to establish this diagnosis. This is extremely important because even with advances in antibiotics, time to surgical intervention is most important in decreasing morbidity and mortality in these patients.

Resources:

Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med. 2004 Nov;22(7):589-93. doi: 10.1016/j.ajem.2004.09.009. PMID: 15666267.

Shelhoss S C, Burgin C M (November 16, 2022) Maximizing Foreign Body Detection by Ultrasound With the Water Bath Technique Coupled With the Focal Zone Advantage: A Technical Report. Cureus 14(11): e31577. doi:10.7759/cureus.31577

Shrimal P, Bhoi S, Sinha TP, Murmu LR, Nayer J, Ekka M, Mishra P, Kumar A, Trikha V, Aggarwal P. Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures. Am J Emerg Med. 2022 Mar;53:118-121. doi: 10.1016/j.ajem.2021.12.067. Epub 2022 Jan 2. PMID: 35016093.

Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am. 2017 Sep;31(3):497-511. doi: 10.1016/j.idc.2017.05.011. PMID: 28779832; PMCID: PMC5656282.

A 2 year old female presents to the ED with fever and difficulty swallowing. Mom reports she has been fussy with intermittent fever and rhinorrhea for 4 days but today did not want to eat or drink much, talking in a whisper and complaining of pain when eating. On exam, the patient is febrile, drooling, and has a swollen posterior oropharynx. A soft tissue neck x-ray is shown below. What’s the diagnosis?

Answer: Retropharyngeal Abscess

• Most common in children under 5 years
• May be preceded by URI symptoms or trauma to posterior pharynx
• Xray finding = widened prevertebral space
  • In children, consider abscess when the prevertebral space is >6mm at C2 or >22mm at C6
  • Accurate assessment requires neck extension during x-ray
• Common organisms involved – often polymicrobial, Staph aureus, Strep pyrogens, Strep viridans, Fusobacterium, Haemophilus specieas or other respiratory anaerobes
• Management:
  • Admission 
  • IV antibiotics
  • Consult ENT for possible I&D
  • Definitive airway if any respiratory compromise
• Complications include airway obstruction and mediastinitis

References:

Jain H, Knorr TL, Sinha V. Retropharyngeal Abscess. [Updated 2019 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK441873/

Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016.

A 45 year old woman with past medical history of DM and nephrolithiasis s/p ureteral stent placement presents with right flank pain. Pain is progressive and associated with nausea and vomiting. She has had subjective fevers at home and dysuria. She denies polyuria or increased urinary frequency. Physical exam is significant for right CVA tenderness and right-sided abdominal pain radiating to the groin. Point of care bilateral renal ultrasound demonstrates the findings below. What’s the diagnosis?

Answer: Bilateral Staghorn Calculi

Patient had a hospital admission 2 weeks prior to this presentation and underwent cystoscopy and right retrograde pyelogram with ureteral stent placement. Urine cultures grew gram-negative rods, she was treated with ceftriaxone.

Learning Points
Staghorn calculi
– Large, complex stones filling the majority of the renal pelvis and calyces.
– Increased rates of infection, urosepsis, and kidney injury leading to increased morbidity and mortailty.
– Often struvite in composition and associated with Proteus mirabilis; a gram-negative rod. Other urease-producing bacteria are potential sources.
– Treatment can be conservative with antibiotics and percutaneous procedures. More often surgical intervention is necessary to prevent complications and mortality.

POCUS – is there hydronephrosis?
– Bedside ultrasound is useful in identifying and grading severity of hydronephrosis.
– Studies have demonstrated a sensitivity of 77-90% and specificity of 71-96% for detecting hydronephrosis for emergency physicians

Retrieved from: https://www.pocus101.com/renal-ultrasound-made-easy-step-by-step-guide/

References:

1. Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol. 2019;11:1756287219847099. Published 2019 May 9. doi:10.1177/1756287219847099
2. Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
3. Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J 2020; 12(1):31.
4. Riddell J, Case A, Wopat R, Beckham S, et al. Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 2014; 15(1).
5. Watkins S, Bowra J, Sharma P, et al. Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australasia 2007;19(3):188-95.
6. Nixon G, Blattner K, Muirhead J & Kerse N. Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of primary health care 2018; 10(4), 324–330.

3 y/o male presenting with significant left arm pain and swelling. He was jumping on the bed when he fell off and landed on his left arm. There were no open wounds or lacerations of the arm. He cried immediately and was brought directly to the emergency department. He was noted to have significant swelling and tenderness of the left elbow and was neurovascularly intact. What’s the diagnosis?

Answer: Monteggia fracture 

• This patient has a proximal ulnar fracture with radial head dislocation. This fracture can be distinguished from a Galeazzi’s fracture as this fracture involves a radial shaft fracture with distal radioulnar joint dislocation. 
• In Monteggia’s fracture, the radiocapitellar line is disrupted, the apex of the ulnar fracture points in the direction of the radial head dislocation.
• This fracture can frequently be missed in the emergency department if the joint alignment is not carefully examined.

• Mechanism: fall on outstretched and or direct blow to the forearm with the elbow extended and forearm in hyperpronation
• Radiocapitellar joint disruption occurs from the energy from the ulnar fracture that transmits along the interosseous membrane leading to rupture of the proximal quadrate and annular ligaments
• Exam: significant swelling and pain of the elbow, may palpate the radial head
• Diagnosis: anterior posterior and lateral elbow x-rays to assess for the radiocapitellar line 
• 4 different types based on the Bado classification

Bado Type	Fracture	Radial head dislocation direction
I	Ulnar shaft	Anterior
II	Ulna	Posterior
III	Ulna	Lateral
IV	Radius and ulna	Anterior

• Treatment of Monteggia fracture involves reduction with long arm splint in the arm in 110 degrees. It is typically recommended to consult Orthopaedic surgery as these fractures can be unstable and occasionally require open reduction and internal fixation 
• Complications: radial nerve injury, posterior interosseous nerve injury, nonunion, recurrent dislocation  

References:

Johnson NP, Silberman M. Monteggia Fractures. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470575/

Mathur N, Lau KK. Monteggia fracture: an easy fracture to miss. Emerg Radiol. 2020 Aug;27(4):377-381. doi: 10.1007/s10140-020-01763-8. Epub 2020 Feb 21. PMID: 32086608.

The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. (n.d.). https://www.rch.org.au/clinicalguide/guideline_index/fractures/monteggia_fracturedislocations_emergency_department_setting/#ED_management 

Tintinalli’s Emergency Medicine (9th ed). Chow, Y. Lee, S. McGraw Hill, 2018. Chapter 270 and Page 1820-1821. 

A 76 yo female presents after a fall down several stairs. She is diagnosed with bilateral pubic rami fractures on x-ray. The patient has difficulty with urination. A foley is placed and there is blood return. A CT cystogram is shown below. What’s the diagnosis?

Answer: Bladder injury (extraperitoneal)

• Occurs with direct blunt trauma to distended bladder
  • 70-97% associated with pelvic fractures
• Clinically, patient will have gross hematuria, lower abdominal tenderness, perineal or scrotal edema, difficulty voiding
• Gold standard diagnosis: retrograde cystogram (either x-ray or CT)
  • Can be missed on routine CT or US
• Intraperitoneal rupture: contrast material leaks into peritoneal cavity
  • Require surgical repair
• Extraperitoneal rupture: contrast material leaks into retroperitoneum
  • Most common
  • Usually managed conservatively and heal within 2 weeks

References:

Gratton MC, French L. Genitourinary Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016.

A 33 year old male presents to the ED reporting he was assaulted last night. He is unsure what weapons were used, and is complaining of pain to his head and face. He reports a loss of consciousness during the assault. He denies pain or injuries to his extremities, visual changes, hearing loss, neck pain. His exam is significant for a lacrosse ball sized injury to his left forehead above his eyebrow. Pupils are equal, reactive and circular, EOMs intact, no midline tenderness in the cervical/thoracic/lumbar spine, no hemotympanum, no otorrhea/rhinorrhea, no facial instability, no nasal deformity or dental injury. No signs of injury on chest, back, abdomen or extremities, neurologic exam is unremarkable and intact in all 4 extremities, gait steady. You obtain CT imaging of the facial bones, head and neck, which reveal:  

Diagnosis: isolated anterior table frontal bone fracture 

• Mechanism: high-energy mechanism required to generate force, ie: unrestrained motor vehicle crashes, assault with blunt objects (bricks, baseball bat)
• High occurrence for concomitant injuries in facial bones, intracranial injury, cervical spine injury and ocular injuries 
• Incident of intracranial injury up to 87% and ocular injuries up to 25%
• If extension into the temporal bones, patients require hearing and facial nerve function evaluation 
• Important to evaluate the anterior and posterior tables of the frontal sinus as involvement of the posterior table requires surgical repair
  • Dura is attached to the posterior table, surgical repair required to prevent complications such as pneumocephalus, CSF leak or infection 
• Consider nonaccidental trauma especially in children, elders, pregnant women 
• Management of isolated anterior table frontal bone fracture: sinus precautions, augmentin course, ENT/plastics follow up 

References:

Hedayati T, Amin DP. Trauma to the Face. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Gaillard F, Bell D, Frontal sinus fracture. Reference article, Radiopaedia.org 

A 27 year old male presents for a right shoulder injury. He was attempting to break up a fight between his dogs when his right arm was pulled and he felt a “pop” in his right shoulder. He has been unable to move his right shoulder since and there is severe pain that is worse with movement. His vitals are within normal limits. On exam, the right upper extremity is neurovascularly intact. There is an obvious deformity of the right shoulder with severely reduced range of motion. An x-ray is performed and shown below. What’s the diagnosis?

Answer: Anterior shoulder dislocation

• Anterior dislocations of the shoulder are the most common type, approximating 99%. The mechanism typically occurs from forced abduction and external rotation. 
• Exam will show a “squared off” appearance of the normal round contour of the shoulder and guarding of the arm in slight abduction and external rotation. The axillary nerve, which provides sensation to the proximal arm and shoulder, is most commonly injured.
• Diagnosis is obtained with plain radiographs. A scapular “Y” view shown on the right can help confirm anterior vs posterior in unclear cases.
• Treatment of simple cases involves closed reduction in the ED. There are various methods which can be achieved with or without sedation.
  • Examples that do not require sedation: Cunningham, Davos, Fares,
  • Examples that typically require sedation: Kocher, Traction-Countertraction
  • Complications include recurrent dislocations (most common) and bony injuries such as Hill-Sachs and Bankart lesions. 

References:

Bjoernsen L, Ebinger A. Shoulder and Humerus Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

The patient is a 40-year-old male with no past medical history who presents with concerns of a rash on his hands. He states that the lesions appeared two days ago, but had a fever, muscle aches, and pruritis two days before that. He does not have a history of hives or contact dermatitis. He does not take any medications, but states he recently developed “cold sores.” His temperature is 100.6^oF, but his other vitals are within normal limits. The cutaneous rash is demonstrated below. When looking in his mouth, blistering lesions are also present. What the diagnosis and management?

Answer: Erythema Multiforme

• Erythema multiforme is the result of a T-cell mediated hypersensitivity reaction resulting in a characteristic pruritic, targetoid papules, with a hazy-center, and surrounding erythematous rings.
• 90% of cases are associated with infectious etiologies, with HSV-1 being most common in adults and Mycoplasma pneumonia in children.
  • Remaining 10% are due to drugs (NSAIDs, antiepileptics, antibiotics), malignancy, and autoimmune diseases. Their mechanism of rash formation is unknown.
• There are two specific subtypes:
  • Erythema multiforme minor: rash without mucosal involvement or constitutional symptoms
  • Erythema multiforme major: rash with mucous membrane involvement and constitutional symptoms (fever, malaise, myalgias etc.)
• Diagnosis is often clinical, but immunofluorescence can be helpful if uncertain.
  • PCR testing for both HSV and Mycoplasma pneumoniae should be done if suspected.
• Treatment is mostly symptomatic, and the rash is usually self-limited.
  • Antihistamines are useful for pruritis.
  • Systemic steroids maybe be used, but the impact on long-term outcomes and symptom duration is unclear.
  • Acyclovir may be used to prevent recurrent HSV infections.
  • Macrolides may be used in Mycoplasma pneumoniae is suspected.

References:

1. Baluzy Matthew, Karaze Tallib. Maculopapular Rashes. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recvFPlc0BmXxYuzp/Maculopapular-Rashes#h.til8vwjxmfh6. Updated June 21, 2023. Accessed January 24, 2024.
2. Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol. 2012;51(8):889-902. doi:10.1111/j.1365-4632.2011.05348.x
3. Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019;100(2):82-88.
4. J. Brady W, Pandit A, R. Sochor M. Generalized Skin Disorders. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed January 24, 2024. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180403
5. DermNet. https://dermnetnz.org/topics/erythema-multiforme-images

A 24 year old female with a history of gallstones presents to the ED with 2 hours of severe, aching right upper quadrant abdominal pain that woke her from sleep associated with nausea and vomiting. Patient has had similar episodes of pain in the past, often after eating fatty foods. On exam, she is tender in RUQ of the abdomen and is actively vomiting. A right upper quadrant abdominal ultrasound is performed and shown below. What’s the diagnosis?

Answer: Symptomatic Cholelithiasis

• Characterized by episodes of RUQ pain that are brought on by obstructing gallstone and relieved when gallstone moves from that position
• Can progress to cholecystitis if gallstone remains in obstructing position and gallbladder subsequently becomes inflamed or infected.
• Differential: cholecystitis, choledocholithiasis, cholangitis.
• If simple symptomatic cholelithiasis (no signs of infection or other biliary obstruction) and pain is controlled, patient can often be discharged from ED with outpatient surgical follow-up.

Symptomatic Cholelithiasis vs Cholecystitis on Ultrasound

Cholecystitis may have the following:

1. Gallstones present in gallbadder
2. Sonographic Murphy’s sign
   • Maximal tenderness over the most anterior portion of GB as defined with US imaging
3. Wall thickness of gallbladder over 3 mm
   • Be sure to measure GB wall thickness at anterior aspect to avoid false positive increased secondary to posterior acoustic enhancement!
4. Pericholecystic fluid

These findings should be used in conjunction with lab results to help identify diagnosis on spectrum of biliary disease.

References:

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Ch 79: Pancreatitis and Cholecystitis. Judith E. Tintinalli

Soni, Nilam, et. al. Point of Care Ultrasound, 2nd Edition. Ch 27: Gallbladder