Rosen & Barkin's 5-Minute Emergency Medicine Consult (704 page)

• Patients with FTS require immediate consultation with a hand specialist and admission.
  
• Patients presenting 24–48 hr may have more conservative therapy to include immobilization, elevation IV antibiotics, and close observation.
  
• Surgical débridement indicated if patient is not improved within the 1st 24 hr, or physical findings are not resolved within 48 hr.
  
• Patients presenting longer than 48 hr require surgical débridement in the operating room.
  
• The hand surgeon may attempt continuous catheter irrigation of the tendon sheath.
  

Infectious or high-pressure etiologies for tenosynovitis should be admitted.

Inflammatory etiologies can be managed as outpatients with appropriate referral.

Stenosing and rheumatoid tenosynovitis

Patients whose etiology is inflammatory should be referred for follow-up within 1–2 wk

• High-pressure injection injuries may have subtle clinical findings, small puncture wounds
  
• Early hand surgeon consultation for suspected infectious etiology or high-pressure injection injuries is paramount
  
• De Quervain tenosynovitis may require thumb spica immobilization in order to improve
  

• Baskar S, Mann JS, Thomas AP, et al. Plant thorn tenosynovitis.
  J Clin Rheumatol
  . 2006;12:137–138.
  
• Mehdinasab SA, Alemohammad SA. Methylprednisolone acetate injection plus casting versus casting alone for the treatment of de Quervain’s tenosynovitis.
  Arch Iran Med
  . 2010;13:270–274.
  
• Torralba KD, Quismorio FP Jr. Soft tissue infections.
  Rheum Dis Clin North Am
  . 2009;35(1):45–62.
  

CODES

• 727.00 Synovitis and tenosynovitis, unspecified
  
• 727.04 Radial styloid tenosynovitis
  
• 727.05 Other tenosynovitis of hand and wrist
  

BASICS

• Rotation of the testicle around the spermatic cord and vascular pedicle
  
• Rotation often occurs medially (two-thirds of cases):
  
  • Ranges from incomplete (90–180°) to complete (360–1,080°) torsion
    
  • Depending on the degree of torsion:
    
    • Vascular occlusion occurs
      
    • Infarction of the testicle after more than 6 hr of warm ischemia
      
• Testicular salvage:
  
  • 73–100% with <6 hr of ischemia
    
  • 50–70% at 6–12 hr
    
  • <20% after 12 hr
    
  • It is still worthwhile to attempt to salvage the testicle up to 24 hr after the onset.
    
• Testicular infarction leads to atrophy and may ultimately decrease fertility.
  

Bimodal distribution of torsion:

• Peak incidences in infancy and adolescence
  
• 85% of cases occur between ages 12 and 18 yr, with a mean of 13 yr.
  
• Torsion is rare after age 30 but still possible.
  

• Congenital abnormality of the genitalia:
  
  • High insertion of the tunica vaginalis on the spermatic cord
    
  • Redundant mesorchium
    
  • Permits increased mobility and twisting of the testicle on its vascular pedicle
    
• The anatomic abnormality is bilateral in 12%, so both testicles are susceptible to torsion.
  

DIAGNOSIS

• Sudden onset of unilateral testicular pain
  
• Scrotal swelling and erythema
  
• Less commonly, torsion may present with pain in the inguinal or lower abdominal area.
  
• Up to 40% of patients may describe previous similar episodes that remitted spontaneously:
  
  • Represents spontaneous torsion and detorsion
    
• Nausea and vomiting occur in 50% of cases.
  
• Low-grade fever occurs in 25%.
  
• There is often a history of minor trauma to the testicle preceding the onset of pain.
  
• Symptoms of urinary infection (dysuria, frequency, and urgency) are absent.
  

• In distinguishing torsion from epididymitis, localized tenderness is helpful early; however, once significant scrotal swelling occurs, the anatomy becomes indistinct.
  
• Torsion of the appendix testis is less painful and does not threaten the viability of the testicle
  
• Characterized by the “blue dot” sign
  
• The affected torsed testicle may lie transversely as opposed to the normal vertical lie.
  
• Cremasteric reflex is frequently absent on the affected side with testicular torsion.
  
• Sensitivity 96%; specificity 66%
  
• Prehn sign:
  
  • Relief of pain on elevation of the testicle in epididymitis
    
  • Worsening or no change in the pain with torsion
    
  • Considered unreliable
    

• The presentation of an “acute scrotum” in a child or adolescent requires rapid assessment and immediate consultation with a urologist.
  
• These patients require noninvasive flow studies or surgical exploration to confirm torsion.
  
• 3.3 (ED)–30% (Urology service) of these patients ultimately prove to have testicular torsion.
  

• Elevated WBC count with a left shift is present in 50% of cases.
  
• Urinalysis is usually normal, but up to 20% of cases of torsion include pyuria.
  
• There are no lab tests specific for testicular torsion.
  

• All imaging techniques have technical limitations in infants:
  
  • Testicular vessels are very small.
    
  • Amount of blood flow to the testicle under normal conditions is minimal.
    
• Scrotal exploration may be required.
  

• Scrotal exploration can be done rapidly under local anesthesia to diagnose and treat torsion.
  
• The “bell-clapper” deformity of both testicles should be corrected by orchiopexy.
  

• Acute hydrocele
  
• Epididymitis/orchitis
  
• Henoch–Schönlein purpura
  
• Incarcerated inguinal hernia
  
• Testicular neoplasm
  
• Testicular trauma or rupture of the testicle
  
• Torsion of the appendix testis (31–70% of acute scrotum cases)
  
• Other intra-abdominal conditions:
  
  • Appendicitis
    
  • Pancreatitis
    
  • Renal colic
    

TREATMENT

• There is no definitive treatment that can be rendered in the field.
  
• Pre-hospital personnel must recognize the urgency of acute testicular pain in young patients.
  
• These patients should be transported to the ED immediately.
  

IV fluid, analgesics as appropriate

• Rapid triage and assessment
  
• Exam of testicle to exclude primary neoplasm
  
• Establish the diagnosis and mobilize appropriate urologic care.
  
• Applying an ice pack to the scrotum relieves pain:
  
  • May prolong the viability of the ischemic testicle
    
• If definitive care is likely to be delayed beyond 4–5 hr from the onset of torsion, manual detorsion may be attempted (26.5–80% successful).
  
  • Externally rotate the affected testicle opposite the usual medial direction of torsion.
    
  • Continue until pain is relieved, normal anatomy is restored, or Doppler US shows return of flow.
    
  • All patients who undergo manual detorsion must be surgically explored.