A football player sustains a finger injury in a preseason scrimmage. He reports getting his finger caught in another team member’s jersey. His right ring finger is tender on the volar surface, and is swollen around the distal interphalangeal joint. He is unable to flex at the distal interphalangeal joint, but can flex at the proximal interphalangeal joint and at the metacarpophalangeal joint. Radiographs do not show any bony abnormality.
You would now:
Correct Answer A: This injury is commonly called jersey finger. It is a tendinous rupture, sometimes with a bony avulsion fracture of the flexor digitorum profundus tendon. The tendon usually retracts, which makes nonsurgical treatment unlikely to result in complete healing. Splinting in hyper-extension will distract the two ends of the tendon and it will not heal. A cast or flexion splint is unlikely to lend itself to complete healing because the tendon ends are unlikely to reattach to each other.
A high incidence of osteonecrosis of the femoral head occurs with:
Correct Answer A: Femoral neck fractures disrupt the blood supply to the femoral head, which can lead to osteonecrosis. This does not occur with the other types of fractures.
While examining a male infant during a routine well child visit, you palpate only one testicle within the scrotum.
Which one of the following is true concerning this problem?
Correct Answer B: Over 4% of boys have an undescended testis at birth. The incidence is higher in premature infants. The majority of undescended testes spontaneously descend before the age of 3 months. If the testis has not descended by 6 months of age in a term infant, it will remain undescended
Infertility and testicular malignancy are associated with undescended testes. The risk of testicular malignancy is thought to be 4-10 times higher in patients with a history of an undescended testis, and higher sill in those with bilateral undescended testes, compared to the general male population. Orchiopexy does not reduce the risk of testicular cancer, which peaks between 15 and 45 years of age. Hormonal treatment with LH-RH of hCG, used in Europe, has not been shown to be effective in randomized, controlled trials. Orchiopexy between 9 and 15 months is the recommended treatment for undescended testes. After orchiopexy, fertility is maintained in 85% of unilateral cases and 50%-65% of bilateral undescended testes.
Which one of the following is true regarding testicular torsion?
Correct Answer C: Testicular torsion is the most common cause of spontaneous testicular pain in boys age 12 years and older and is uncommon before 10 years of age. There is inadequate fixation of the testis within the scrotum, resulting in excessive mobility. Shortly after torsion, there is acute pain and swelling of the scrotum, which is very tender. The normal cremasteric reflex is nearly always absent. The differential diagnosis includes strangulated inguinal hernia, which most often causes inguinal swelling, unlike torsion. There is no antecedent association of hydrocele with testicular torsion.
Spermatogenesis can be lost within 6 hours of the loss of blood flow, making prompt diagnosis and surgical detorsion and fixation essential. Either a 99mTc-Pertechnetate flow scan of colour Doppler ultrasonography is about 95% accurate in determining flow, but results can be misleading if torsion is less that 360˚. These tests are reasonable, but should not delay surgical intervention given the small window of therapeutic opportunity.
While performing a vasectomy on a 33 year old male, you are unable to definitely identify the left vas deferens. You take some time to try and find the vas, but the patient is becoming very uncomfortable. You can easily isolate the right vas. The patient has fathered three children and has no difficulty with erectile function. The examination of his external genitalia was normal.
What should you do next?
Correct Answer D: If a vas cannot be located by an experienced surgeon, the possibility of congenital absence of the vas must be considered. This is usually associated with agenesis of the ipsilateral kidney. The vas which can be palpated should be ligated, and a semen specimen checked at the usual time.
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