Evaluation of hand infections in the emergency department using point-of-care ultrasound

doi:10.5847/wjem.j.1920-8642.2024.049

Abstract

Abstract:

BACKGROUND: We aimed to evaluate the utility of point-of-care ultrasound (POCUS) in the assessment of hand infections that present to the emergency department (ED) and its impact on medical decision making and patient management.

METHODS: We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections (SSTI) of the hand between December 2015 and December 2021. Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand. We then reviewed patients’ electronic health records (EHR) for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, consultations, impact of POCUS on patient care and final disposition.

RESULTS: We included a total of 50 cases (28 male, 22 female) in the final analysis. The most common presenting symptoms and exam findings were pain (100%), swelling (90%), and erythema (74%). The most common sonographic findings were edema (76%), soft tissue swelling (78%), and fluid surrounding the tendon (57%). POCUS was used in medical decision making 68% of the time (n=34), with the use of POCUS leading to changes in management 38% of the time (n=19). POCUS use led to early antibiotic use (11/19), early consultation (10/19), and led to the performance of a required procedure (8/19). The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times, abscess 12/16 times, and cellulitis 14/20 times.

CONCLUSION: POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.

Key words: Ultrasound, Point-of-care ultrasound, Cellulitis, Abscess, Flexor tenosynovitis

David Ahmad Haidar, David Mintz, Brandon M Wubben, Omar Rizvi, Srikar Adhikari. Evaluation of hand infections in the emergency department using point-of-care ultrasound[J]. World Journal of Emergency Medicine, 2024, 15(4): 283-288.

Figures/Tables 8

Table 1.

Figure 1.

Figure 2.

Table 2.

Table 3.

Figure 3.

Figure 4.

Table 4.

References 18

[1]	Teo WZW, Chung KC. Hand infections. Clin Plast Surg. 2019; 46(3): 371-81. doi: S0094-1298(19)30027-6 pmid: 31103082
[2]	Gottlieb J, Mailhot T, Chilstrom M. Point-of-care ultrasound diagnosis of deep space hand infection. J Emerg Med. 2016; 50(3): 458-61. doi: 10.1016/j.jemermed.2015.09.012 pmid: 26482828
[3]	Rerucha CM, Ewing JT, Oppenlander KE, Cowan WC. Acute hand infections. Am Fam Physician. 2019; 99(4): 228-36. pmid: 30763047
[4]	Koshy JC, Bell B. Hand infections. J Hand Surg Am. 2019; 44(1): 46-54. doi: S0363-5023(17)31725-2 pmid: 30017648
[5]	Turecki MB, Taljanovic MS, Stubbs AY, Graham AR, Holden DA, Hunter TB, et al. Imaging of musculoskeletal soft tissue infections. Skeletal Radiol. 2010; 39(10): 957-71. doi: 10.1007/s00256-009-0780-0 pmid: 19714328
[6]	Acuña J, Pierre CM, Sorenson J, Adhikari S. Point-of-care ultrasound to evaluate breast pathology in the emergency department. West J Emerg Med. 2021; 22(2): 284-90. doi: 10.5811/westjem.2020.10.48008 pmid: 33856313
[7]	Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006; 13(4): 384-8. doi: 10.1197/j.aem.2005.11.074 pmid: 16531602
[8]	Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med. 2005; 12(7): 601-6. doi: 10.1197/j.aem.2005.01.016 pmid: 15995090
[9]	Situ-La Casse E, Grieger RW, Crabbe S, Waterbrook AL, Friedman L, Adhikari S. Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology. World J Emerg Med. 2018; 9(4): 262-6. doi: 10.5847/wjem.j.1920-8642.2018.04.004 pmid: 30181793
[10]	Hansen W, Mitchell CE, Bhattarai B, Ayutyanont N, Stowell JR. Perception of point-of-care ultrasound performed by emergency medicine physicians. J Clin Ultrasound. 2017; 45(7): 408-15. doi: 10.1002/jcu.22443 pmid: 28164320
[11]	Hosokawa T, Tanami Y, Sato Y, Deguchi K, Takei H, Oguma E. Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review. World J Pediatr. 2023; 19(1):20-34.
[12]	Gaspari R, Dayno M, Briones J, Blehar D. Comparison of computerized tomography and ultrasound for diagnosing soft tissue abscesses. Crit Ultrasound J. 2012; 4(1): 5.
[13]	Amini R, Camacho L, Acuña J, Situ-La Casse EH, Adhikari S. Point of care ultrasound in pyogenic tenosynovitis: a case report. Bull Emerg Trauma. 2020; 8(1): 41-6.
[14]	Lahham S, Shniter I, Desai M, Andary R, Saadat S, Fox JC, et al. Point of care ultrasound in the diagnosis of necrotizing fasciitis. Am J Emerg Med. 2022;51: 397-400.
[15]	American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med. 2009; 53(4): 550-70. doi: 10.1016/j.annemergmed.2008.12.013 pmid: 19303521
[16]	Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J. Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann Emerg Med. 1995; 25(2): 215-23. doi: 10.1016/s0196-0644(95)70327-6 pmid: 7832350
[17]	Kennedy CD, Lauder AS, Pribaz JR, Kennedy SA. Differentiation between pyogenic flexor tenosynovitis and other finger infections. Hand. 2017; 12(6): 585-90.
[18]	Bollard SM, Kelly B, McDermott C, Potter S. The use of point of care ultrasound in hand surgery. J Hand Surg Am. 2021; 46(7): 602-7.

Patient population characteristics	Frequency (%)
Patient characteristics
Alcohol abuse	6 (12)
Allergies	18 (36)
Diabetes	7 (14)
Fractures	3 (6)
Homelessness	14 (28)
IV drug use	18 (36)
Prior ED visit for SSTIs	27 (54)
Smoking	36 (72)
Presenting symptom
Chills	9 (18)
Fever	10 (20)
Nausea	7 (14)
Pain	50 (100)
Redness	31 (62)
Retained foreign body	3 (6)
Swelling	45 (90)
Trauma	10 (20)
Wound discharge	11 (22)
Physical examination finding
Discharge	7 (14)
Erythema	37 (74)
Fluctuance	8 (16)
Induration	7 (14)
Laceration	3 (6)
Limited range of motion	19 (38)
Open wound	14 (28)
Pain with extension	13 (26)
Swelling	41 (82)
Tenderness	31 (62)

POCUS findings	Fellow 1	Fellow 2	Mean (%)
Echogenic material	1	1	1 (2)
Edema	34	42	38 (76)
Fluid surrounding tendon	27	30	28.5 (57)
Hyperemia	0	6	3 (6)
Soft tissue swelling	34	44	39 (78)
Thickened tendon	6	18	12 (24)
Visible tendon sheath	6	24	15 (30)

Outcomes	n (%)
POCUS use in medical decision making	34 (68)
Changes in management	19 (38)
Additional radiology imaging	1 (2)
Avoided unnecessary ED procedure	4 (8)
Changed disposition	4 (8)
Early antibiotics	11 (22)
Early consultation	10 (20)

Diagnosis	ED diagnosis	Discharge diagnosis	Percent correct
Abscess	12	16	75%
Cellulitis	14	20	70%
Osteomyelitis	0	2	0%
Tenosynovitis	8	12	67%