Imaging findings of complications affecting the upper extremity in intravenous drug users: featured cases

CT Angiography of the Upper Extremities: Review of Acute Arterial Entities

Historically, evaluation of the upper extremity vasculature was performed using digital subtraction angiography. With the advancement of cross-sectional imaging and submillimeter isotropic data acquisition, CT angiography (CTA) has become an excellent noninvasive diagnostic tool for evaluation of the vasculature of the upper extremities. CTA allows quick evaluation of vessel patency and irregularity and achievement of the anatomic detail needed in preoperative planning. When interpreting CTA of the upper extremities, radiologists must be familiar with the normal vascular anatomy, common vascular anomalies, and pitfalls or artifacts that may mimic or mask abnormality. In this review, the authors provide an overview of the utility of CTA of the upper extremities. Also discussed are CTA techniques and the use of several newer technologies including dual-energy and photon-counting detector CT. The utility of CTA in patients with upper extremity trauma is explored, with a focus on assessing vascular injury. Other vascular abnormalities including infection, acute limb ischemia, and vasculitis are discussed. It is imperative for radiologists to be accustomed to CTA of the upper extremities in diagnosing acute vascular abnormalities and to recognize common pitfalls and mimics of these abnormalities. ©RSNA, 2025 Supplemental material is available for this article.

Increasing Prevalence of Xylazine and Worsening Upper-Extremity Wounds in Injection Drug Use: A Local Phenomenon With National Implications

The rising presence of xylazine in Philadelphia's fentanyl supply has led to various upper-extremity complications in individuals who inject drugs. Sociogeographic trends predict that our current local phenomenon will spread nationally. We aim to discuss the drug's impact on clinical presentation and patient care via a cohort of five patients with upper-extremity wounds related to drug use. Interventions included local wound care, revascularization, compartment release, free flap reconstruction, and amputation. Successful treatment of these patients, who are often in challenging psychosocial environments, requires an individualized and interdisciplinary approach including surgical services, infectious disease, wound care, addiction medicine, psychiatry, social services, and prosthetic services.

Exploring the uncommon: Unusual instance of retained fractured needles in a patient of intravenous drugs abuse

Retained needle fragments commonly serve as sources of recurrent infections with a potential to embolize to the heart and lungs and can lead to life-threatening consequences. Here, we report a case of a 46-year-old male with a history of intravenous drug user and chronic forearm wounds, presenting with sepsis. Several retained needles are identified on CT scan, several days postadmission. This case highlights the importance of timely assessment of infectious sources in patients with history of intravenous drug abuse.

Necrotizing Fasciitis of the Upper Extremity - A Review

Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.

Imaging and Laboratory Workup for Hand Infections

Hand infections can lead to significant morbidity if not treated promptly. Most of these infections, such as abscesses, tenosynovitis, cellulitis, and necrotizing fasciitis, can be diagnosed clinically. Laboratory values, such as white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and recently, procalcitonin and interleukin-6, are helpful in supporting the diagnosis and trending disease progression. Radiographs should be obtained in all cases of infection. Ultrasound is a dynamic study that can provide quick evaluation of deeper structures but is operator dependent. Computed tomographic and MRI studies are useful for evaluating deep space or bony infections and preoperative surgical planning.

Radiographic Musculoskeletal Findings Indicating Opioid Misuse: An Overview for Orthopedic Surgeons

BACKGROUND

Given the high prevalence of musculoskeletal conditions in the USA, it is important for orthopedic surgeons to promptly identify patients who may be at risk for opioid misuse.

QUESTIONS/PURPOSES

The aim of this literature review was to elucidate various musculoskeletal pathologies and complications, as seen on imaging, that may indicate opioid misuse or opioid use disorder.

METHODS

A literature search was conducted using the PubMed, Scopus, and Cochrane Library databases for articles related to imaging findings associated with chronic opioid use or misuse in orthopedic patients. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

We reviewed 36 full-text articles and categorized the radiographic evidence of opioid misuse as follows: soft-tissue radiologic findings, cellulitis, necrotizing fasciitis, abscess formation, retained needles, discitis, myopathy and rhabdomyolysis, osteomyelitis, septic arthritis, and septic thrombophlebitis.

CONCLUSION

Knowledge of the radiologic findings of opioid misuse will assist orthopedic surgeons in making timely diagnoses that may alter therapeutic regimens for their patients.

"Puffy hand syndrome"

Intravenous drug addiction is responsible for many complications, especially cutaneous and infectious. There is a syndrome, rarely observed in rheumatology, resulting in "puffy hands": the puffy hand syndrome. We report two cases of this condition from our rheumatologic consultation. Our two patients had intravenous drug addiction. They presented with an edema of the hands, bilateral, painless, no pitting, occurring in one of our patient during heroin intoxication, and in the other 2 years after stopping injections. In our two patients, additional investigations (biological, radiological, ultrasound) were unremarkable, which helped us, in the context, to put the diagnosis of puffy hand syndrome. The pathophysiology, still unclear, is based in part on a lymphatic toxicity of drugs and their excipients. There is no etiological treatment but elastic compression by night has improved edema of the hands in one of our patients.

Magnetic resonance imaging of musculoskeletal infections: systematic diagnostic assessment and key points

Prompt diagnosis and treatment are essential in preventing the complications of musculoskeletal infection. In this context, imaging is often used to confirm clinically suspected diagnoses, define the extent of infection, and ensure appropriate management. Because of its superior soft-tissue contrast resolution, magnetic resonance imaging (MRI) is the modality of choice for evaluating musculoskeletal infections. This article describes the MRI features along the full spectrum of musculoskeletal infections and provides several illustrative case examples.

Skeletal muscle disease: patterns of MRI appearances

Although the presumptive diagnosis of skeletal muscle disease (myopathy) may be made on the basis of clinical-radiological correlation in many cases, muscle biopsy remains the cornerstone of diagnosis. Myopathy is suspected when patients complain that the involved muscle is painful and tender, when they experience difficulty performing tasks that require muscle strength or when they develop various systemic manifestations. Because the cause of musculoskeletal pain may be difficult to determine clinically in many cases, MRI is increasingly utilised to assess the anatomical location, extent and severity of several pathological conditions affecting muscle. Infectious, inflammatory, traumatic, neurological, neoplastic and iatrogenic conditions can cause abnormal signal intensity on MRI. Although diverse, some diseases have similar MRI appearances, whereas others present distinct patterns of signal intensity abnormality. In general, alterations in muscle signal intensity fall into one of three cardinal patterns: muscle oedema, fatty infiltration and mass lesion. Because some of the muscular disorders may require medical or surgical treatment, correct diagnosis is essential. In this regard, MRI features, when correlated with clinical and laboratory findings as well as findings from other methods such as electromyography, may facilitate correct diagnosis. This article will review and illustrate the spectrum of MRI appearances in several primary and systemic disorders affecting muscle, both common and uncommon. The aim of this article is to provide radiologists and clinicians with a collective, yet succinct and useful, guide to a wide array of myopathies.