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“I’m 0 for 2 tonight” your resident says after yet another exasperating interaction with one of your institution’s feisty surgery residents. “The first consult was called too early. The last one was called too late!” Overhearing your conversation, the charge nurse walks over and says, “Well Goldilocks, maybe this next consult with be just right…we just roomed a guy with a pretty gnarly arm laceration. Wanna go take a look?”

In the exam room you are confronted with an intoxicated and belligerent young man who is spitting at the tech trying to help hold pressure over his bleeding wound. The patient’s left forearm is bleeding profusely through the bandage the paramedics applied, and you notice shards of glass all over his clothing. Your resident approaches the patient with a balance of caution and confidence, learning that he locked himself out of his house and had to “break the window with his hand” to get in. The neighbors called the police when they heard the commotion, who in turn called EMS for his injured arm. The patient punctuates his answers with obscenities, shouting, “I can’t move my f---ing hand!” Your resident’s attempts to examine his bleeding extremity are met with more obscenities and the patient flailing his bleeding extremity.

You suspect that this guy might have an injury that will require operative intervention, but you also realize that your resident is going to need definitive, objective data to help appease the surgery resident taking consults. You pull your resident out of the room to discuss your management options. The patient is clearly not going to cooperate with the subtleties of a detailed neurovascular and tendon exam, and you doubt he’s going to tolerate a thorough wound exploration with local anesthetic alone. You don’t want to sedate the patient just to examine his wound, especially since he is already drunk, but you also don’t want to risk one of your staff getting hurt. You saw how he lashed out at the nurse who started his IV, and noted how he almost punched the X-ray tech, so you know your options are limited. Your patient is still refusing to flex his wrist or move his fingers, and you have to figure out if it’s because he can’t, or just won’t, before you chat with the surgical team.

As if she has read your mind, your resident calmly walks over to the sink and fills a basin full of water. She places the water basin in front of the patient and wheels over one of the department’s ultrasound machines. In a calming, yet firm tone, she tells the patient she needs to immerse his arm in the water basin to examine and clean out his wound. She promises “no needles” and bargains with a bit more IV morphine. In the water basin, you can see the patient has a large set of lacerations across his volar aspect of his distal forearm. Your resident floats the linear array transducer over the region of injury and carefully examines the flexor tendons near the forearm lacerations. She obtains the images below.

What do you see?

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Conclusion on next page

 

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