Posts filed under Orthopedics

Must Not Miss Fractures in the ED

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Written by:  MTerese Whipple , MD (NUEM PGY-3) Edited by: Ashley Amick, MD (NUEM alum '18) Expert commentary by: Matthew Pirrotte, MD

Undiagnosed fractures occur frequently in the Emergency Department setting, with a total miss rate of 1-3%.  These missed fractures not only lead to poor patient outcomes, but also account for the second highest cost of litigation against EM docs, behind only MI.1,2  This may not seem relevant if you are lucky enough to have access to a Radiologist 24-7,  however there are several injuries that will be missed if they are not included in the differential diagnosis, because even the best radiologist can’t read a film if it wasn’t ordered. This blog post will cover three ‘must not miss’ injuries to keep in mind when assessing your run-of-the-mill orthopedic injuries namely:  the Maissoneuve fracture, Lisfranc injury, and Galeazzi/Montaggia fracture-dislocations.  Finding these tricky injuries require additional radiographic views beyond those standardly ordered, but keeping them in your differential will mean better outcomes for you and your patients.

Massonieuve Fracture:

What is it and how will it present?

 A Massonieuve Fracture (which can be as difficult to pronounce as it is to miss) is a spiral fracture of the proximal 1/3 of the fibula with a disruption of the distal tibiofibular syndesmosis, which occurs in 5% of ankle injuries3. The injury occurs with pronation and external rotational forces are applied to a fixed foot, with damage propagating from the stressed tibial bone or deltoid ligament up through the interosseus membrane, causing a fracture to the proximal fibula.4 A twisted ankle in high heels is a classic mechanism for his injury.  In some cases the only apparent deformity is soft tissue swelling, pain, or ecchymosis at the ankle.  Patients may complain only of ankle pain, and because they are unable to bear weight they don’t load the damaged fibula, and therefore do not complain of lateral leg pain.  


The patient will likely have pain with palpation over the ankle fracture/injured ligaments. Evaluate the ankle syndesmosis with compression and dorsiflexion eversion testing (will simulating a “high ankle” syndesmotic injury). In addition, make sure to palpate the proximal fibula both directly along the proximal shaft and head, and with gentle squeezing of the proximal leg just below the knee joint (a squeeze test).  Pain with these maneuvers should prompt additional radiographs.  Finally, test peroneal nerve function with ankle dorsiflexion and dorsal foot sensation. It is subject to injury in fibular fracture.


Radiologic Findings:

View you may not think of: Tib-fib or knee XR

Ankle AP:

Look for fractures of the medial malleolus or posterior margin of the tibia. Also look for avulsion fractures indicating interosseus ligament disruption, such as in this case, with both a fracture of the lateral malleolus and a chip fracture indicated by the white arrow [3,5]. There is obvious widening of the syndesmosis.




Look for joint space widening (white arrow) or widening of the syndesmosis (black arrow) [6]. If patient can’t stand, you may have to perform manual stress of the joint while the radiographs are taken (as indicated in this AP).



Knee or Tib/fib:


Proximal fibular fracture {3}







Management and why it matters:

This fracture is considered by many to be among the most unstable ankle injuries [4].  If there is an intact mortise with no joint space widening, the patient can be casted and follow up with orthopedics. If there is joint-space widening at the ankle mortise, surgical intervention is likely required. If undiagnosed, a patient with a Massonieuve fracture may incur a host of bad outcomes including delayed orthopedic intervention, chronic pain, arthritis, and impaired mobility.


Lisfranc Fracture-Dislocation

What is it and how will it present?

Lisfranc injury broadly refers to disruption of the metatarsals from the tarsus, with emphasis on the second tarsometa-tarsal joint and Lisfranc ligament [7].  The Lisfranc ligament runs obliquely from the medial cuneiform to the base of the second metatarsal (see below image for a refresher on normal foot anatomy). Injuries run the spectrum from sprain to an unstable fracture/dislocation. A dislocation of the tarsometatarsal (Lisfranc) joint is often associated with fractures, most commonly at the base of the second metatarsal or cuboid bone. It is estimated that 20-40% of Lisfranc injuries are missed on initial presentation. It can be caused by diverse mechanisms of injury including direct, high-energy trauma, such as MVCs (45% of injuries), or indirect mechanisms including [8]:

  1. Forced flexion of the forefoot with a fixed hind foot (a horseback rider falling with a foot caught in a stirrup)
  2. Forced supination/pronation on a plantar flexed foot (a soccer player having their forefoot stepped on and subsequently falling)
  3. Axial load on a flexed foot (a drunken cubs fan celebrating the World Series win by jumping from Harry Caray’s statue onto a plantar flexed foot)

Physical Exam:

Pain localizes to the midfoot.  The exam may be subtle, or there may be significant swelling and deformity present. The patient can be ambulatory or unable to bear weight.  Test the joint by stabilizing the hindfoot, any twisting of the forefoot may cause pain. Compression across the forefoot will stress the space between the first and second metatarsals, causing a pain or a palpable click if a Lisfranc injury is present.  The Piano-key test is preformed by stabilizing the hindfood, grasping the metatarsals, and preforming passive dorsiflexion and plantar flexion at the tarsometatarsal joint, looking for pain or subluxation.9  Rarely they can have associated dorsalis Pedis injury as it courses near the joint, so make sure to check pulses. The tibialis anterior nerve can also become interposed and cause the big toe to point upwards, called the “Toe Up Sign.”

Radiologic Findings:

If a Lisfranc injury is suspected, foot radiographs with additional views including WEIGHT BEARING AP, lateral, and oblique are essential.

First a normal foot:

  1. The lateral margin of the 1st metatarsal should be aligned with the lateral margin of the medial cuneiform.
  2. The medial aspect of the base of the 2nd metatarsal should align with the medial border of the middle cuneiform.
  3. The medial margins of the 4th metatarsal and cuboid should be aligned [10].




Findings suggesting injury:

AP: Diastasis of >2 mm between the base of the 1st and 2nd metatarsals indicates Lisfranc injury. 90% have associated avulsion fracture of the base of the second metatarsal or medial cuneiform, known as Fleck Sign (pictured at left). The pictured radiograph also demonstrates lateral displacement of all 5 metatarsals [11,12].

Lateral: Allows for identification of any dorsal or plantar dislocation [12]. 

Oblique: Allows for evaluation of the alignment of the 3rd and 4th metatarsals with the cuboid and cuneiform [12]. 




Management and why it matters:

If there is no evidence of widening of the Lisfranc joint space, the patient can be splinted and follow up with orthopedics, however they MUST BE non-weightbearing. Any evidence of fracture-dislocation >2 mm requires orthopedic consultation in the ED for likely operative fixation. Fractures found later have worse outcomes. Delayed ORIF after late recognition is better than no intervention, however most patients still require shoe modification or orthoses [12]. 

Galeazzi and Monteggia Fracture Dislocations

The radius and ulna are joined by an interosseus membrane. When one is injured the other is likely to be affected as well (just like the tibia/fibula).

Management and why it matters: 

If either fracture is suspected, consult hand surgery/orthopedics for reduction and definitive management. Both almost always require ORIF or other surgical treatment. Chronic pain and limitation of supination and pronation can occur if not properly treated [13]. 

Expert Commentary

Drs. Whipple and Amick do a nice job of highlighting several eponymous fractures which can be tricky to diagnose. In general I find that missed extra-axial orthopedic injuries in the emergency department are the result of several factors

  1.    Failure to “film what hurts.” If a patient feels that their injury was sufficiently serious to warrant a visit to the emergency department, the prudent practitioner maintains a low threshold for imaging. Clinical decision rules for judicious imaging are clearly valid but need to be applied judiciously. When in doubt, get the film.
  2.  Failure to review films directly. Radiologists, while skilled and vital partners, rarely have the detailed information gleaned from simply pressing on patient’s bones and figuring out where they hurt. Correlation with point tenderness is a critical part of radiographic assessment. Scrutiny of radiographic bony anatomy near the sites of tenderness can lead to discovery of subtle fractures.
  3.  Failure to consider mechanism. Given the frequency with which we in the ED see serious trauma, it is easy to fall into a trap of being unimpressed with mechanisms that are actually quite severe. Every experienced acute care practitioner has had the chance to be absolutely flabbergasted by the severe polytrauma that can result from “low impact’ mechanisms such as stair falls, falls from standing, and pedestrians struck by vehicles at low speed.

The ramifications of a missed fracture can be significant. A recent analysis of closed legal claims in emergency medicine found that three of the top ten diagnoses in medical malpractice lawsuits were related to fracture care(vertebral, radius/ulna, tibia/fibula) [14]. A similar analysis of pediatric cases demonstrated that in children over the age of 3, fractures remain the most common source of medical malpractice claims [15]. This is to say nothing of the obvious morbidity and potential disability that may result from a missed injury.

The interesting thing about the fractures that discussed by Drs. Whipple and Amick is that, at least in the case of the Maisonneuve and forearm fractures, what tends to be missed is the severity and operative nature of these injuries rather than the fractures themselves.A clinician seeing a patient with an eponymous forearm fracture will likely not misdiagnose them as an elbow sprain. Similarly, few people would interpret the ankle films of a patient with Maisonneuve fracture to be normal, the problem comes in missing the fibular injury. Lisfranc’s fracture is a different entity; it is not uncommon for these patients to be misdiagnosed several times as having a “foot sprain” before the proper diagnosis is made.


One thing you can take to the bank in emergency orthopedics is that if the fracture is named after someone the injury involved can usually find a way to trick even a savvy clinician. Bennett, Rolando, Jefferson, Smith, and Sagond are also names that will you will encounter in your career.  As yet no one has attached their name to the nondisplaced fracture of the distal phalanx of the small toe, but one never knows.




Matthew Pirrotte, MD

Assistant Professor of Emergency Medicine, NUEM



How to cite this post

[Peer-Reviewed, Web Publication]   Whipple M, Amick A (2018, August 6). Can't Miss Fractures in the ED.  [NUEM Blog. Expert Commentary by Pirotte M]. Retrieved from

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  1. Schwartz, D. Ten Most Commonly Missed Radiographic Findings in the ED. Boston Scientific Assembly. Thursday, October 8, 2009. Boston Convention & Exhibition Center.
  2.  Hallas P and T Ellingsen. Errors in fracture diagnoses in the emergency department – characteristics of patients and diurnal variation. BMC Emergency Medicine. 2006. 6(4).  doi:10.1186/1471-227X-6-4.
  3. Millen JC and D Lindberg. Maissoneuve Fracture. The Journal of Emergency Medicine. 2011. 41(1): 77–78.
  4. Charopoulos I, Kokoroghiannis C, Karagiannis S, Lyritis GP, Papaioannou N. Maisonneuve fracture without deltoid ligament disruption: a rare pattern of injury. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 49(1):86.e11-7
  5. Sports Medicine for the Emergency Physician: A Practical Handbook. Ed. A. Waterbrook. Cambridge University Press: NY, NY. 2016. 75-77, 130-131, 248-249, 273.
  6. Taweel NR et al. The proximal fibula should be examined in all patients with ankle injury: A case series of missed Maisonneuve fractures. The Journal of Emergency Medicine. 2013. 44(2): 251-255.
  7. Wynter S, Grigg C. Lisfranc injuries. Aust Fam Physician. 2017 Mar;46(3):116-119.
  8. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int 2006;27(8):653–60.
  9. Seybold JD, Coetzee JC. Lisfranc injuries: When to observe, fix, or fuse. Clin Sports Med 2015;34(4):705–23.
  10. Sherief TI, Mucci B, Greiss M. Lisfranc injury: How frequently does it get missed? And how can we improve? Injury, Int. J. Care Injured. 2007. 38: 856—860.
  11. Gupta, RT et al. Lisfranc injury: Imaging findings for this important, but often missed diagnosis. Curr Probl Diagn Radiol.  2008 May/June. 115-126.
  12. van Rijn J et al. Missing the Lisfranc Fracture:  A case report and review of the literature. The Journal of Foot & Ankle Surgery. 2012. 51: 270-274.
  13. Perron, A et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia Fracture-Dislocation. Am J Em Med. 2001 May. 19(3): 225-228.
  14. Brown, T. W., McCarthy, M. L., Kelen, G. D. and Levy, F. (2010), An Epidemiologic Study of Closed Emergency Department Malpractice Claims in a National Database of Physician Malpractice Insurers. Academic Emergency Medicine, 17: 553–560
  15.  Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005 Mar; 21 (3): 165-169

Posted on August 6, 2018 and filed under Orthopedics.

A Recipe for Reduction: Five alternative approaches for reducing an anterior shoulder dislocation

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Written by:  Abiye Ibiebele, MD (NUEM PGY-1) Edited by: Jacob Stelter, MD, (NUEM PGY-3) Expert commentary by: Andrew Ketterer, MD

“With great power comes great responsibility.”
“That’s one small step for man, one giant leap for mankind.”
“Every emergency medicine physician should know three ways to reduce a shoulder, not including traction-countertraction.”

            Now that last one may be not as well known as the other quotes, but it was a pearl passed along to me during my Sports Medicine rotation by my attending. The traction-countertraction method is often used due to physician familiarity and is considered the standard technique due to a high success rate [1,7] However, due to need for adequate sedation and the amount of force generated during the reduction, below we will examine five alternative methods of reduction for anterior shoulder dislocations.

Stimson Method

Figure 1: Stimson maneuver of shoulder reduction Image credit:

  • Have the patient lay prone on an elevated stretcher with the injured extremity hanging off the edge of the stretcher. [1]
  • Apply traction by suspending 5 to 10 lbs of weight from the wrist. [1]
  • Have the patient maintain this position for 20-30 mins. [1]
  • If needed, manual traction can be added with external rotation to aid in reduction. [1]


  •  Success rate for the Stimson technique alone is about 28%. [3,4]
  • Success rate improves when combined with scapular manipulation.
  • Reasons for failure include discomfort in prolonged prone position and discontinuing the reduction with prolonged times which can reach over 20 mins. [4]
  •  Moderately painful, ~5.3 out of 10 on pain scale. [3]

Scapular Manipulation Method

Figure 2: Scapular Manipulation Technique.  Adapted from Horn, A., & Ufberg, J. (2013), Management of Common Dislocations. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine (6th ed.). Philadelphia, PA: Elsevier/Saunders.

  • Place the patient in a prone position with the shoulder in 90 degrees of forward flexion and slight external rotation. [1,2]
  • Apply traction to the shoulder as mentioned in the Stimson technique above. [1,2]
  • As patient begins to relax, stabilize the superior aspect of the scapula with one hand, with the thumb on lateral border of scapula. [1,2]
  • With other hand, push the inferior tip of scapula medially towards spine, while rotating superior aspect laterally with the first hand. [1,2]

  •  Some dorsal displacement of the tip of the scapula (lifting it) may be necessary as medial displacement is maximized. [1,2]



 Variation: This technique can also be done in a seated position, with an assistant assisting applying traction on the affected arm and countertraction on ipsilateral clavicle. This is actually the preferred method by many, however this is a technically more difficult reduction [1].

  • Success rate for the Stimson technique has ranged from ~90-97%. [2,3]
  • Fast reduction, takes less than 5 minutes to perform. [2,3]
  • Noted to be one of the least painful methods of reduction: a recent systematic review describes pain ~1.5 out of 10 during reduction. [3]
  • There have not been any reported complications of this technique. [2,3]


External Rotation Method

Figure 3: External Rotation Technique.  Adapted from Horn, A., & Ufberg, J. (2013), Management of Common Dislocations. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine (6th ed.). Philadelphia, PA: Elsevier/Saunders.

  •  Have the patient lie supine on a stretcher and position yourself on the side of the affected arm. [1,5]
  • Fully adduct the affected arm and flex the elbow to 90 degrees. [1,5]
  • Place one hand on the wrist and another hand on the patient’s elbow. [1,5]
  • Using the grasped wrist as a guide, slowly begin to externally rotate the patient’s arm. [1,5]
  • Stop movement any time patient feels pain to allow the muscles to relax before resuming. [1,5]
  • Reduction typically occurs between 70 and 110 degrees of external rotation. [6]


  •   If dislocation persists after full external rotation, you can apply steady gentle traction at the elbow, or slowly bring the arm back into internal rotation which can lead to reduction [1,6}.
    •  You can also proceed to the Milch technique from full external rotation (see below). [8]
  •  Success rate ranges from 81-91%. [3,6]
  • Average time to reduction is around 3 mins but it can take up to 10 mins to perform. [3,6]
  • Well tolerated by patients, ~ 3 out of 10 on pain scale. [3]
  • No reported complications of this technique. [3,6]

Milch Technique

  •  Have the patient lie on a stretcher; the patient can be either supine or prone based on his or her comfort. [1,4,6]
  •  Have the patient abduct the affected arm to place their hand behind their head, if they are able, and then straighten the arm at the elbow. [1,6]
    • If the patient cannot do this unassisted, then grab patient’s arm at either the elbow or the wrist and guide arm into full abduction. [1,4,6]
  •   With the arm fully abducted, apply gentle longitudinal traction and gentle external rotation to achieve reduction. [1,4,6]
  •  If reduction does not occur quickly, apply gentle cephalad pressure to the humeral head while continuing to hold traction. [1,4,6]
  •  If external rotation has already been attempted (see external rotation technique above), you can proceed to the Milch technique by abducting the arm in a wide arc from full external rotation, while applying gentle traction throughout. [8]

Figure 4: Milch Technique.  Adapted from Horn, A., & Ufberg, J. (2013), Management of Common Dislocations. In Roberts and Hedges' Clinical Procedures in Emergency Medicine (6th ed.). Philadelphia, PA: Elsevier/Saunders.

  • Success rate ranges from 70-95%. [1,6]
  •  On average, takes about 4-5 mins to perform. [3,4]
  • Moderately painful, ~ 5.3 out of 10 on pain scale. [3,4]
  • No reported complications of this technique. [3,4]

FARES Method (“FAst, REliable, Safe)

  •  Have the patient lie supine on the stretcher and stand on the affected side. [9]
  •  Apply gentle longitudinal traction on the arm and begin to bring the arm into abduction. [9]
  •  While abducting arm, oscillate the arm in an up and down fashion
    • Oscillations should be brief (2-3 full cycles per second) and short (about 5 cm above/below midline). [9]
  •  After 90 degrees of abduction, continue oscillations and add gentle external rotation. [9]
  •  Reduction is usually achieved around 120 degrees of abduction. Afterwards gently internally rotate the arm to bring the forearm to lie across the patient’s chest. [9]
  •  A helpful demonstration video can be viewed here


  • Success rate ranges from 88-95%. [9, 10]
  •  Reduction time: ~2-3 mins. [3,9,10]
  •  Well tolerated, pain 1-2 out of 10 on VAS scale. [3,9]
  • No reported complication of this technique. [3.9]

So, the next time an anterior shoulder dislocation walks into the ER, go ahead and give one of these reduction techniques a try. No single reduction method is 100% successful, so it’s good to be facile in a variety of methods. Remember to obtain pre- and post-reduction films and assess neurovascular status before and after reduction [1]. Time to reduce some shoulders!

Expert Commentary

This is a very nice overview of some less brutal approaches to a common and sometimes difficult problem. The classic traction-countertraction techniques (e.g. the Hippocratic method, wherein the physician places a foot in the axilla of the patient’s affected arm and applies distal traction) tend to have higher complication rates, including axillary nerve injury, humeral neck and shaft fractures, and glenohumeral capsular damage. They also tend to be quite painful, usually necessitating procedural sedation, which of course carries its own risks.

In addition to the above, one method I have had great success with is the Cunningham technique: The patient is placed in a sitting position, with the affected arm completely adducted and the elbow flexed to 90 degrees. The physician supports the patient’s forearm with their own forearm, with the hand on the patient’s elbow, and applies very gentle downward traction – the weight supplied by the physician’s forearm is usually adequate. The physician sequentially massages the patient’s trapezius, deltoid, and biceps muscles until the humeral head reduces. This technique won’t usually cause a satisfying “clunk,” so you’ll need to check periodically to see whether the shoulder has been reduced. Resolution of the lateral shoulder step-off might be the only immediately visible sign of successful reduction.

[Video of Cunningham technique]

Often, I will combine this technique with the FARES method by oscillating the patient’s forearm up and down as I externally rotate their shoulder. This usually results in quick and nearly painless reduction and has an exceptionally low complication risk. In order for these techniques to work, the patient must be relaxed – as soon as you hit resistance or cause pain their muscles will tense up, so if this happens you need to pause and wait for them to feel better before continuing. A whiff of opioids can do wonders here, accomplishing both pain relief and anxiolysis.

The reasoning behind the various shoulder reduction techniques is that spasm of the biceps, trapezius, and deltoid muscles is keeping the humeral head out of the glenoid fossa. Fatiguing these muscles with traction or distracting the patient will allow you to mobilize the humeral head and get it back into the glenoid fossa. It’s worth noting that muscle spasm becomes increasingly hard to overcome the longer a patient is dislocated. This means that the FARES method and other distraction techniques are less likely to work if the patient has been dislocated for too long, and more painful fatigue techniques such as Stimson, Milch, or good old traction-countertraction may become necessary. Still, it’s good to have a number of tricks up your sleeve, and if one doesn’t work, you have plenty of others to choose from.


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Andrew Ketterer, MD

Medical Education Fellow, Beth Israel Deaconess Emergency Medicine



[Peer-Reviewed, Web Publication]   Ibiebele A,   Stelter J (2018, May 21 ). A Recipe for Reduction: Five alternative approaches for reducing an anterior shoulder dislocation.  [NUEM Blog. Expert Commentary by Ketterer, A]. Retrieved from


1.     Horn, A., & Ufberg, J. (2013), Management of Common Dislocations.In Roberts and Hedges' Clinical Procedures in Emergency Medicine (6th ed.). Philadelphia, PA: Elsevier/Saunders.

2.     Anderson, D., Zvirbulis, R., & Ciullo, J. (1982). Scapular manipulation for reduction of anterior shoulder dislocations. Clinical orthopaedics and related research, 164, 181-183.

3.     Alkaduhimi, H., van der Linde, J. A., Willigenburg, N. W., van Deurzen, D. F. P., & van den Bekerom, M. P. J. (2017). A systematic comparison of the closed shoulder reduction techniques. Archives of orthopaedic and trauma surgery, 137(5), 589-599.

4.     Amar, E., Maman, E., Khashan, M., Kauffman, E., Rath, E., & Chechik, O. (2012). Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. Journal of shoulder and elbow surgery, 21(11), 1443-1449.

5.     Eachempati, K. K., Dua, A., Malhotra, R., Bhan, S., & Bera, J. R. (2004). The external rotation method for reduction of acute anterior dislocations and fracture-dislocations of the shoulder. JBJS, 86(11), 2431-2434.

6.     Ufberg, J. W., Vilke, G. M., Chan, T. C., & Harrigan, R. A. (2004). Anterior shoulder dislocations: beyond traction-countertraction. The Journal of emergency medicine, 27(3), 301-306.

7.     Ghane, M. R., Hoseini, S. H., Javadzadeh, H. R., Mahmoudi, S., & Saburi, A. (2014). Comparison between traction-countertraction and modified scapular manipulation for reduction of shoulder dislocation. Chinese Journal of Traumatology, 17(2), 93-98.

8.     Hendey, G. W. (2016). Managing anterior shoulder dislocation. Annals of emergency medicine, 67(1), 76-80.

9.     Sayegh, F. E., Kenanidis, E. I., Papavasiliou, K. A., Potoupnis, M. E., Kirkos, J. M., & Kapetanos, G. A. (2009). Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. JBJS, 91(12), 2775-2782.

10.  Maity, A., Roy, D. S., & Mondal, B. C. (2012). A prospective randomised clinical trial comparing FARES method with the Eachempati external rotation method for reduction of acute anterior dislocation of shoulder. Injury, 43(7), 1066-1070.




A Visual Guide to Upper Extremity Joint Aspirations

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Written by:  Will Ford, MD (NUEM PGY-3), Amy Ford, MD (Loyola Orthopedic Surgery PGY-3)  Edited by: Keith Hemmert, MD, (NUEM PGY-4) Expert commentary by:  Lucas Rosiere, MD

What follows is an overview of joint aspiration techniques in the upper extremity.  We will be covering the shoulder, elbow, and wrist.



Identify your landmarks.  In this setting, the skin marker is your friend.  See the following pictures.

1. Find the coracoid.  Mark it with a circle.

2. Find the notch where the acromion and the clavicle meet.  Mark it with a point.

3. Find the anterolateral and posterolateral corners of the acromion.  Mark each with a point.  These two points should make an equilateral triangle with your point from #2.


From L to R: Anterolateral corner of acromion, meeting between the acromion, posterolateral corner of the acromion


4.     Roll your marker off the lateral edge of the acromion.  Mark this line.

5.     Draw out the borders of the clavicle and the scapular spine.


Two common sites of entry are the posterior and anterior approaches.  You will find that some patients have better landmarks posteriorly or anteriorly – this can vary depending on patient habitus and positioning. 

Posterior approach

The posterior approach traditionally begins approximately 2cm medial and inferior from the posterolateral corner of the acromion.  You should feel a soft spot here.  In a patient without a septic joint, you can move the humeral head anteriorly and posteriorly and feel the joint from this spot.  When aspirating from the posterior approach, go in through the soft spot and point your needle toward the coracoid circle you marked previously.

The anterior approach uses your coracoid landmark to protect yourself from injuring important neurovascular structures.  Never go medial to the coracoid.  Your insertion spot will be just lateral to the coracoid.  Aim directly posterior and slightly superior.

Anterior approach 

When dealing with shoulder injections with distorted anatomy (for example, in the shoulder dislocation), it can still be helpful to draw out the anatomy and imagine where it will be easiest to enter the joint.  For instance, in an anterior shoulder dislocation, you may be able to palpate the humeral head anteriorly and easily enter the joint space around the humeral head.

The Elbow

Identify your landmarks.  Again, the skin marker can be helpful to visualize your entry point.

  1.  With the elbow at 45-90° flexion, mark the lateral epicondyle of the humerus with a point.

2. Mark the radial head with a point.  You can identify this by pronating and supinating the forearm and feeling the rotation of the radial head.

3. Mark the tip of the olecranon with a point.  The three points should make something close to an equilateral triangle.


Your entry point will be in the center of the triangle.  Again, you should feel a soft spot here.  When directing your needle, orient it perpendicular to the skin and go straight in.

The Wrist

Identify your landmarks: 

  1. Find Lister’s tubercle (tubercle on the dorsal distal tip of the radius).  Your entry point will be approximately 1cm distal to this tubercle. 
  2. Find the extensor tendons of the thumb and index finger (extensor pollicis longus and extensor digitorum communis/extensor indicis proprius).  Your entry point will be between these tendons.

You should feel a soft spot at the wrist joint between these landmarks.  It may be helpful to flex the wrist slightly (15-30°) and to point your needle proximally (30-45°) to respect the slope of the distal radius.  Another helpful trick is to have an assistant grab the patient’s forearm with one hand and the patient’s index and middle fingers with the other hand, and distract across the joint to open up the space.  Alternatively, you could hang the arm up in finger-traps for the same effect.

"Arthrocentesis & Injections: Wrist (Radiocarpal)." RheumaKnowledgy Arthrocentesis Injections Wrist Radiocarpal Comments. N.p., 15 Oct. 2014. Web. 14 May 2017. 

General tips for joint aspiration:

  • To produce greater suction power needed to aspirate viscous fluid, use a larger bore needle and a smaller syringe. 
  • If there is any question about length of needle needed to reach the joint, use a spinal needle to avoid multiple attempts.  However, in smaller joints, a shorter needle is preferable because it will improve your proprioceptive senses.
  •  If you enter and hit bone, don’t panic, just try to visualize the anatomy and redirect your needle gently.
  •  If anesthetizing the skin/subcutaneous tissue prior to aspiration, be careful to stay subcutaneous, as injecting lidocaine into the joint space would jeopardize the accuracy of your cell count results.
  •    Lab tests to order on synovial fluid:
    •  Culture + gram stain (most important)
    •  Cell count
    • Crystals

General indications for joint aspiration:

  • The most absolute indication for aspiration is concern for septic arthritis, as evidenced by:
    • Extreme apprehension from the patient to move the joint, such that only passive motion is possible
    • Very limited motion due to pain
    • Painful throughout entire arc of motion (i.e. no painless arcs of motion)
    • Presence of effusion
  • Aspiration may be done to obtain crystals for a diagnosis of gout.
  • Therapeutic aspiration of a hemarthrosis should not be done routinely, and should only be used as a last resort if noninvasive measures (immobilization, compression, ice, analgesics) have failed.

General contraindications for joint aspiration:

  • Aspiration through cellulitis should generally be avoided due to the risk of seeding an uninfected joint.
  •  Aspiration of prosthetic joints should not be performed by the Emergency Medicine provider for the same reason as above, and the decision on whether or not to do so should be deferred to Orthopaedic Surgery.
  • Anticoagulation is not a contraindication for aspiration.

Expert Commentary

Thanks Dr. Ford and Dr. Hemmert for this procedure guide.  

A thorough understanding of these techniques is essential to the general emergency physician.  Outside of an academic center, you will be the one aspirating joints in the ED (with the exception of the hip).  Rare is the day you'll have your orthopedist in the department for help with this diagnostic part of the work-up.  So it is imperative we can safely and efficiently get this done.

This review focuses a lot on anatomy and skin markers.  Rightly so.  Much like a lumbar puncture, the more time you spend on accurate positioning and palpation, the fewer times you'll poke, the less pain you'll cause, and the more likely you are to produce an atraumatic aspiration.  

I urge you to feel these bony landmarks on yourself.  If you don't do this every day, this can be difficult.  Even on the most slender of people (and few patients fit that description), feeling a coracoid process or radial head may be difficult.  

Whether I can feel the landmarks perfectly or not, I love to spend 60 seconds and use ultrasound.  It can find bones deep in the soft tissues of the obese, it can find surprising locations of joint spaces and can also give you a better idea of the trajectory your needle ought to pass.  Great for patient satisfaction.  Very simple.  Just use the linear probe and place it across the expected joint line so you can see bone on left, bone on right, space in the middle.  Then mark the skin.  No need to use it during the aspiration itself, just while marking the skin.

Regarding the specific techniques listed here, the descriptions are fantastic.  I can only add that, for the wrist, you will also like to avoid puncturing the extensor carpi radialis brevis tendon.  If you have the patient actively extend the wrist a little (may be painful), you should feel the tendon between the tendons of the extensor digitorum and extensor pollicus longus.  I'd go just ulnar to that.

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Lucas Rosiere, MD

NUEM Graduate 2012, Physician Central DuPage Hospital

How to cite this post

[Peer-Reviewed, Web Publication]  Ford W,   Hemmert K  (2018, May 7 ). A visual guide to upper extremity joint aspirations.  [NUEM Blog. Expert Commentary by Rosiere, L ]. Retrieved from

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Demystifying the Hand Exam

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Written by: Terese Whipple, MD (NUEM PGY-2) Edited by: Victor Gappmaier, MD, (NUEM PGY-4) Expert commentary by:  Aviram Gialdi, MD, MS

The human hand is a fascinatingly intricate arrangement of pulleys, tendons, muscles, and nerves that work together in a complex system to perform daily tasks. It is often difficult to visualize the various paths that the tendons and muscles take.  It can also make a thorough hand exam difficult to perform with proficiency. This post will review the clinically relevant anatomy of the hand, and apply it to both a screening exam and detailed exam with maneuvers used in the diagnosis of common hand injuries.

This screening exam can be used in the case of a fracture/dislocation at or proximal to the wrist, or in a general trauma to ensure that there has not been a nerve injury – from the cervical spine, through the brachial plexus, and into the extremity.

Basic Screening Exam:  


To examine the vascular supply of the hand the examiner should palpate the radial pulse and check digital capillary refill.  Using a finger pulse oximeter is a useful adjunct for evaluating perfusion; anything below 95 in a traumatized limb/digit raises concern.


The radial, median, and ulnar nerves each have sensory and motor functions that should be evaluated. 

 Radial (C5-C8):

Img 1. Sensory innervation of hand

  • Motor: Extend the wrist. If too painful due to injury, then extension of the thumb IP joint may be substituted.
  • Sensory: Test the dorsal webspace between the thumb and index finger

Median (C5-T1):

  • Motor:
    •  Recurrent motor branch of the median nerve: Have the patient attempt opposition (bringing the thumb tip across to the small finger tip)
    • Anterior interosseus branch of the median nerve:  Make an OK sign by having the patient touch the tip of the thumb to the tip of the index finger

Img 2. Correct OK Sign

Img 3. Incorrect OK Sign

  •  Sensory: Palmar surface of the index finger or thumb

Ulnar (C8-T1):

  • Motor: Test by having patient spread fingers against resistance
  • Sensory: Palmar aspect of the little finger


Check the individual digital sensory nerves to any finger by testing the radial and ulnar sides of each digit

If the patient can perform each of the above functions and has intact sensation, as well as good cap refill and pulses, they have passed the basic screening exam and are “neurovascularly intact.”

Now for a more detailed exam, which should be used when a patient comes in with a specific hand complaint or if there is concern for muscle or tendon injury.

A thorough musculoskeletal (MSK) exam should include:

  • Inspection
  • Palpation
  • Range of Motion (ROM)
  • Nerve/Vascular assessment
  • Muscle/tendon exam
  • Specific maneuvers

Detailed Hand Exam:


Inspect the hand for evidence of:

Img 3. Mallet finger

  • Asymmetry
  • Lacerations/abrasions: Any skin break over a joint (eg : fight bite) may look innocent, but actually provides a route for inoculation of the joint with infection and can be serious.
  • Inflammation:  Can be acute from recent injury/infection or chronic from inflammatory states such as RA.
  • Atrophy: Think critically about the location of the atrophy, is it diffuse or does it fit one nerve distribution? For example, carpal tunnel syndrome may produce atrophy in the thenar muscles supplied by the median nerve. Ulnar nerve entrapment at the elbow (Cubital tunnel syndrome) could cause hypothenar muscle wasting and intrinsic wasting (most visible at first dorsal interosseous, along dorsal radial border of the index metacarpal).
  • Any evidence of traumatic deformity such as unusual angulation or rotation. You should always check alignment of the fingers in flexion and extension. Sometimes abnormal rotation will only be visible when making a fist, when one finger crosses over/under the next
    • Any alteration to the normal cascade of the fingers (one finger that is not flexed/extended to match the position of the others) may represent a tendon injury
    • Mallet finger: A flexed DIP with inability to actively extend due to rupture of the terminal extensor tendon of the digit. (Img. 3)
    • Boxer’s fracture: May have a “dropped knuckle sign” where the fracture of the metacarpal shaft causes a “disappearance” of the metacarpal head  (Img. 4)

Img 4. Dropped knuckle sign




Img 5. Scaphoid Tubercle

It can be difficult to visualize all of the bones in the hand and wrist in order to palpate them correctly. However, there are a few that emergency medical providers should know in order to catch the most common and consequential injuries.

The scaphoid is technically part of the wrist, however it is usually part of a screening hand exam for anyone with a fall onto a hand. It can be palpated in 3 places:

Img 6. Anatomic snuffbox

  • Scaphoid tubercle   
  • The waist of the scaphoid can be palpated in the anatomic snuffbox 
  • The proximal scaphoid can be palpated on the dorsal wrist in the soft spot between the tendons of the 3rd and 4th compartment of the wrist, just distal to Lister’s tubercle 

Img 7. Lister's Tubercle

Img 8. Proximal Scaphoid

Previous studies have demonstrated that tenderness at the scaphoid tubercle is actually more sensitive than the anatomic snuffbox (95% v. 85%) in diagnosing scaphoid fracture. When palpating the anatomic snuffbox you can maximize the surface area that you are palpating by having the patient move their hand into ulnar deviation and thumb abduction.

Range of Motion

Test range of motion both passively and actively in each joint. Passive ROM gives you information about the joint.  You may feel clicking, catching or crepitance. Active ROM provides information about nerve function, muscle strength, joint congruity/stability, and tendon integrity.

[Insert aforementioned neurovascular exam here]

Muscle/tendon exam

A full muscle/tendon exam doesn’t need to be a part of every exam in the Emergency Department, we don’t have the time. However, if there is an injury that makes you concerned about the integrity of deep structures in the hand, wrist, or forearm, knowing the course and function of each muscle and tendon is useful.  Theoretical cases have been included to provide context.

Case 1:

A patient sustained a deep laceration to his right volar forearm from a glass bottle during an altercation at a bar. The sensory exam in the hand is normal, but function is abnormal.  In addition to the usual laceration care, you want to ensure all of the underlying tendons from the extrinsic muscles are intact. You need to check the finger and wrist flexors. Most of these are innervated by the median nerve, with the exception being the Flexor Carpi Ulnaris and the Flexor Digitorum Profundus to the small and ring fingers, which are innervated by the ulnar nerve.

Img 9. Flexors of forearm

  • Flexor Pollicis Longus (FPL): Test by asking patient to flex thumb at the IP joint (AIN)
  • Flexor Digitorum Profundus (FDP): Test by asking patient to flex DIP joint of index or middle finger while stabilizing PIP of the same digit
  • Flexor Digitorum Superficialis (FDS): Test by asking patient to flex PIP while examiner holds all the other digits in extension (this blocks FDP and completely isolates the FDS)
  • Flexor Carpi Ulnaris and Flexor Carpi Radialis: Test by asking patient to flex the wrist and palpate tendon/muscular contraction


In summary, to test the extrinsic flexors:

  • Flex thumb IP joint
  • Stabilize PIP and have patient flex each DIP in succession
  • Hold remainder of fingers in extension, ask patient to flex each PIP in succession
  • Volar flex wrist


Case 2:

The same patient presents again after a bar fight, this time sustaining a deep laceration to his dorsal forearm.  You want to ensure all of the underlying tendons from the extrinsic muscles are intact. You need to check the extensors.  These muscles are all innervated by the radial nerve and are separated into six compartments.

First Dorsal Wrist Compartment

  • Abductor Pollicis Longus and Extensor Pollicis Brevis: Ask the patient to bring their thumb out to the side (abduct) and palpate the tendons along the radial border of the wrist

Img 10. Extensors of forearm

2nd Dorsal Wrist Compartment

  • Extensor Carpi Radialis Longus (ECRL) and Extensor Carpi Radialis Brevis (ECRB): Have the patient make a fist and extend against resistance

3rd Dorsal Wrist Compartment

  • Extensor Pollicis Longus: Place hand flat on table and lift thumb off the table

4th Dorsal Wrist Compartment (the MCP joint extensors of the fingers)

  • Extensor Digitorum Communis and Extensor Indicis Proprius (EIP): Test by straightening individual fingers at the MCP. The EIP can be isolated by extending index finger with the rest of the fingers closed in a fist

Img 11. Extensors of forearm 

5th Dorsal Wrist Compartment

  • Extensor Digiti Minimi: Extend small finger with the rest of the fingers closed in a fist

6th Dorsal Wrist Compartment

  • Extensor Carpi Ulnaris: Extend and ulnar deviate wrist

In summary, to test the finger extensors:

  • Abduct the thumb, then place on table and lift thumb off
  • Extend fingers against resistance at MCP
  • Make fist and extend wrist against resistance
  • Ulnar deviate fist
  • Extend index finger from closed fist
  • Extend small finger from closed fist

Case 3:

The same unfortunate patient returns after yet another bar fight. His other two lacerations are well healed, but now he has sustained a deep laceration to his right palm. This time you need to check the intrinsic muscles and tendons of the hand. These are innervated by the median and ulnar nerves and are also separated into compartments.

Thenar muscles: both median and ulnar nerve innervation

Img 12. Intrinsic muscles of hand

  • Abductor Pollicis Brevis, Opponens Pollicis, Flexor Pollicis Brevis (median n.): Ask the patient to touch thumb and small finger tips together so the nails are parallel
  • Adductor pollicis (ulnar n.): Have the patient hold paper between thumb base and radial side of 1st finger.  Try to pull the paper away and see if they can hold it.  When the adductor muscle is weak the thumb flexes at the IP joint to grab the paper (Froment’s sign)


Interosseus and Lumbrical: ulnar nerve innervation

Interosseus testing

  • Lumbricals: Flex MCP and straighten IP
  • Interosseus: Adduct and abduct the fingers.  Place the hand flat on table to eliminate interference by extrinsic extensors, hyperextend middle MCP, and move finger from side to side.


Hypothenar muscles: ulnar nerve innervation (difficult to isolate, especially in an injured patient)

  • Abductor Digiti Minimi: Test by abducting small finger
  • Opponens Digiti Minimi: Function to bring small finger towards thumb

In summary, to test the intrinsic muscles of the hand:

  • Touch small finger to the thumb so the nails are parallel
  • Pinch paper between thumb and radial side of index finger in the first webspace
  • Flex MCP and straighten PIP
  • Place hand flat on table, hyperextend at MCP, adduct and abduct each finger
  • Spread fingers against resistance, (also abducts the 5th finger and tests the hypothenar muscles)


Special tests:

There are several tests that can be used to examine for common and important injuries.

Case 4

You are working at a ski clinic in Lake Tahoe as part of an elective rotation. A patient presents after a fall backwards onto his R hand while holding his ski pole.  He has pain in his thumb, especially on the ulnar aspect of the MCP joint.

  • Most likely diagnosis: Skier’s thumb/Gamekeeper's thumb, a rupture of the ulnar collateral ligament (UCL)
  •  Evaluation: Test UCL integrity. Hold thumb metacarpal with one hand, and fully extend thumb MCP and apply gentle radial deviation force to see if there is laxity or pain. Test again at 30 degrees of MCP flexion. Test other thumb as a reference (people vary widely in baseline joint laxity).

Case 5

A patient reports that he was playing pickup basketball, got a finger snagged on the opposing player’s shirt, and felt pain when the player pulled away suddenly.  Now he has difficulty flexing the fingertip.

  • Most likely diagnosis: Jersey finger, a rupture of the FDP tendon from the distal phalanx.
  • Special test:  Hold the patient's MCP and PIP in full extension and ask patient to flex at the DIP. If the FDP is intact the patient will be able to flex at the DIP.  The PIP must be held in full extension to isolate FDP function. 

Case 6

The same patient presents 6 months later, again playing pickup basketball, but this time he got his finger jammed on the ball going up for a rebound.  Now he cannot fully extend it at the tip.

  • Most likely diagnosis: Mallet finger, an avulsion of the extensor digitorum from the distal phalanx.
  • Special test: Hold the middle phalanx of affected finger to isolate DIP and ask patient to actively straighten DIP. If the patient cannot, then the test is positive for Extensor Digitorum injury.  You can also passively extend the tip and see if patient is able to hold it there or if it returns to the flexed position.

Case 7

A patient presents with a deep laceration to the dorsum of his 3rd finger, over the middle phalanx. He appears to be able to extend and flex the finger easily, however as an astute ED physician, you are concerned about occult tendon injury.

Screen Shot 2018-04-14 at 3.40.35 PM.png
  • Most likely diagnosis: Central slip injury, a rupture of the central band of the extensor mechanism causes the lateral bands to slide ventrally, preventing extension of the PIP and extension of the DIP.
  • Special Test: Elston’s test. Passively flex the PIP to 90 degrees to relax the lateral bands. Have patient try to extend the finger and provide counter force on middle phalanx. When the patient tries to extend the PIP test the tension at the DIP: If DIP is floppy the central slip is intact, but if the DIP becomes taut then central slip is injured.

Expert Commentary

Evaluating hand trauma requires understanding the anatomy and the functions associated with that anatomy.  Having a systematic approach helps, as pain, bleeding, intoxication, and fear can affect the upper extremity exam.   It is good practice to start by evaluating for deformity, color change, and wounds.  Ask the patient to make a fist and then open it, which can help direct you to the problem area.  Test wrist flexion and extension.  Evaluate extension of each finger.  Evaluate flexion and extension of the thumb IP.  Evaluate FDP and FDS of each finger.  Test OK sign, fingers crossed (index and middle), spread fingers wide and hold them out against resistance.  Test gross sensation in each fingertip, and on the back of the hand.  If you do this every time, you are unlikely to miss a substantial injury. From the findings of the general hand exam you can then focally test any trouble areas.

Determining adequate perfusion, often via clinical exam (color, temperature, turgor, etc) is critical.  Using a pulse oximeter on an injured finger can help identify threatened digits before the clinical ischemia or venous congestion becomes obvious.  Doppler exam of each digital vessel is another useful evaluation tool. 

Always consider the proximal to distal nature of the anatomy, and tailor the focal exam based on the level of injury.  For example, if a patient presents with an injury at the wrist, testing finger flexion will not give any information about the median nerve.  The level of injury helps guide what additional components of the exam you need to perform to get the full picture, as laid out in the different discussions between cases 1 and 3 above.

The sensory exam is often challenging, especially in traumatized fingers.  Pain can be distracting, and edema can cause sensory changes.  Gentle sharp sensation (pin-prick) testing is a useful adjunct to the digital sensory exam, especially if only one side is injured and you are trying to clarify whether the digital nerve is intact.  Also, if a patient had a tourniquet placed in the field, they may present with an abnormal sensory exam (or even functional exam, depending on duration of ischemia) even if all structures are intact.

And, although this may be an obvious reminder, always document a thorough sensory exam before ever administering local anesthesia. 


Screen Shot 2018-04-14 at 3.45.33 PM.png


Aviram Giladi, MD, MS

The Curtis National Hand Center, MedStar Union Memorial Hospital

 How to cite this post

[Peer-Reviewed, Web Publication]  Whipple T,   Gappmeier V (2018, April 16). Demystifying the Hand Exam.  [NUEM Blog. Expert Commentary by Giladi A ]. Retrieved from

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• Ghane, MR et al. How trustworthy are clinical examinations and plain radiographs for diagnosis of scaphoid fractures. Trauma Mon Nov 2016. 21(5): e23345.

• Giuglae, J et al. The palpable scaphoid surface area in various wrist positions. Journal of Hand Surgery. 1 Oct 2015. 40(1): 2039-2044. 

• Netters Orthopedic Clinical Exam. Ed: Cleland, Joshua A., PT, DPT, PhD; Koppenhaver, Shane, PT, PhD; Su, Jonathan, PT, DPT, LMT. Third Edition. Copyright 2017

• Lin, M.  Quick Tip: Elston’s Test for the Finger.  Jul 29 2013. ALiEM.

• Bookman, A. A., von Schroeder, H. P., & Pham, A. G. (2010). The Wrist and Hand. In Fam’s Muskuloskeletal Exam and Joint Injection Techniques (pp. 29–43). Mosby.

• Seiler, JG. (2002). Essentials of Hand Surgery (pp 23-48). Lippincott Williams & Wilkins.

Approach to Nail Trauma

Screen Shot 2018-03-05 at 8.26.14 AM.png

Written by: Gabby Alzadeh, MD (NUEM PGY-3) Edited by: Jim Kenny, MD, (NUEM PGY-4) Expert commentary by:  Matt Levine, MD

Why nails are important

  • Nail injuries may have significant associated functional and cosmetic morbidity
  • The nail bed provides adherence and support for the nail
Nail_anatomy diagram 2.png

Nail Anatomy

  •  Nail bed: overlies the cortex of the distal phalanx and lies directly beneath the nail plate
  •  Eponychium: the skin that covers the proximal end
  •  Hyponychium: the skin edge at the distal nail margin
  • Cuticle: an outgrowth of the eponychium that provides a seal between the proximal nail fold and nail plate
  • Germinal matrix: the proximal portion of the nail bed responsible for nail formation and begins 7 to 8 mm under the eponychium; the distal end of the germinal matrix is the lunula


Subungual Hematoma

  • A simple subungual hematoma is not an indication to remove the nail. Trephination is not indicated if the hematoma encompasses only 25%, there is no significant pain, or if injury was over 24 hours ago, as the blood likely clotted and will not flow out.
  • Blood under the cuticle proximal to the nail is a clue that there is a deeper injury and usually the nail should be removed if there is significant pain.
  • There is controversy regarding treatment of subungual hematomas and whether simple trephination is enough or whether inspection of the nail bed for injury is required.
  • It was suggested that for subungual hematomas involving more than 50% of the nail bed, the nail should be removed given the risk of nail bed laceration.
    • This was based on an initial study in 1987 that found that 16/27 patients with hematomas >50% had associated nail bed lacerations that required repair
    • This study did not follow up with patients and did not have a control group, so long term outcomes are unknown.
    • However, subsequent studies have shown that if there is no other significant finger tip injury, treatment by trephinating alone provides a similar good cosmetic and functional result.
  •  If you don’t have a trephinator, what else can you use?
    •  Heated paper clip
    • 23-gauge 1-inch needle: Hold the needle over the hematoma, avoiding the lunula, twist and rotate the needle back and forth like a drill; no pressure needed.
    •  Number 11 scalpel (slower, more painful, larger hole and better drainage)
    •  Insulin syringe needle (29-gauge)
  •  What if there is a fracture underneath?
    • Though there is a risk of turning the fracture into an open fracture, consider still performing the procedure if the injury is painful.
    •  You can consider antibiotics if trephination is pursued, though there is no data.
    •  It is always important to obtain an x-ray with any traumatic injury.

Nail Bed Repair

Suture the nail bed if a large subungual hematoma is associated with an unstable or avulsed nail. Good outcome depends on maintaining the space under the cuticle where the new nail will grow out from (the germinal matrix). If this area scars down a new nail will not grow. 

 Figure 1

Figure 1

  •  If the nail is only partially avulsed or loose, especially at the base, lift the nail slightly to assess the nail bed.
  • If the nail is completely transected, it is best to remove the entire nail to suture the nail bed. In this case, suture the proximal and lateral nail folds first for better approximation prior to repairing the actual nail bed.
  • A sturdy needle (3-0 or 4-0) is needed to suture the nail back in place. Before replacing the nail and suturing it back in place, you can poke a hole through so the needle and suture can pass more easily.
  • A study in 2008 used dermabond for nail bed laceration repair showed similar follow up cosmetic and functional outcomes; using dermabond took about 1/3 of the time. It was a small study with only 40 patients and repair was done by orthopedic residents, but definitely a consideration
    •  The key to success is achieving hemostasis and making sure you have a dry field before dermabond application
  • Another method to secure the nail in place is the figure 8 stitch (Figure 1, 2) proposed by hand surgeons 

Figure 2



Protecting the exposed nail bed is essential, which can be done with the nail itself (wash well beforehand with normal saline), with the sterile aluminum foil from the suture pack, or with a piece of vaseline gauze. The nail should be reinserted under the eponychium to protect the open space for nail growth. Consider a hand surgeon consult if the nail bed is extensively lacerated or if part of the nail bed is lost, as the patient my need a matrix graft.


Discharge Instructions:

  • Tell the patient to return for a wound check 3-5 days post repair. Replace any non-adherent material that was inserted into the proximal nail fold. Afterwards, the patient should perform dressing changes every 3-5 days.
  • Sutures that were used to reattach the nail should be removed in 2 weeks.
  • Nails grow at a rate of 0.1 mm/day and it takes approximately 6 months for a new nail to grow.
  • Instruct the patient to avoid any trauma or chemical irritants to the healing nail.


Figure 3

  • Always use absorbable suture to repair the nail 
  • Use a large suture and sturdy needle when suturing the nail back in place; consider dermabond as an option
  • Use a finger tourniquet to maintain a bloodless field (Figure 3)
  • Digital blocks are key
  • Clean the nail bed prior to repair; clean the nail very well before replacement
  • If possible use the avulsed nail to protect the exposed nail bed and maintain the space for a new nail to grow
  • Repair the proximal and lateral nail folds first

Expert Commentary

Dr Ahlzadeh has presented a nice review of the approach to nail trauma and some useful techniques.  While there are seldom formal lectures during residency training dedicated to nail trauma, it is something we regularly see and treat in the ED, so it is important that we do this well.  It is well within the scope of practice of Emergency Medicine to be the primary providers for most nail injuries.

The subungual hematoma is probably the most common nail injury encountered in Emergency Medicine.  Traditional dogma directed the provider to remove the nail to repair underlying injuries in the presence of >25-50% hematoma.  This recommendation left many of us scratching our heads. We would go through the elaborate procedure of removing the nail by dissecting the nail away from the underlying nailbed, meticulously repairing a nailbed laceration if required, and then stenting the eponychial fold open, hoping that a normal nail would regrow without deformity despite the trauma from the injury and the procedure itself.  It seemed like we were introducing a lot of trauma to the nail bed and eponychial fold for a theoretical (non evidence based) benefit.  The more we did this, the more many of us would ask ourselves, “What if we just left this alone?”

Today it seems the tide has turned.  It is now well accepted practice to leave a nail in place in the setting of a subungual hematoma as long as the nail is intact and laying flat on the nailbed, regardless of the percentage size of the hematoma.  This makes intuitive sense.  An anatomically intact nail lying flat upon the nailbed should lead to the flat healing of an underlying laceration.  A common practice to ensure that the nail remains flat after discharge is to trephinate nail so that pressure from the underlying hematoma does not elevate the nail off of the nailbed after discharge.

Nail trephination is one of the more rewarding procedures in Emergency Medicine.  Patients present with throbbing pressure from the tense subungual hematoma and typically get immediate improvement once the nail is trephinated.  Many techniques have been described. Dr Ahlzadeh even refers to a “trephinator”.  I am not actually sure what this device even is.  Regardless, this procedure should be quick and easy.  No anesthesia is necessary.  I suggest keeping it simple.  Rather than heating a needle or paper clip, use a cautery device.  In our ED we have a cordless disposable plastic cautery device that is the size of a magic marker.  It has a single button and the tip becomes orange with heat when the button is pressed so you know it is hot and ready to go.  Warn the patient that they will feel some heat and possibly see or smell a bit of smoke but it will be brief and not painful (unless you are too forceful, in which case it will be hot and painful!).  Pick the location in the center of the hematoma.  Repeatedly very lightly touch the hot cautery tip to the nail over the center of the hematoma until you are through the nail.  You will know you are through when a drop of blood comes out of the hole you have trephinated.  At that point you can stop and gently express whatever blood you can.  That’s the whole procedure.  It should take mere seconds. When the patient gets over the initial anxiety of the procedure they typically realize they feel better. 

Nails that are deformed or elevated off of the nail bed are not good candidates for trephination. These nails should be removed for nailbed repair so that the nailbed heals flat.  Don’t even bother unless your digital block is highly effective.  We do not have commercial finger tourniquets in our ED so I like to make my own professional looking tourniquet.  I get a sterile glove is about the size (or a half size smaller) than would fit the patient.  I cut the very tip off the finger of the glove that corresponds with the patient’s injured finger.  Then I put the glove on the patient and roll the cut glove finger proximally and voila, you have both a tourniquet and a clean field.  Now you are ready to get comfy and repair the nail bed according to Dr Ahlzadeh’s techniques!  While a sturdy needle is needed to puncture through a nail, I still find the nail often deforms the needle. So instead of piercing the nail with my needle, I once again use my trusty cautery device to make holes in the nail that my needle will easily pass through without deformity.

Screen Shot 2018-04-08 at 5.24.00 PM.png


Matt Levine, MD

Assistant Professor, Northwestern Emergency Medicine


 How to cite this post

[Peer-Reviewed, Web Publication]  Alzadeh G,  Kenny J  (2018, April 8). Nail Trauma.  [NUEM Blog. Expert Commentary by Levine M ]. Retrieved from 


  • Batrick N. Treatment of uncomplicated subungual hematoma. Emerg Med J 2003;20:65.
  • Bowen WT, Slaven EM. Evidence-based management of acute hand injuries in the emergency department. Emergency Medicine Practice  EB Medicine. 2014;16(12):1-28.
  • Guthrie, Kane. “Minor Injuries 001.” Life in the Fastlane. <>.
  • Hedges, Jerris, James Robers. “Methods of Wound Closure.” Clinical Procedures in Emergency Medicine, 6th ed. Philadelphia: Elsevier/Saunders, 2014.
  • Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am]1999;24:1166–70.
  • Strauss E, Weil W, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250-253.


Acute Compartment Syndrome

Acute compartment syndrome (CS) of the extremity is a clinical diagnosis. However, patients without the ability to convey a good history increase our reliance on objective measures.  This week's post will review the characteristics of CS injuries by mechanism and location, utility of clinical symptoms, and the use of compartment pressures in the diagnosis of CS.