Bedside Ultrasound in the Diagnosis of Complex Hand Infections

A Case Series

Brett A. Marvel, MD; Gavin R. Budhram, MD

Disclosures

J Emerg Med. 2015;48(1):63-68. 

In This Article

Abstract and Introduction

Abstract

Background The red, swollen, infected hand can be a diagnostically challenging presentation in the emergency department (ED). Hand infections are a relatively uncommon ED complaint, and diagnoses may range from simple cellulitis to deep space abscess, and even to suppurative flexor tenosynovitis. The accurate differentiation of these clinical entities is of paramount importance to healing and recovery of function.

Case Series In this case series, we review 4 patients with similar presenting complaints of a red, swollen hand, but with much different diagnoses and eventual treatment strategies. We describe how ultrasound was used to assist in making the diagnosis and initiating the most appropriate therapy. Finally, we review techniques for sonographic evaluation of the hand and provide imaging tips to improve visualization and accurate diagnosis. Why should an emergency physician be aware of this? Bedside ultrasound may allow for a more rapid and accurate diagnosis of various hand infections when diagnosis by physical examination is unclear.

Introduction

Recent data show that 2.6% of all emergency department (ED) visits are due to cellulitis or abscess, and hand infections are a relatively uncommon subset of this group.[1] The spectrum of potential diagnoses ranges from a relatively benign superficial cellulitis to the surgically emergent deep space infections and tendon sheath infections. Because coordinated and precise hand movements are required in the daily activities of life and work, missed diagnoses can carry a high cost. Approximately two-thirds of the total first-year cost incurred by patients with hand injuries is due to lost wages.[2]

The following is a review of four cases in which patients presented with painful, red, swollen hands. We describe how ultrasound was used to make the appropriate diagnosis and guide subsequent disposition. Finally, we review the literature describing physical examination findings, imaging modalities in hand infections, and investigate bedside ultrasound as a new diagnostic tool that might be beneficial to the emergency physician (EP).

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