Septic Arthritis - Dr. Cameron Shoraka
Case: 53yo male p/w atraumatic left ankle pain. Hx of IVDU and previous endocarditis.
Xray left ankle: Soft tissue edema. No fractures.
POCUS left ankle: joint effusion.
Hospital Course: arthrocentesis, MRI + for septic arthritis. OR with intra-op cx + for Staph Aureus. IV Vanco and Cefepime, d/c'd with PICC line and continued IV abx.
NECROTIZING FASCIITIS - Dr. Andrea Alvarado
63yo M with PMHx of HTN, DM, medication non-adherence presents with 1.5 weeks of worsening right foot pain and expanding wound. * Patient provided written consent for use of photograph.
WBC 12,1000, Gluc 518, CRP 22
Finger Pain - Dr. Max Rippe
53 year-old female presents with right 2nd distal phalangeal pain, redness, swelling x 2 weeks.
•Bactrim without improvement
•Slow blackening of cuticle 6 months ago with loss of nail
•New nail grew over
Notice the ovioid lesion within the phalanx.
XR finger: lytic lesion in distal phalanx
MRI finger: T2 hyperintense lesion centered in the index finger distal phalanx. Differential includes abscess or inclusion cyst. No evidence of peritumoral osteomyelitis.
Taken to OR for resection of intraosseous mass
Surgical Path: Intraosseous epidermal inclusion cyst.
Original US finger: “No drainable collection visualized. No obvious mass or vascular abnormality.” Did not use hand immersion – missed mass!!!
Using a water bath can reduce discomfort as no skin contact is needed. Additionally, the technique can improve imaging as the “step-off” allows for the object of interest to fall into the Focal Zone. This increases the likelihood of identifying objects just below the skin’s surface
"Squish" Sign - Dr. Melissa Velasquez
•41 yo M with history of IVDU presenting with diffuse buttocks pain with subjective fevers
Denies history or trauma to buttocks or rectal bleeding
Afebrile, tachycardic to 105, other vitals wnl
Physical exam notable for extensive L perirectal fluctuance extending to base of penis, tender to palpation with overlying erythema
Is there a drainable fluid collection? The "mass" is ISOECHOIC..... try COMPRESSION:
If you see heteroechoic material, you can differentiate abscess vs soft tissue mass with squish sign! Not all abscesses are anechoic.
When you have an isoechoic abscess, try compressing it and you’ll see movement of abscess debris
Some other tips are the irregular, hyperechoic borders
This patient was obvious given clinical picture but it can be useful in a well-appearing patient with minimal overlying cellulitis or tenderness on exam
CT showed rim-enhancing fluid collection measuring approximately 9.2 x 3.5 x 5.7 cm, concerning for abscess.
31 y/o male with no pmh p/w a cc of chest pain after an MVC. Chest struck the steering wheel.
All VS WNL. Sternal tenderness to palpation.
Sternal Fracture on CT, CXR, and Ultrasound.
Clavicle Fracture - Dr. Sarah Jabre
Case: 37 year old male previously healthy brought in by EMS s/p MVA in which he was ejected at a low speed from his motorcycle. Patient complaining of left sided chest pain and left arm pain upon arrival to the ED with no associated left arm/hand weakness or numbness.
PE was positive for mid clavicle deformity with tenderness upon palpation. Normal motor/sensory function of left UE.
Bedside US highlighted a cortical irregularity with displacement along the mid clavicle.
Findings were confirmed by an Xray that showed a comminuted midshaft left clavicle fracture with 2.7 cm displacement.
Is US enough to diagnose a clavicle fracture in the ED?
Sensitivity 89 to 95% - Specificity 89.5-98.25 % (3 studies using XRay as control - 2 studies in pediatrics)
Treatment is with a sling or figure-of-eight brace for 2 to 3 weeks.
ONLY the rare clavicle fracture with neurovascular or mediastinal injury by severely displaced fractures needs orthopedics consultation!
NECROTIZING FASCIITIS - Dr. Michael Osinski
31 y/o male with uncontrolled DM p/w 5 days of worsening “abscess” of right thigh
Afebrile, appears uncomfortable, but does not appear toxic. BS >500.
No crepitus, although exam limited by severe tenderness
***Written consent obtained by patient to obtain and use image for educational purposes.
Right thigh, distant from bullae.
Right thigh, near bullae.
NSTI Findings (STAFF):
Fascial Fluid (>4mm deep along deep fascial layer)
Sensitivity 88.2%, Specificity 93.3%, PPV 83.3%, NPV 95.4% for Necrotizing Fasciitis
Air in tissue present in advanced cases, and may obscure visualization of deeper structures
Acute Care Surgery was immediately consulted and CT obtained after their evaluation:
•Patient taken emergently to OR for debridement of necrotizing fasciitis, and did well following surgery.
HIP FRACTURE - Dr. Dennis D'Urso
•65 M patient with pmh dementia brought in from ALF after being found on the ground
•No complaints, states he accidentally rolled out of bed; no h/o falls or mobility issues
•No bruising or obvious deformities, able to reposition freely in bed, noted to favor right leg in externally rotated position
POSTERIOR SHOULDER DISLOCATION - Dr. Dennis D'Urso
•31 y.o. male bicyclist hit by car presents to ED with left shoulder pain and limited ROM
•Denies head trauma, LOC, or neck pain
•VS WNL, AAOx4, GCS 15
•Diffuse tenderness around L shoulder; ROM limited by pain (active > passive); distal pulses, sensation, motor intact. No obvious deformities, but PE limited by body habitus. Skin exam unrevealing (no ecchymosis, no swelling)
Preliminary report: AP (internal and external rotation) and Y view X-rays negative for fracture or dislocation.
POCUS: C6-2 curvilinear probe placed on posterior shoulder at level of humeral head. LEFT and RIGHT shoulders.
Left humeral head (HH) displaced posteriorly in relation to spine of scapula (SS) = diagnosis of posterior shoulder dislocation
•Dislocated L shoulder reduced with moderate sedation using traction-counter traction
•Patient’s pain and mobility improved
•Discharged home with sling, pain medication, and orthopedics f/u
•Final report by attending radiologist = posterior shoulder dislocation (missed by resident)