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SAEM Clinical Images: Man vs Snow Blower

Posted by Ivana Marji, MD on

A 28-year-old man presents to the emergency department after a snow blower accident while at work. The patient was performing maintenance and he placed his hand into a clogged snow blower while the machine was still on. His hand subsequently got jammed in the snow blower, catching his second and third digits. The patient has an obvious amputation of the right third digit with the stump still connected to the hand via the flexor tendon, which is attached to the distal phalanx. He has pain in the right hand and lack of sensation to the distal phalanx.

Additional Image

Physical Exam

General:

  • Alert and cooperative

Extremity:

  • Amputation of the distal portion of the 3rd digit, avulsion of the flexor tendon
  • The musculotendinous junction is seen at the amputation site. The tendon is still attached to the avulsed portion of the 3rd digit.
  • The patient is able to flex his distal interphalangeal (DIP) joint on his 3rd digit, although this joint is very stiff. He does have motion of the metacarpophalangeal (MCP) joint, but this is limited due to stiffness.
  • The amputated portion of the distal phalanx is cool and pale.
  • The remaining fingers are pink and warm to the touch.

The rest of the exam is unremarkable.

Case Question: What is the most likely diagnosis?

Guillotine Amputation

The patient was found to have a guillotine amputation along the right middle phalanx just proximal to the DIP, with avulsion of the flexor digitorum profundus (FDP).

Case Question: What is the likely functional outcome of this injury?

The finger was amputated at the myotendinous junction. The patient remains able to mildly flex at the DIP, as well as the MCP joint. The patient continues to experience persistent dysesthesias in the finger, as well as persistent stiffness.

Case Discussion

Take-Home Points

  • Pathophysiology of this type of injury of the FDP tendon includes forced hyperextension of the DIP joint while the finger is actively flexing [1, 2].
  • Knowing the anatomy of the fingers is essential to maintaining the attachments of the flexor and extensor tendons in an effort to improve functional outcomes.

References

  1. Woon, C., & Vitale, M. (2016, October 4). Ring Avulsion Injuries. Retrieved January 2, 2020, from https://www.orthobullets.com/
  2. Tempelaere C, Brun M, Doursounian L, Feron JM. Traumatic avulsion of the flexor digitorum profundus tendon. Jersey finger, a 29 cases report. Hand Surg Rehabil. 2017 Oct;36(5):368-372. doi: 10.1016/j.hansur.2017.06.002. Epub 2017 Jul 8. PMID: 28694076

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Author information

Ivana Marji, MD

Emergency Medicine Resident
Wellspan York Hospital

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