Author: Danielle Ginsburg, DO
Co Author #1: Ashley Jones, M.D.
Senior Editor: Drew Duerson, MD
Editor: Kelley Anderson, DO

Patient Presentation:
A 33-year-old male presented with an avulsion of the third finger nailbed, a traumatic amputation to the fourth finger and a fracture of the fifth finger all of the right hand. In addition to the hand injuries, he presented with acute right shoulder pain after getting caught in a boundary line while ski patrolling.

History:
The patient was a 33-year-old male who had been working as a ski patroller gathering rope for a boundary line when the rope became caught in the auger of an oncoming snow cat. The rope became tangled in the patient's right arm and hand. As the snow cat continued to move forward, the rope was placed under extreme tension and caused avulsion of his right third fingernail bed, traumatic amputation of the distal right fourth finger, and a closed distal phalanx fracture of the right fifth finger. The injuries to the digits were promptly repaired. The patient also experienced mild neck pain and right shoulder pain immediately following the incident. He underwent X-rays and an MRI of the right shoulder, both of which were negative. Approximately four weeks after the injury, he developed worsening right shoulder weakness and atrophy of his right rhomboid muscle. His right-sided neck pain had significantly worsened and was aggravated by flexion and extension. Rotation of his neck caused paresthesia in his right hand. This led to a referral to a Physical Medicine and Rehabilitation physician for further evaluation, where imaging of his cervical spine and electromyography were performed.

Physical Exam:
He was resting comfortably and was not in acute distress. Musculoskeletal examination of the right upper extremity revealed strength of 3 out of 5 in the supraspinatus muscle, with patchy dysesthesias noted diffusely throughout the right hand. Right hand grip strength was 3 out of 5, and deltoid strength was 4 out of 5, with evidence of posterior atrophy. In addition to absent biceps and brachioradialis reflexes and a 1 plus triceps reflex, he had decreased sensation over the right pectoralis and right deltoid muscles. He had an avulsion of the nail bed of the right third finger and an amputation of the distal phalanx of the right fourth finger. There was no obvious evidence of infection, and distal pulses were intact and symmetric. Cervical spine examination was limited in range of motion due to pain with extension and left rotation. He had a negative Spurling test but exhibited tenderness over the right C5 facet and bilateral cervical paraspinal muscles, with greater tenderness on the right.

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