Presentation The patient has either cut into the nail with a sharp edge or crushed a finger (commonly in a door). With shearing forces, the nail may be avulsed from the nail bed to varying degrees, and there may be an underlying bony injury. The nail bed is prone to lacerations in these types of injuries. You’re Reading a Preview Become a Clinical Tree membership for…

Presentation After coming into contact with marine life, the patient may seek medical attention because of local pain, swelling, or skin discoloration. While more common in coastal areas, envenomation can also occur from handling animals kept in saltwater aquaria. Marine animal envenomations can be divided into two major categories: macropenetration and micropenetration. Macropenetration occurs after contact with spiny fish or mollusks and is due to stingers…

Presentation Histories of animal bites are usually volunteered, but the history of a human bite, such as one obtained over the knuckle during a fight, is more likely to be denied or explained only after direct questioning. Dog bites make up about 60% to 80% of all bite injuries, followed by cats (20–30%). Urban medical centers may see human bites more frequently (up to 20%). In…

Presentation A patient presents with swelling of the lower extremity. It may be mildly painful, but there has been no trauma. The patient denies any fever, chest pain, difficulty breathing, or other systemic symptoms. Peripheral edema can be categorized in two different ways: unilateral versus bilateral and pitting versus non-pitting. The list of differential diagnoses varies; a comprehensive history, physical exam, and target laboratory testing are…

Presentation Lacerations arise from either a cut with a sharp object or direct blunt trauma that exceeds the tensile strength of the skin. Consequently, lacerations may be linear ( Fig. 140.1 ) or stellate/complex with various amounts of tissue loss. The elderly and patients on chronic steroid therapy may present with “wet tissue paper” skin tears following relatively minor trauma. What to Do A history should…

Presentation A sharp metal object, such as a needle, heavy wire, or nail, is driven into the soft tissue. The patient may arrive with an additional large object attached (e.g., a child who has stepped on a nail going through a board) ( Fig. 139.1 ). Any of these skin-piercing foreign objects, such as impaled Taser darts, can be quite dramatic and can be the cause…

Presentation The patient complains of a paint chip or wooden sliver under the nail. Due to high sensory nerve density, these injuries are often quite painful. Most subungual foreign bodies are completely visible and are lodged under the distal portion of the nail. Occasionally, a wooden sliver will be large and deeply embedded over the proximal germinal matrix. Often the patient has unsuccessfully attempted to remove…

Presentation The patient has been snagged with a fishhook and arrives with it embedded in the skin ( Fig. 137.1 ). This most commonly occurs on the hand, face, scalp, or upper extremity but can involve any body part. Removal of the fishhook is often the sole procedure necessary, except when the injury involves the eye. Fishhooks have between one and four barbed prongs ( Fig.…

Presentation A patient arrives holding a bandage over a missing fingertip. The patient may or may not have brought along the avulsed tissue. Traumatic finger pad injuries are common. The mechanisms of injury can be diverse: A knife, a meat slicer, a mandolin, a closing door, broken glass, spinning fan blades, and turning gears are a few examples. Depending on the angle of the amputation, varying…

Presentation Blunt trauma to the distal phalanx may result in nail avulsion, nail bed laceration, and distal phalanx fractures. The nail may be completely avulsed, partially held in place by the nail folds, or adhering only to the proximal nail bed ( Fig. 135.1 ). On occasion, an exposed nail bed will have a pearly appearance, with minimal bleeding, making it seem as if the nail…

Presentation The patient has experienced blunt trauma such as a fall or other impact injury. The initial pain has subsided, but point tenderness, swelling, ecchymosis, and pain with use remain after 3 days. On physical examination, there is insignificant loss of function and no bony tenderness, instability, or crepitus. A contusion is soft tissue damage with diffuse capillary rupture due to focal blunt trauma. Extravasated blood…

Presentation A small child, riding on the back of a friend’s bicycle, gets their foot caught between the spinning spokes and the frame. The skin over the lateral and medial aspects of the foot or ankle is crushed and abraded with underlying soft tissue swelling ( Fig. 133.1 ). You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become…

Presentation The patient fell while holding on to a ski pole, banister, or other fixed object, forcing the thumb radially into abduction and causing pain at the base of the thumb. The metacarpophalangeal (MCP) joint of the thumb is swollen and tender and may be ecchymotic. When tested for stability, it may show varying degrees of joint widening toward the radial (or palmar) aspect more than…

Presentation The patient, usually a young or middle-aged adult, complains of neck pain and is unable to turn the head, usually holding it twisted to one side, with involuntary spasm of the neck muscles and the chin pointing to the other side. Attempts at movement generally cause the pain to worsen. These symptoms may have developed gradually, after minor turning of the head, after vigorous exercise,…

Presentation A patient has stubbed, hyperflexed, hyperextended, hyperabducted, or dropped a weight on a toe. The patient presents with pain, swelling, ecchymosis, and decreased range of motion (ROM) or point tenderness. There may or may not be deformity or angulation. Often, after stubbing the toe, there is little discomfort and no deformity, but the toe appears purple, and the patient just wants to be sure that…

Presentation There is pain along an involved tendon, often poorly localized, that worsens with motion, resisted contraction, or passive stretching. A vibratory crepitus may be felt on palpation over the tendon during tendon movement. Common sites include the posterior heel, the inferior aspect of the patella, the greater tuberosity of the shoulder, the thumb side of the wrist (de Quervain disease, see Chapter 105 ), and…

Presentation The patient arrives holding one arm with the opposite hand, complaining of severe pain that increases with any movement of the injured shoulder joint. The patient states that the “shoulder is out,” and is unable to move it because of the pain. Patients with anterior dislocations typically present with their arm held fixed, slightly internally rotated, and abducted. Often, the patient had had the arm…

Presentation The patient (usually 14–40 years of age) fell on an outstretched hand (FOOSH) with the wrist held rigid and extended and now complains of decreased range of motion (ROM) and a deep full pain in the wrist, particularly on the dorsal radial side. Physical examination discloses no deformity or ecchymosis but shows pain with motion and palpation and often swelling. Swelling may be seen, especially…

Presentation The patient has injured the upper arm, usually by sleeping with the arm over the back of a chair. The patient now presents, usually the next day, holding the affected hand and wrist with the good hand and reports decreased or absent sensation on the radial and dorsal side of the hand and wrist and the inability to extend the wrist (wrist drop), thumb, and…

Presentation A patient has fallen on an outstretched hand and has a normal, nonpainful shoulder, wrist, and hand; on careful examination, however, the patient has pain in the elbow joint. Swelling may be noted over the antecubital fossa, and the patient may be able to fully flex the elbow joint, but there is pain and decreased range of motion (ROM) on extension, supination, and pronation of…