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Intravenous Drug User With Hand and Forearm Pain

Authors: 

JIMMY Y. SAADE, MD, ERGENT M. ZHIVA, MD,
ANTHONY M. SALIBI, and DAVID EFFRON, MD

Dr Saade is a staff physician in the department of emergency medicine and a resident in radiology at MetroHealth Medical Center, and consultant emergency physician at the Cleveland Clinic. Dr Zhiva is a resident in radiology at MetroHealth Medical Center. Mr Salibi is a B.S. candidate in kinesiology at Arizona State University. Dr Effron is assistant professor at Case Western Reserve University, attending physician in the department of emergency medicine at the MetroHealth
Medical Center, and consultant emergency physician at the Cleveland Clinic, all in Cleveland.


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HISTORY
A 50-year-old man, who is right hand dominant, presents to the emergency department (ED) with swelling of the left hand and intense pain. He is an intravenous drug user with multiple prior admissions because of abscess formation in both upper extremities. A radiograph of the right forearm from a previous visit (A) shows retained needle fragments (arrows). The irregularity of the volar skin margin (open arrow) is attributable to scarring and disfigurement from a long history of intravenous drug injection. As a result of ongoing intravenous drug abuse, he has obliterated most of the veins of both upper extremities and has started injecting directly into muscles.

Two days before he presented to the ED, he injected into the dorsum of his left hand. A few hours later, the hand became swollen and very painful, and the symptoms progressively worsened. He denies fever, chills, nausea, vomiting, and lightheadedness.

PHYSICAL EXAMINATION
The patient is alert and oriented to person, time, and place. Blood pressure is 138/69 mm Hg; heart rate, 77 beats per minute; respiration rate, 18 breaths per minute; oxygen saturation, 98% on room air; and oral temperature, 35.3°C (95.5°F).

There is marked disfigurement of both upper extremities. The left hand is diffusely swollen, with associated erythema extending from the metacarpophalangeal (MCP) joints to 5 cm proximal to the wrist along the dorsum. This area is tender to palpation. Pain is also elicited with active and passive flexion and extension of the wrist, MCP joints, and proximal interphalangeal joints. There are no areas of focal fluid collection or fluctuance. Strength is 5/5 and symmetric in both hands and forearms. Sensation to light touch is preserved throughout all nerve distributions. No palpable lymphadenopathy in the left upper extremity or axilla is present. Results of the pulmonary and cardiac examinations are unremarkable.

IMAGING STUDIES
As part of the work-up, a radiograph of the left hand (B) is obtained. It shows marked soft tissue swelling, especially along the dorsum of the hand (arrow). A sonographic examination of the left forearm extensor compartment is also performed (C, D, and E).


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