EM REMS

This is a patient with pain in the thumb after punching another person:

Fractures of the base of the 1st (thumb) metacarpal are highly morbid injuries.  Most of these should be operative but many end up with severe arthritis of the MCP joint despite optimal therapy.  The thumb is a very important functional joint especially on the dominant hand, as in this patient.

Radiographically there are several eponym fractures for the base of the 1st metacarpal:  Rolando and Bennett are the most widely discussed eponym fractures.

Which one is this (if either)?

Answer to follow.

Author:  Russell Jones, MD

I can think of only a couple worse places for an Epipen® to accidently be stuck:

This is a pediatric patient that one of my colleagues saw.  Fortunately as you can see from the xray the tip of the needle went right through the bone and exited out the other side and the digit was not ischemic.

Accidental injection of epinephrine into a digit actually occurs somewhat frequently.  There are case reports and articles written on management if the digit is ischemic.  I’ll refer you to one that was published in the UK in 2004:

Velissariou I, Cottrell S, Berry K, Wilson B: Management of adrenaline (epinephrine) induced digital ischaemia in children after accidental injection from an EpiPen. Emerg Med J 2004, 21:387-388.

The article was a summary of three case reports out of the United Kingdom.  They used warm water immersion, topical nitroglycerin, and in one case local injection of 1.5 mg of phentolamine in 1ml of Lidocaine 2% was used with good effect.  Phentolamine is a short acting α blocker and can counteract the α mediated vasoconstriction epinephrine provides.  If you are practicing in the U.S., keep in mind that local Poison Control Centers can be good references if you have questions on management.

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD