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© 2017 Virginia Mason Medical Center

Soft Tissue Emergencies

C. Craig Blackmore, MD, MPH, FASERVirginia Mason Medical Center

Seattle, WA

© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center


T2 Fat Sat



• Infections§ Superficial vs deep§ Specific infections

• Hemorrhage• Burns and frostbite• Inflammatory conditions• Miscellaneous


Superficial Infections

• Skin injury with extension• Predisposing factors§ Diabetes, immunocompromised§ Circulation (arterial or venous), trauma

• Imaging§ Abscess, extent of infection§ Involvement of bone, joint§ Foreign body

• Ultrasound, radiography, CT, MRI


Immunosuppressed Abscess

STIR T1 Gad


Intravenous Drug Use


Foreign Body

Splinter in thumb

Courtesy of B. Hashimoto, MD


Deep Infections

• Involvement of muscle, deep fascialcompartments

• Osteomyelitis, septic arthritis• Venous structures (deep)• Intrathoracic/intraabdominal structures


Muscle AbscessSTIR

STIR

T1 Gad


Types of Infections

• Animal bites• Marine infections• Pyomyositis• Necrotizing fasciitis (gas/wet gangrene)§ Fournier’s gangrene§ Diabetic foot


Animal Bites

• 2-5 million per year in USA• Mixed oral flora• Dog (80%) extensive soft tissue damage• Cat (15%) deep puncture• Rodent (3%)• Human (2%) underestimate initial damage


Animal Bites


Dog Bite

• Soft tissueswelling only


Dog Bite

3 weeks


Dog Bite

2 weeks

STIR

T1 Gad


Human Bite

8 days later

STIR T1 Gad

T1 Gad


Rattlesnake Bite


Marine Infections

• Sea urchins, corals, fish, stingrays• High risk of infection§ Vibrio sp§ Deep, necrotic infections rare

• Local treatment• Foreign body


Sea Urchin

79 spines removed


Sea Urchin


Pyomyositis

• Predisposing factors§ Immunocompromise§ Intravenous drug use§ Trauma

• Staph aureus/MRSA, strep, E. coli• Hematogenous• DDX: muscle injury, hematoma, muscle infarct,

septic arthritis• Myositis progresses to abscess


Muscle AbscessT1 Gad

STIR

STIR


Muscle Abscess


Intravenous Drug Use


Arm Abscess

STIR T1 Gad

T1 Gad

T1 Gad

T1


Atypical Infections: MAI

STIR

T1 Gad

T1 GadT1 Gad


Necrotizing Fasciitis

• Rapidly progressive soft tissue infection• Type 1: Polymicrobial, clostridium§ Diabetes, vascular disease,

immunocompromised§ Fournier’s Gangrene

• Type 2: Group A Strep, Staph Aureus§ Immunocompetent§ “Flesh eating bacteria”



• Rapidly Progressive• Spreads along fascial planes§ Less muscle involvement

• Microvascular occlusion, necrosis• Endotoxin release• Mortality of 70-80%



• 63 yo obese diabetic female



• 65 yr old diabetic with ulcer on foot


Necrotizing Fasciitis4 days later



• 66 yr old male with “blood blister” on great toe thatruptured


Hematoma

• May be indistinguishable from infection• Peripheral enhancement• May require aspiration for diagnosis• Anti-coagulants, bleeding dyscrasia• Compartment syndrome


HematomaSTIRT1 Gad

T1


Hematoma

STIR

T1


Hemophilia


Hemorrhagic Bursitis

PD Fat Sat

PD Fat Sat


Morel-Levalee

PD Fat Sat PD Fat Sat


Thermal Injury

• Clinical§ Size, depth§ Age, risk factors

• Imaging§ Integrity of underlying structures§ Vascular supply§ Complications


Burns

Courtesy of K. Linnau, MD


Burns

17 year old, 2 months after 3rd degree burn bilateral lower extremity



Electrical Burns• Spare skin-higher resistance• Deeper structures at risk



Frostbite

• Toes, fingers§ Spare thumb

• Depth of injury• Viability of tissue• Late§ Tissue loss§ Secondary osteomyelitis


Frostbite5 months after frostbite

8 months 21 months


16 months


“Dry” Gangrene

48 year old woman Lupus, Raynaud’s


Inflammatory Conditions

• Muscle inflammation• Edema, cellular infiltration, cell death, fatty

replacement• Multiple etiologies:§ Inflammatory myositis§ Dermatomyositis§ Rhabdomyolysis§ Overuse


Inflammatory MyositisSTIR

T2 Fat Sat


Inflammatory MyositisSTIR

STIR


Radiation MyositisT1 Gad T1 Gad

T2 Fat Sat


Myositis


DermatomyositisSTIR

T1 Fat Sat

T1 Gad

T1 Gad


Rhabdomyolysis

STIR

T1 Gad

T1 Pre

• Myonecrosis syndrome• Trauma, muscle compression• Overuse• Drugs, toxins, electrolyte

disturbance


Delayed Onset MuscleSoreness (DOMS)

STIR


Compartment Syndrome• Increased pressure in anatomically

confined space• Decrease blood flow• Necrosis

• Calf (36%), forearm (10%)


Compartment Syndrome



Leukemia

T1 Gad

T1 Gad

T1 Gad

T1

T2


Barotrauma

• Navy diver at 50 feet tank failure



• Infections§ Superficial vs deep§ Specific infections

• Hemorrhage• Burns and frostbite• Inflammatory conditions• Miscellaneous


Thank You!

soft tissue emergencies - amazon web servicesh24-files.s3.amazonaws.com/110213/954792-bkgm6.pdf ·...

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