WhiteCoat

“Emergency” House

I couldn’t make this post part of the “CSI Whitecoat” series because there was no crime committed. But figuring out what was wrong with this patient took a little bit of observation and some detective work. So everyone can play “House, MD” from the emergency department.

A 76 year old nursing home patient was brought into the emergency department for evaluation of swelling from the forearm to the fingers for the prior 3-4 days. The nurse sent the patient for an x-ray of her wrist from triage. AP and lateral views are shown below.

The patient’s physical examination was unremarkable except for the swelling about her distal forearm and hand as shown. She had normal sensation, normal motion, and normal circulatory examinations.

Why is the patient’s arm swollen? Answer in the comment section.

Arm Swelling X-ray

Arm Swelling Comparison

16 Responses to ““Emergency” House”

  1. WhiteCoat says:

    The case reminded me of a quote one of my mentors once taught me – bilateral findings suggest systemic problems, unilateral findings suggest local problems. I actually saw the x-rays before I saw the patient and suspected the findings from the x-ray alone.
    Not the atherosclerosis. The nursing home’s tracking bracelet was too tight and it was impeding venous return, causing the distal edema. See the indentation on the skin from the bracelet right next to the word “No” on the bottom of the lateral view? That clued me in.
    By the time I went to see the patient, the daughter had cut off the bracelet so I could “examine her better.” If you look closely at the picture, you can see indentations from the band on the patient’s forearm just above the swelling – at the tip of the middle finger on the patient’s right hand.
    After discussing my suspicions with the family, the patient’s daughter remarked – “Come to think of it, that same thing happened to momma’s leg 2 weeks ago, that’s why they put the bracelet on her arm.”
    And I didn’t even draw blood.

  2. shadowfax says:

    If you squeeze her wrist can you hear it crackle?

  3. Clinton says:

    I thought it was a watch, but same idea.

  4. I agree with your interpretation of the x-ray but on the web the forearm looks a bit angulated, about 20 degrees, apex on the ulnar side just proximal to the area of ecchymosis and indentation from the tight band. If that isn’t an artifact or a fleshy forearm, then a forearm x-ray will reveal the fracture just proximal to the current film edge. If the band started out fitting well it would become tight after the swelling due to the forearm fracture, so the images don’t exclude that possibility.

  5. Pod A says:

    I was going to say watch as well. This is a good case to present to med/nurse/medic students. It’s a nice way to teach them the how and why constricting bands should be used instead of torniquets for starting IVs. I’m not sure I’m making my point well. Oh well.

  6. DefendUSA says:

    My Gram had a paralyzed left side from age 44. The older she got, the worse that kind of thing would get. Eventually, on the lame side, she could not wear jewelry as it would always swell. She was very prone to breaks from just moving that arm.
    The way they treated stroke patients in her day was not as proactive as today. I am convinced if it were the same she would have had full use of both limbs.

  7. Nurse K says:

    Ha, I saw that photo and read “nursing home” and thought, “Someone went crayzee with the coban on her poor arm.” Close!

  8. RSDS says:

    Please, make sure that the swelling from the constriction of the tracking band does not lead into Complex Regional Pain Syndrome (CRPS) formerly known as Reflex Sympathetic Dystrophy Syndrome (RSDS).

    Mine came from an overly tight Spica Thumb Splint; the compression bandage of which had to be dug out of my arm, and the splint pried off.

    RSDS

  9. ERP says:

    Yeah, I was going to say someone left the bp cuff on too long.

  10. ArkieRN says:

    The watch that is shown in the x ray was causing venous stasis and resulting edema.

  11. hashmd says:

    Is that a PortaCath that migrated? It is something under the skin.

    • WhiteCoat says:

      You talking about the calcified blood vessels on the volar surface of the forearm? The alarm is just caught on an angle in the x-ray film.

  12. ArkieRN says:

    Sooooooo, who was right (if anybody)?

  13. SerenityNow says:

    Judgning by all the athelerosclerosis on her XR I’m going with some sort of clot or venous insufficiency

  14. tv doc says:

    I say you should break into the patients house and look for more clues…it usually works on House MD. ;)

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