VOTW: Big Flex

Ariella Cohen · April 15, 2024 ·

77 yoF presented to the ED with left middle finger pain, swelling, and discoloration of ~1 week proximally (image 1).

She was tachycardic and febrile on arrival. Physical exam revealed ¾ Kanavel signs (flexion at rest, pain with passive extension, fusiform swelling of the digit). Ultrasound was performed using a water bath (image 2).

POCUS findings concerning for flexor tenosynovitis include a hypoechoic peritendunous effusion and a thickened synovial sheath that may be hyperemic.

Video 1/Image 3: shows fluid surrounding the flexor tendon in short axis.

Image 3: Short axis of flexor tendon with surrounding fluid

Video 2/Image 4: shows a long axis view of the finger with fluid in the pre-tendon area and surrounding edema.

Image 4: Long axis of flexor tendon with abscess/edema

Case conclusion: orthopedics was called and performed a bedside I&D. They were able to express “copious amounts of purulent fluid” but did not appreciate pus along the tendon sheath itself. The patient was admitted for IV abx and is getting daily wound checks by orthopedics.

Note: While the Kanavel signs and ultrasound are useful diagnostic aids, they are non-specific and should not be used as a rule-out test. Remember that many inflammatory processes will often create edema that appears hypoechoic on ultrasound.

Happy scanning!

- Ariella Cohen

References:

https://www.emdocs.net/ultrasound-probe-pocus-for-flexor-tenosynovitis/

https://www.researchgate.net/figure/Ultrasound-appearance-of-normal-flexor-tendon-sheath-and-tenosynovitis-a-Normal_fig1_51104450

EMS Protocol of the Week - Bone and Joint Injuries (Adult and Pediatric)

David Eng · May 24, 2022 · EMS

A lot of the meat behind the protocol for bone and joint injuries was previously due to it being where to find the options for prehospital analgesia. Now that we have a dedicated pain management protocol, it’s since been thinned out a bit, but it’s still worth a skim for a review of assessment and stabilization of broken bones, as well as instructions for how to reduce a dislocated patella (if approved by OLMC – make sure they’re describing a patellar dislocation and not a knee dislocation!).

Have fun out there! www.nycremsco.org or the protocol binder for anything else you may…knee-d. Bye!

Dave

Joint Aspiration: Ankle

Sirivalli Chamarti · October 22, 2019 · Orthopedics, Procedures, Ultrasound

When to tap?

When you have a debilitating ankle injury with swelling at the tibiotalar joint preventing range of motion at that joint ie: dorsiflexion/plantarflexion.

What about the differential?

Ankle arthrocentesis allows for rapid identification of septic arthritis vs. gout vs. pseudogout vs. osteoarthritis vs. rheumatoid arthritis.

What are your landmarks?

The goal is to avoid the Dorsalis pedal artery, the peroneal nerve and the tendon of the Extensor Hallucis Longus (EHL). It is recommended to use an anterolateral approach where the joint line can be found between the lateral edge of the EDL and the medial edge of the lateral malleolus (Yellow Arrow Image 1). Plantarflex the ankle while the patient is bent at the knee in the supine position to widen the joint space prior to performing the procedure.

IMAGE 1:

How do you perform it?

1. Patient should be in a supine position with the ankle in plantar flexion with plantar surface flat on the bed.
2. Mark you landmarks (see above).
3. Prepare the site (ex. chloraprep)
4. Anesthetize the area with smaller needle(23/25 gauge) creating a wheal and then advance creating the start of a projected path towards the joint capsule.
5. Attach a 5 or 10 cc syringe to a 20 or 22 gauge needle and advance the needle into the joint space pulling negative pressure as you advance. The needle should be directed perpendicular to the tibia. If your syringe starts to fill up, and you need to get more fluid out, change out your syringe using hemostats to hold the needle. Most wrist and ankle effusions will yield only 1-3cc of fluid.

What about Ultrasound Guidance?

YES. This can absolutely be used to assist you in performing the procedure and will allow for visualization of your needle tip during aspiration.

For ultrasound guidance an anteromedial approach is generally used.

Landmarks- Place probe in between the TA tendon and EHL tendon, then rotate longitudinally with the probe marker facing the patient’s head (Blue Arrow IMAGE 1). You will actually be inserting your needle medial to the TA tendon (Red Arrow IMAGE 1).

Image 2: