Zachary D. Ferrell, DO
Resident Physician PM&R
Sunrise Health GME Consortium
North Las Vegas, Nevada, United States
Puffy Hand Syndrome pathology within the residual limb of a 60-year-old male with transtibial amputation complicating the use of his prosthesis and leading to deconditioning.
Case Description:
60-year-old right transtibial amputee secondary to a motor vehicle accident in 1983 with a history of chronic IV drug use presented with a poorly fitting prosthesis due to chronic residual limb swelling. Unable to use his prosthesis for over a year, he was ambulating only in his wheelchair. The swelling involved both hands, the residual limb, and the left leg. He had previously received multiple courses of antibiotics for cellulitis, without improvement. On exam, his hands and lower extremities had non-pitting edema without increased warmth or erythema. He independently transferred from his chair to the exam table but was unable to perform a single-leg stand. His lab work was unrevealing. Venous dopplers were negative for DVT. He was diagnosed with “Puffy Hand Syndrome.” Education was given on disease and progression. He was given a shrinker and referred to behavioral health and lymphedema clinics.
Discussions:
Puffy Hand Syndrome (PHS) is an underrecognized complication of IV drug use causing swelling and edema leading to fibrosis in the subcutaneous tissues. This phenomenon may be due to a foreign-body granulomatous response to impurities in the injectate. PHS is a diagnosis of exclusion, and it is imperative to rule out other causes of extremity swelling in its workup. Due to the extent of the disease progression seen in this patient, he was no longer able to use his prosthesis and stopped walking for an extended period which led to his deconditioning.
Conclusions:
It is important to consider PHS when evaluating residual limbs in patients with IV drug use as size vitally affects the utility of a prosthetic limb. Educating patients about PHS may help prevent or stall the progression of this pathology.
