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…

Presentation The patient will come in limping, having suffered a whiplike sting in the calf while stepping off the foot hard or attempting a lunging shot during a game of tennis or similar activity. The patient may have actually heard or felt a “snap,” described as being like the “pop” of a champagne cork, at the time of injury or may think someone actually kicked or…

Presentation Patients seek help because of gradually increasing inferior heel pain that has progressed to the point of inhibiting their normal daily activities. This fasciitis can develop in anyone who is ambulatory but appears to be more common in athletes (especially runners), those older than 30 years of age, those who stand for prolonged periods of time, and the overweight. There is no defining episode of…

Presentation After a direct blow to the medial aspect of the patella or, more commonly, without contact and only after a sudden twisting motion to the opposite side of an outward-pointing planted foot (with a powerful contraction of the quadriceps while the thigh is turning inward), the patient’s kneecap dislocates laterally. The patient, who is usually an adolescent, is brought in with the knee guarded and…

Presentation In myofascial pain syndrome, the patient, who is generally 25 to 50 years of age, will be troubled by the gradual onset of localized or regional unilateral fibromuscular pain that at times can be immobilizing. There may be a history of either acute strain or predisposing activities such as holding a telephone receiver between the ear and shoulder to free the arms, prolonged bending, poor…

Presentation Strains are acute injuries to muscle-tendon units that result from overstretching or overexerting. Strains may occur in the trapezius or paravertebral muscles during a motor vehicle collision, with a whiplash-type injury to the neck. A strain can also occur in the anterior thigh, posterior hamstring group, groin, or gastrocnemius muscle while a person is accelerating, running, or playing in a sport such as tennis. There…

Presentation The patient complains of painful, visible, palpable muscle contractions, often affecting the gastrocnemius muscle or small muscles of the foot or hand. Ordinary cramps occur chiefly at rest during the night or after trivial movement but also can occur after forceful muscle contraction. Other muscle cramps are associated with exercise in the heat, occupations that cause overuse, pregnancy, hemodialysis, electrolyte disturbances, dehydration, and drug or…

Presentation The patient complains of one joint that has become acutely red, swollen, hot, painful, and stiff, with pain on minimal range of motion (ROM). Rapid onset with fever and local warmth suggests the possibility of septic arthritis. A prominent monarticular synovitis with comparatively little pain, but where the joint is warm with a large effusion, especially of the knee, is typical of Lyme disease. A…