Injuries to the Collateral Ligaments of the Metacarpophalangeal and Interphalangeal Joints: Sonographic Appearance

Injuries to the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal (IP) joints are commonly encountered in both athletes and nonathletes. They require prompt evaluation to ensure proper management and prevent loss of joint motion and permanent disability. Imaging is often required to confirm the diagnosis and assess injury severity. This review article aims to provide physicians with guidelines for sonographic assessment of the collateral ligaments of the MCP and IP and related injuries. Sonographic features of ligament injuries ranging from sprains and partial‐thickness tears to full‐thickness tears are described. Specific lesions of the ulnar collateral ligament of the thumb MCP joint, such as gamekeeper's thumb, skier's thumb, and Stener lesions, are also included. In conclusion, sonography is effective in evaluating the collateral ligaments of the MCP and IP joints and related injuries and represents a valuable tool for diagnosis.     

Recognition and Differential Diagnosis of Hereditary Angioedema in the Emergency Department

BackgroundAngioedema (AE) is a clinical syndrome marked by localized swelling of the subcutaneous layer of the skin or the submucosal layer of the respiratory or gastrointestinal tracts. While AE is commonly mediated by histamine (allergic AE), some types result from excessive bradykinin activity, including hereditary AE (HAE), acquired AE, and angiotensin-converting enzyme inhibitor–induced AE. These are less common but important to consider given different treatment requirements and potentially serious outcomes, including death from laryngeal swelling.ObjectiveThis review describes the pathophysiology and clinical features of AE as well as the diagnosis and treatment of AE in the emergency department (ED).DiscussionBradykinin-mediated AE does not respond to antihistamines and corticosteroids. By contrast, several targeted, effective therapies are available, including C1-inhibitor (C1-INH) concentrates, which replace the missing protein activity underlying some bradykinin-mediated AE, and medications that directly lessen bradykinin activity (eg, ecallantide and icatibant). Urticaria is generally absent in bradykinin-mediated AE and serves as a primary differentiating factor in the clinical diagnosis. Relevant laboratory assessments may include C1-INH levels, C1-INH function, and C4 complement. Patients with HAE or a family member can communicate their known diagnosis when presenting to the ED, and some may even bring their own medication(s) with them. Patients newly diagnosed with HAE in the ED should be referred for specialized outpatient care upon ED discharge.ConclusionsThere is a great need for ED clinicians to be aware of HAE, its differential diagnosis, and appropriate treatment to ensure that patients receive optimal and timely treatment.     

Out-of-hospital Provider Use of Epinephrine for Allergic Reactions: Pilot Program

Objective: To describe experience with an out-of-hospital provider program for the recognition and field management of allergic reactions by advanced life support (ALS) and basic life support (BLS) providers.
Methods: Data sheets completed between June 1, 1988, and August 31, 1993, and records from receiving sites (physicians' offices or EDs) were reviewed for information regarding the presentation of the allergic reaction, the time course and treatment provided out of hospital, and the clinical outcome at the receiving health care facility.
Results: Thirty-seven data sheets were completed during the study period. Fourteen (38%) of the providers were BLS providers. The epinephrine was supplied from the emergency medical services (EMS) provider's personal kit in 35% of the cases, from an EMS vehicle in 57% of the cases, and by the patient in 8% of the cases. Availability of the kits allowed administration of epinephrine prior to the arrival of the first EMS vehicle in 41 % of the instances and prior to physician on-line medical command in 65% of all the instances (predominantly by BLS providers). Overall, 77% of the patients experienced alleviation of their symptoms of respiratory difficulty, swelling, or rash after epinephrine administration, while 20% were unchanged and 3% worsened. All patients receiving epinephrine had an ED diagnosis of allergic reaction, and no adverse event was encountered on follow-up of the patients treated.
Conclusions: Severe allergic reactions can be reliably identified and safely managed by out-of-hospital providers, including BLS providers. Providing personal anaphylactic treatment kits and increasing the pool of providers trained to manage allergic reactions (including BLS providers) can often decrease the time to treatment.     

Sonographic features of colonic Crohn's disease: comparison of in vivo and in vitro studies

The entire length of the colon, starting at the recto-sigmoid junction and ending at the cecum, can be sonographically visualized by retrograde water instillation into the colon. In order to evaluate the validity of colonic sonography as a diagnostic method, in vivo transabdominal ultrasound examination of the colon wall after water insufflation was compared with in vitro ultrasound examination of the same colon wall on four resected surgical specimens from patients with colonic Crohn's disease and four controls. The normal colon wall specimens were easy to recognize in that they had a thickness of 4 mm and five layers of different echo patterns, which could be demonstrated both in vivo and in vitro. On the other hand, in patients with Crohn's disease, a distinct wall thickening of up to 1.5 cm was found, and the typical five-layer stratification could no longer be recognized. The sonographic changes demonstrated in vivo and in vitro were thus comparable both in wall thickness and wall structural alterations. This study shows that transabdominal colonic sonography of the fluid-filled colon is a diagnostic method that permits a detailed and accurate assessment of the normal and the pathologically changed colonic wall.