Testicular Torsion | Epididymitis | Torsion of Testicular Appendage | |
|---|---|---|---|
Age group | Neonatal, 12–28 yo (66%) | Sexually active adolescents | 7–14 yo |
Onset | Sudden | Gradual | Gradual/sudden |
Testicular lie | High | Low | Low |
Cremasteric reflex | Usually not present | Present | Present |
Prehn’s sign* | Negative | Positive | Variable |
Urinalysis | Normal | +WBCs on UA | Normal |
Presentation | Acute onset of pain, nausea/vomiting, purple, swollen, painful testes | Fever, chills, urethral discharge, nausea, neonatal, 12–28 yo (66%), edematous and tender epididymis | Pain located in the superior pole of testicle; mild erythema or edema; blue dot sign (21%) |
Doppler ultrasonography | ↓ or absent flow | Normal or ↑ flow in epididymis | Torsed appendage with ↓ flow but normal flow to testes |
Treatment | Emergency surgery: Bilateral fixation of testes (irreversible damage possible in 5–6 h) Manual detorsion (open book technique) if timely surgical intervention not available | Scrotal support (briefs), NSAIDs Antibiotics†
| Scrotal support (briefs) NSAID Resolves within 2–12 days |
% of non-traumatic causes | |
|---|---|
Fracture | 2% |
Overuse (soft tissue injury, muscular strain, Osgood-Schlatter’s disese, hematoma of the thigh) | 18% |
Osteomyelitis Other (appendicitis, PID, torsion constipation, etc.) | 2% |
Transient synovitis | 40% |
Legg-Calve-Perthes syndrome (avascular necrosis of the femoral head) | 2% |
Inflammation (rheumatologic: JRA, SLE, reactive arthritis or HSP) Infection (skin, soft tissue, joint, septic arthritis) | 3% 4% |
Foreign body | |
Tumor “Toddler’s fracture” (nondisplaced spiral fracture of the tibial shaft) Trauma | 1% 1% — |
SCFE Sickle cell pain crisis | <1% |
- Diagnosis
- History: Time of onset, mechanism (trauma, change in activity), location, severity, radiation, effect on ADLs, aggravating or alleviating factors. Ask about fever, recent infections (viral or GABHS), weight loss, back, abdominal pain, cough, joint swelling, stiffness, erythema, incontinence, recent IM injection (sterile abscess). Prior h/o of family h/o cellulitis/abscesses or sickle cell disease connective tissue disease, IBD, or bleeding or neuromuscular disorder.
- Physical exam
- Inspection: Rash, inflammation, warmth, erythema, deformity, limb length discrepancies
- Palpation: Joint or bone tenderness, joint effusion, neurovascular status
- ROM: Active and passive ROM, grade strength
- Neurovascular exam: Pulse, perfusion, sensation
- Other: Do not forget to examine the spine, back, abdomen, and GU area
- Inspection: Rash, inflammation, warmth, erythema, deformity, limb length discrepancies
- Laboratory studies: See table below for appropriate workup based on H&P.
- History: Time of onset, mechanism (trauma, change in activity), location, severity, radiation, effect on ADLs, aggravating or alleviating factors. Ask about fever, recent infections (viral or GABHS), weight loss, back, abdominal pain, cough, joint swelling, stiffness, erythema, incontinence, recent IM injection (sterile abscess). Prior h/o of family h/o cellulitis/abscesses or sickle cell disease connective tissue disease, IBD, or bleeding or neuromuscular disorder.
Category | History | Physical Examination May Reveal | Laboratory Studies | Radiology |
|---|---|---|---|---|
Traumatic | High–impact fall | Localized pain, swelling, loss or ↓ ROM | None unless infection is suspected | X-rays |
Infectious | Fever, chills, erythema, induration, pain | Guarding, warmth, erythema, induration, discharge | CBC, ESR, CRP, blood cx, joint aspirate, skin or abscess culture | X-rays, MRI (deep infection or onset <1–2 weeks prior), bone scan (unclear site) |
Inflammatory | Acute onset | Guarding, can bear weight, allows passive ROM ± swelling, ± erythema | CBC, ESR, CRP | X-rays |
Chronic: Pain >6 mo ± FHx of RA | Warmth or erythema, one or more joints | CBC, ESR, CRP, joint aspiration | ||
Neoplastic | Night pain, pain unrelated to activity, not relieved by OTC meds, ± fever | Mass, local tenderness | CBC, ESR, CRP, Alk Phos, calcium, electrolytes; joint aspirate | X-rays, MRI or CT, bone scan, staging workup |
Congenital | Problem since birth | Deformity, leg length discrepancy, loss of ROM | None | X-rays |
Neurologic | Ataxia, loss of balance, disorganized gait | ↑ or ↓ muscle tone, ↑ or ↓ DTR, cavus foot or claw toes | CK (if DMD is in differential diagnosis) | X-rays |
Developmental | Painless limp (LCP disease), knee pain (LCP disease, SCFE) | Loss of ROM in joints, asymmetric ROM, pain with ROM | None | X-rays |
Septic arthritis | Transient synovitis | |
|---|---|---|
History and physical exam | Fever (usually >101.3°F)*; refusal to bear weight*; warm red, swollen joint; ↓ ROM (may be rigid); if septic hip (hip flexed and abducted); most sxs ∼3 days duration; recent URI (53%) trauma (31%) | Recent URI, low grade to normal temperature, allows passive ROM, can bear some weight |
Laboratory studies | CBC* (↑ WBC, usually >12,000/mm3), ↑ ESR* (usually >40), ↑ CRP (>2) | None required; CBC usually normal, ESR or CRP mild elevation |
Radiologic studies | US of joint (85% show effusion), MRI ⊕ in 88%, radiography (20% reveal joint space widening) | U/S or Ultrasound, MRI not needed unless need to help distinguish from septic arthritis. Consider X-rays to rule out femoral neck fractures. |
Etiology | Staphylococcus aureus (MRSA) > Kingella > Streptococcus pneumoniae > Salmonella; consider GBS in neonates | Postinfectious reactive fluid in joint (joint fluid cx results negative) |
Treatment | Orthopedic emergency (needs immediate drainage), joint aspiration (send for WBC, protein, cx), blood cx Antibiotics: MRSA coverage (eg, vancomycin) + GNR coverage (eg, cefotaxime/gentamicin) ± MSSA, strep coverage (eg, nafcillin) X-rays → modify based on cx results; usual duration, 3–4 wk total | NSAIDS scheduled until symptomatically improved |
- Treatment:
- Irrigation is very important for infection prevention (100 mL NS, sterile water, or tap water per cm laceration)
- Debride devitalized tissue
- If wound appears infected, culture but do not close
- First-degree closure should be avoided in puncture wounds, wounds on hands and feet, and wounds through cartilage
- Antibiotic prophylaxis is not routinely recommended except in special cases (see table below)
- Tetanus vaccine status should be verified for all patients and prophylaxis provided as indicated.
- Rabies prophylaxis:
- Consider when exposure to saliva is sufficient for infection (bite not required); saliva exposure to bats [most common cause in United States], raccoons, foxes, skunks (uncommon in small rodents (squirrels, rats) and rabbits).
- Treatment
- No suspicion → no treatment.
- Any suspicion → attempt to quarantine and observe animal and discuss with local health department.
- High suspicion or animal not in custody → one-time dose of human rabies immunoglobulin (20 IU/kg, with half given IM and half infiltrated locally at the wound site if feasible) followed by 4 IM injections of human diploid cell vaccine (1 mL) to be given on days 0, 3, 7, and 14 (CDC: ACIP Provisional Recommendations for the Prevention of Human Rabies: http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf or MMWR 2010;59(02):1
- No suspicion → no treatment.
- Irrigation is very important for infection prevention (100 mL NS, sterile water, or tap water per cm laceration)
Cats | Dogs | Humans | |
|---|---|---|---|
Percentage | 5–10% | 80–90% | 2–3% |
Appearance | Puncture wounds | Tears and punctures | Moon shaped |
Suture? | Do not close punctures | Can close if <12h old | Can close if <8h old |
Infection rate | 50% | 30% | 60% |
Organisms | Pasteurella multocida, Streptococcus spp., Staphylococcus spp. | Streptococcus spp., Staphylococcus spp., Eikenella corrodens, anaerobes | |
Treat with prophylactic antibiotics | Prophylaxis for all high risk wounds (deep puncture wounds (e.g cat bites), moderate to severe wounds with associated crush injury, wound in area of underlying venous and/or lymphatic compromise, wound on the hand or close to a bone or joint, wounds requiring closure, wounds in compromised hosts (eg, immunocompromised, asplenia or splenic dysfunction) First line: Amoxicillin/clavulanate Second line: First-generation cephalosporin PCN allergic: Doxycycline or clindamycin, + Trimethoprim/Sulfamethoxazole | ||
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