A 52 year old female presents via EMS after being found down outside. Medical history is notable for reported insulin-dependent diabetes. The patient is found to have altered mental status on presentation, and is unable to provide further history. Vitals are notable for heart rate of 138, blood pressure 92/50, and temperature of 102.1F; POC blood glucose shows blood sugar over 600. On physical exam, patient is found to have hemorrhagic bullae of her left lower extremity with palpable crepitus. Labs in the emergency department are notable for WBC of 36k, anion gap of 30, and lactate of 2.5.

Point-of-care ultrasound of the left lower extremity is shown below. What is the most likely diagnosis, and what findings on the ultrasound imaging support this?

Answer: Necrotizing Fasciitis; “dirty shadowing”

• Subcutaneous air results will appear as hyperechoic lines on soft tissue ultrasound, with “dirty shadowing” of tissue/structures deep to the air.
• These hyperechoic lines are seen at the borders between air and soft-tissue, due to a scattering of ultrasound waves that occurs at these boundaries.
• Additional findings of necrotizing fasciitis on ultrasound include a “cobblestone” appearance of the subcutaneous tissue with abnormal fluid collections. These findings are not specific to necrotizing fasciitis, however.

References:

Tso DK, Singh AK. Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls. Br J Radiol. 2018 Jul;91(1088):20180093. doi: 10.1259/bjr.20180093. Epub 2018 Mar 28. PMID: 29537292; PMCID: PMC6209465.

Buttar S, Cooper D Jr, Olivieri P, Barca M, Drake AB, Ku M, Rose G, Siadecki SD, Saul T. Air and its Sonographic Appearance: Understanding the Artifacts. J Emerg Med. 2017 Aug;53(2):241-247. doi: 10.1016/j.jemermed.2017.01.054. Epub 2017 Mar 31. PMID: 28372830.

A 55 year old male with a past medical history of colon cancer on chemotherapy presents with a chief complaint of right lower extremity pain/discoloration to his calf and thigh as well shortness of breath that has developed over the past 48 hours. A physical exam reveals dopplerable DP and PT pulses. The right calf and thigh is visualized as in the image below. What’s the diagnosis?

Answer: Phlegmasia Cerulea Dolens (PCD) – a near-total occlusion of the major deep venous system of an extremity as well as the majority of microvascular collateral veins of the extremity. 

PCD occurs on a spectrum with phlegmasia albans dolens (PAD): thrombosis of the deep venous system with patency of the collateral veins and venous gangrene: when there is complete obstruction of venous outflow with irreversible capillary involvement and muscle infarction. It is differentiated from PAD by a pale/white limb versus a dusky/cyanotic limb in PCD. 

Clinical Features: Triad of swelling, pain, cyanosis. Limb can develop firmness and there is a risk for arterial compromise and compartment syndrome. Thrombosis can extend into the IVC and it is often accompanied by pulmonary embolism with the incidence reported to vary from 12-40%.  

Diagnosis: Clinical history/exam in conjunction with imaging. Gold standard diagnosis is contrast venography, however often due to difficulty and length of time to attain this ultrasound venography is often preferred. CT-venogram is useful for visualization of extension of thrombus in the IVC. 

Management: Immediate elevation of affected extremity above the level of the heart to encourage return of circulation. Anticoagulation with unfractionated IV heparin bolus at 10-15 units/kg followed by an infusion titrated to an aPTT of 1.5-2 times the lab control value. Immediate vascular/interventional radiology consultation for possibly thrombectomy versus catheter-directed thrombolysis. If no service is available and transfer is unable to be arranged within 6 hours then consider systemic fibrinolytics if no contraindications are present. 

Case Continued: Duplex ultrasound, CT-venogram, and CTA Chest on our patient revealed DVT of the major deep veins of the right lower extremity that extended into the IVC as well as bilateral pulmonary embolisms. He was started on heparin and had a mechanical thrombectomy of the right iliofemoral/IVC DVT. He was able to be discharged on apixaban several days later. 

Resources:

Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., Yealy, D. M., & Kline, J. A. (2020). Venous Thromboembolism Including Pulmonary Embolism. In Tintinalli’s emergency medicine: A comprehensive study guide (pp. 389–398). essay, McGraw-Hill Education. 

Gardnella, L., & Falk, J. (n.d.). Phlegmasia Alba and cerulea Dolens – StatPearls – NCBI Bookshelf. Phlegmasia Alba and Cerulea Dolens. https://www.ncbi.nlm.nih.gov/books/NBK563137/ 

Perkins, J. M., Magee, T. R., & Galland, R. B. (1996). Phlegmasia caerulea dolens and venous gangrene. British Journal of Surgery, 83(1), 19–23. https://doi.org/10.1002/bjs.1800830106 

A 44 year old male presents for left foot and ankle pain. He was running and stepped into a hole, stating he heard a “crack”. He has been unable to bear weight since the injury. On exam, his left lower extremity is neurovascularly intact. He has swelling and marked bony tenderness of both the lateral and medial malleoli and heel. X-rays of the left foot is obtained and shown below. What’s the diagnosis?

Answer: Comminuted Calcaneal Fracture

Etiology

• Most commonly due to high axial load injuries such as fall from height or MVC
• Most common tarsal fracture

Presentation

• Diffuse pain, swelling, and ecchymosis after trauma
• Often unable to bear weight
• Deformity of heel or plantar arch on exam
• Mondor’s sign – ecchymosis/hematoma that tracks along sole of foot
  • Pathognomonic for calcaneal fracture

Diagnosis

• Plain radiographs of ankle/foot
• Harris view: calcaneus in axial view
• Non-contrast CT of foot/ankle is gold standard and assists with surgical planning
• Sander’s Classification (based on CT)
  • Type I: All intra-articular fractures that have < 2 mm displacement, regardless of number of fracture lines or fragments
  • Type II: Two bony fragments involving posterior facet
  • Type III: Three bony fragments including depressed middle fragment
  • Type IV: Four comminuted bony fragments

ED Treatment

• Analgesia, ice, elevation
• Splinting, often with bulky Jones dressing
• Orthopedics consultation
  • Most intra-articular fractures require surgical repair
  • Most extra-articular fractures can be managed conservatively with 10-12 weeks of casting and non-weight bearing

References:

Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471

A 78 year old female presents to the ED from a cardiac rehabilitation facility with increasing shortness of breath and a productive cough. She was discharged from the hospital two weeks ago after having a coronary stent placed which was complicated by pneumonia and developing heart failure. She was discharged on PO amoxicillin-clavulanate. Vitals are notable for a heart rate of 101 and are otherwise within normal limits. 

Labs are remarkable for an elevated WBC of 18.55 and elevated NT-ProBNP of 2155. Point-of-care cardiac ultrasound shows a normal ejection fraction. Right sided point-of-care lung ultrasound findings are shown below. What’s the most likely diagnosis, and what pathognomonic ultrasound “sign” is seen?

Answer: Pneumonia; Hepatization of the lung

• Normally, lung is not well visualized on ultrasound because the alveoli are filled with air which does not transmit ultrasound beams well to produce an image.
  • Aerated lung will produce horizontal “A lines”, a reverberation artifact from the result of sound waves bouncing between the skin and pleural line.
• With consolidation of the lung or pneumonia, ultrasound beams are able to travel through the purulent or fluid filled alveoli.
  • The lung will appear hypoechoic and heterogeneous, resembling the liver, hence the term “hepatization of the lung.”

References:

Dawson M, Mallin M. Introduction to Bedside Ultrasound: Volume 1. Emergency Ultrasound Solutions; 2013. 

Durant A, Nagdev A. Ultrasound detection of lung hepatization. West J Emerg Med. 2010;11(4):322-323

https://litfl.com/lung-ultrasound-pneumonia/

A 44 year old woman with a past medical history of kidney stones and diabetes presents to the ED with 3 days of intermittent flank pain for which Tylenol is not helping. On exam, she is crying and in pain with some tenderness in RLQ and suprapubic area. No CVA tenderness noted. She denies fever and dysuria. A CT abdomen and pelvis with IV contrast was obtained and shown below. What’s the diagnosis?

Answer: bilateral emphysematous pyelonephritis (Findings: bilateral xanthogranulomatous pyelonephritis. Right perinephric stranding. Gas within both renal collecting systems and urinary bladder.)

This is a severe necrotizing infection of the kidney parenchyma. Primarily, cases occur in those with uncontrolled diabetes (95%) and a secondary factor is kidney obstruction (25-40%). The usual bacteria involved is E. Coli (69%) or K. Pneumoniae (29%). If caught early medical management of kidney function and antibiotics is the primary mode of treatment. Failure of initial treatment can lead to a nephrectomy.

• Class 1: gas in the collecting system only
• Class 2: gas in the renal parenchyma without extension to extrarenal space
• Class 3A: extension of gas or abscess to perinephric space
• Class 3B: extension of gas or abscess to pararenal space
• Class 4: bilateral EPN or solitary kidney with EPN

Management: admit for IV antibiotics and urological consult

This particular case has Proteus as the infective species as evident by staghorn calculi and urine culture. Because of preserved kidney function (Cr 0.87) and WBC (4.45), Urology elected to monitor and treat infection first and schedule outpatient procedure for stone removal to prevent urosepsis.

References:

Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805. doi: 10.1001/archinte.160.6.797. PMID: 10737279.

Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14. PMID: 20840327.

A 40 year old male presents for right wrist pain. Onset was just before arrival when he was lifting at work, “felt a pop”, and had a sudden onset of pain. Exam reveals swelling and tenderness of the right wrist. Neurovascular exam is normal. A right wrist x-ray is performed and shown below. What’s the diagnosis?

Answer: Scapholunate Dissociation

• Background
  • Scapholunate ligament is most commonly injured ligament in the wrist
  • SLD is part of a spectrum of traumatic carpal bone instabilities
• Etiology
  • Most commonly occurs with FOOSH injury causing forceful wrist extension, rupturing the scapholunate interosseous ligament
  • Also associated with spastic paresis, rheumatoid arthritis, and congenital ligament laxity
• Presentation
  • Wrist swelling and point tenderness over dorsal aspect of wrist
  • Pain with wrist extension, radial deviation, and “clicking” sensation with movement
• Diagnosis
  • Obtain AP and lateral views (+/- grip compression view/wrist in ulnar deviation)
  • Radiographic signs:
    • Widening of the scapholunate joint space > 3mm (“Terry Thomas sign”)
    • Cortical ring sign – loss of ligamentous support results in rotary subluxation and palmar tilt of the scaphoid on AP radiograph 
  • MRI provides definitive diagnosis, rarely done in ED 
• ED Management
  • Pain management
  • Radial gutter splint
  • Urgent referral to orthopedics/hand specialist 
• Pearls and Pitfalls
  • Prompt recognition crucial
  • Delayed diagnosis is associated with chronic pain, joint instability, inflammatory arthritis, long-term degenerative changes

References:

Casey PD, Youngberg R.Scapholunate dissociation: a practical approach for the emergency physician.J EmergMed. 1993;11(6):701-707. doi:10.1016/0736-4679(93)90629-l

Long B, Koyfman A. Wrist Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, StapczynskiJ, Cline DM, ThomasSH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed September 29,2020.https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=222324635

Ramponi D, McSwigan T. ScapholunateDissociation.Adv Emerg Nurs J. 2016;38(1):10-14.doi:10.1097/TME.0000000000000094

Stevenson M, Levis JT. Image Diagnosis: Scapholunate Dissociation.Perm J. 2019;23:18-237. doi:10.7812/TPP/18-237

A 29 year old male with no past medical history presents with sudden onset, pleuritic chest pain radiating to right flank while swimming yesterday. He notes associated dyspnea, particularly with deep inspiration. Social history is notable for smoking tobacco and marijuana. Vital signs are: Temp 98.7F, HR 54, BP 125/76, RR 16, SpO2 98% RA. Exam shows a thin appearing male in no acute distress with clear bilateral lung sounds. A CXR is obtained and shown below. What’s the diagnosis?

Answer: Spontaneous Pneumothorax (see pleural line at apex of right lung)

• Is there an association between smoking marijuana and spontaneous pneumothorax (PTX)?
  • A brief literature review showed multiple cases but no studies proved causality.^{2, 3} However, one case control study had evidence that patients with spontaneous PTX and marijuana smoking history were at higher risk for poorer outcomes such as having larger pneumothoraces, prolonged post-op stays, and recurrence.¹

• Treatment: Depends on clinical status and size of PTX
  • Tension PTX = immediate needle decompression followed by thoracostomy
  • Supplemental O₂
  • Observation for small primary spontaneous PTX (<2 cm between lung margin and and chest wall) with no significant dyspnea OR asymptomatic patient with large primary spontaneous PTX (>2 cm) with serial CXRs
  • Chest tube insertion site: within the “triangle of safety” (see figure below)

References:

1. Stefani A, Aramini B, Baraldi C, Pellesi L, Della Casa G, Morandi U, Guerzoni S. Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study. PLoS One. 2020 Mar 30;15(3):e0230419. doi: 10.1371/journal.pone.0230419. PMID: 32226050; PMCID: PMC7105102.

2. Manasrah N, Al Sbihi AF, Al Qasem S, Naik R, Hettiarachchi M. Recurrent Spontaneous Pneumothorax Associated With Marijuana Abuse: Case Report and Literature Review. Cureus. 2021 Feb 7;13(2):e13205. doi: 10.7759/cureus.13205. PMID: 33717745; PMCID: PMC7943398.

3. https://doi.org/10.1016/j.chest.2020.05.026

4. Dynamed, AMBOSS

A 36 year old male presents with left lower extremity pain after a motor vehicle vs pedestrian accident. The patient was crossing a crosswalk when a car hit him at low speed. On exam, there is an obvious deformity with significant swelling and tenderness of the left lower leg. What type of fracture pattern is present and what delayed surgical emergency can potentially occur from this injury?

Answer: Comminuted displaced fractures of distal tibia and fibula – high risk for development of Acute Compartment Syndrome

• After a fracture, there can be extravasation of blood with increased tissue swelling and venous flow impairment within the fascial compartments. The build up in pressure causes circulatory compromise, neurologic damage, and muscle necrosis. 
• The most common site of compartment syndrome is in the lower extremities at the tibia and fibula with a majority of cases occurring in the anterior compartment. Acute compartment syndrome can occur within a few hours of inciting trauma and can present up to 48 hours after.
• Patient’s typically feel pain out of proportion to exam with a tense “wood-like” compartment. Alarming symptoms include:
  • Pain with passive or active stretching (most sensitive exam finding)
  • Active contraction against resistance
  • Direct pressure over the compartments
• Diagnosis:
  • Exam findings can be sufficient to make the diagnosis in the correct setting of an inciting event along with alarming symptoms.
  • Using intracompartmental pressures alone as a guide, <30 mmHg would not require intervention whereas pressure >45 mmHg requires decompression.
  • Obtaining the “delta pressure” between the direct compartment pressure and diastolic pressure, a difference <30 mmHg should warrant fasciotomy.
• Rapid diagnosis is key as within 3-4 hours in the muscle there can be reversible change and after 8 hours there is irreversible muscle damage; in the nerve, as soon as within 2 hours patients can have loss of nerve conduction and within 8 hours there is irreversible damage.
• Treatment:
  • Immediately remove restrictive casts or dressings and place affected limbs at the level of the heart.
  • Surgical fasciotomy to reduce compartment pressure in a timely fashion.
    • These wounds post operatively are left open for a second operating room look within 48-72 hours for wound closure.
  • If delay in treatment, patient’s can have functional impairment including permanent neuropathy and contractures.

References:

Tintinalli’s Emergency Medicine (9th ed). Mayersak, R. J. McGraw Hill, 2018. Chapter 267 and 278. Page 1782, 1876-1879 

Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/

A 45 year old male with a history of ESRD on hemodialysis and insulin dependent diabetes presents with left knee pain after slipping at work. Vitals are within normal limits. On exam, the left lower extremity is distally neurovascularly intact with palpable distal pulses. There is obvious swelling over the knee with the worst pain superior to the patella. He is unable to extend the lower leg. An x-ray is performed and shown below. What’s the diagnosis?

Answer: quadriceps tendon rupture

• At first glance, lateral XR does not show obvious deformity… however, you may notice calcifications just superior to the patella representing retracted tendon.
• Quadriceps tendon ruptures tend to occur in individuals > 40, while patellar tendon ruptures occur more frequently in individuals < 40.
  • Overall, quadricep tendon ruptures are more common (risk factors include rheumatologic disease, renal failure, DM, chronic steroid use).
• In both injuries, classic exam finding is inability to extend the knee. You can often palpate a defect just above the patella in quadriceps tendon ruptures.
• High riding patella (“patella alta”) on lateral films is more frequently seen in patellar tendon ruptures. Low riding patella (“patella baja”) may be seen on lateral film with complete quadricep tendon tear (intact patellar tendon displaces patella inferiorly).
• X-rays may be normal! Ultrasound is the diagnostic modality of choice in the ED as it has both high sensitivity and specificity.
• Orthopedic consultation is always warranted for these cases. Management involves a knee immobilizer and prompt follow up. Early surgical repair is associated with better outcomes in severe cases.

References:

Bengtzen RR, Glaspy JN, Steele MT. Knee Injuries. In: Tintinalli JE, Stapczynski JS, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016: (Ch) 274. 

Pope JD, El Bitar Y, Mabrouk A, et al. Quadriceps Tendon Rupture. [Updated 2023 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482389/