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Crazy 5th finger fracture…

June 16, 2016

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This patient presented with pain after jamming their finger:

 

Interesting fracture pattern!

On the AP view the fracture is subtle; the distal end of the proximal 5th phalanx looks irregular and lacks a solid radial side.  On the lateral it is more obvious.  The fracture line appears to have travelled obliquely and it almost looks like there are two distal phalanx!  The distal portion of the finger is dislocated at the PIP joint.

Author:  Russell Jones, MD

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Interesting osteomyelitis…

May 6, 2014

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This patient presented with multiple skin lesions with an ulcerative mass to his thumb…

OM hand

This patient had an ulcerative, indurated lesion to the distal thumb which can be seen on the above radiograph.  The radiograph also demonstrates periostitis and osseous erosion of the distal thumb and metacarpal joint of the thumb.  There are subtle periosteal changes to the third phalanx as well.

It turns out this patient has sporothrix schenkii osteomyelitis.

Author:  Russell Jones, MD

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What to do with a thumb dislocation?

June 7, 2013

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This patient presented with thumb pain after an MVC:thumb mcp 2thumb mcp3

The xray shows a dorsal dislocation at the thumb MCP joint, some fragments concerning for avulsion fractures as well.  The mechanism was likely hyperextension from the steering wheel.  It is important to note that this type of injury is almost always associated with complete disruption of the volar plate and is often associated with collateral ligamentous injury.  This results in an unstable MCP joint even after reduction.  The thumb MCP is a very important joint and instability can lead to decreased pincher grasp function causing significant morbidity long-term.   Operative indications according to Wheeless’ Textbook of Orthopedics include:

1.  Inability to reduce

2.  Radial or ulnar instability >40 degrees after reduction (stress xray views can help quantitate)

3.  Fracture through the sesamoids

Thumb MCP dislocation

We had good success reducing this after a median nerve block.  Clinically the joint was very unstable with stress angles nearing 60 degrees.  The patient was placed in a thumb spica splint and referred to hand surgery.

Author:  Russell Jones, MD

References:

1.  Dislocations of the Thumb MP Joint. Wheeless’ Textbook of Orthopedics online.  http://www.wheelessonline.com/ortho/dislocations_of_the_thumb_mp_joint  Accessed: 5/2013

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Rolando, Bennett…which one?

January 5, 2013

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

MC Thumb fx 2MC Thumb fx 1

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

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EPIPEN® in the finger…

January 3, 2013

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

EPIPEN finger 1

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

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