Case # 14: Whirlpool swirling, twisting and turning

A 13-year-old male presents to the emergency department with right testicular pain for one-hour duration. The pain began while having a bowel movement. He had no nausea or vomiting. His exam is notable for a high riding right testicle and tenderness to palpation over the right testicle.

Vitals: T: 97.8, HR: 106, BP: 135/79, RR: 16, Sat: 96% on RA

A bedside ultrasound of the testicles is performed. What do you see?

Answer and Learning Points

Answer

These ultrasound images demonstrates limited flow into the right testicle suggestive of testicular torsion. Manual detorsion was performed at the bedside using the “open-the-book” maneuver with subsequent ultrasound demonstrating return of flow to the right testicle. Urology was consulted, and the patient was scheduled for an outpatient orchiopexy.

Learning Points

The acute scrotum is a presentation that requires timely evaluation and management by the emergency physician. Of all causes of acute scrotum, testicular torsion is the diagnosis that requires the most emergent action because of the limited time window of testicular salvageability.1 Unfortunately, in many clinical settings including urgent cares, clinics, and rural community emergency rooms, it can be challenging to confirm our clinical suspicion in a timely fashion because of the difficulty in obtaining an official scrotal ultrasound. For this reason, POCUS is an important tool for emergency physicians in the diagnosis of patients with acute scrotum.

Ultrasound findings of testicular torsion:

Loss or reduction of color Doppler flow/Spectral Doppler tracings to affected testicle (Must compare to other testicle)

Affected testicle becomes more heterogeneous than other testicle

Adhikari, S. R. (2008). Small parts - Testicular ultrasound. Retrieved from https://www.acep.org/sonoguide/smparts_testicular.html

Thickened, hypoechoic mediastinum

Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. 2009 Sep-Oct;34(5):648-61. doi: 10.1007/s00261-008-9449-8. Review. PubMed PMID: 18709404. 

Whirlpool sign6

Author

Marissa Wolfe, MS4; Amir Aminlari, MD, Emergency Ultrasound Fellowship Director at UCSD

References

  1. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2017 Sep 25. doi: 10.1097/PEC.0000000000001287. [Epub ahead of print] PubMed PMID: 28953100.
  2. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15;88(12):835-40. Review. PubMed PMID: 24364548.
  3. Wang S, Scoutt L. Testicular torsion and manual detorsion. Ultrasound Q. 2013 Sep;29(3):261-2. doi: 10.1097/RUQ.0b013e3182a2d129. PubMed PMID: 23945494.
  4. Adhikari, S. R. (2008). Small parts - Testicular ultrasound. Retrieved from https://www.acep.org/sonoguide/smparts_testicular.html
  5. Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. 2009 Sep-Oct;34(5):648-61. doi: 10.1007/s00261-008-9449-8. Review. PubMed PMID: 18709404.
  6. Kalfa N, Veyrac C, Lopez M, Lopez C, Maurel A, Kaselas C, Sibai S, Arena F, Vaos G, Bréaud J, Merrot T, Kalfa D, Khochman I, Mironescu A, Minaev S, Avérous M, Galifer RB. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007 Jan;177(1):297-301; discussion 301. PubMed PMID: 17162068.
  7. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006 May;25(5):563-74. PubMed PMID: 16632779.

Case # 10: A Mechanical Issue

A 32 year old male was carrying a heavy pipe overhead with his right arm and slipped falling forward, onto the right side. He notes pain in the right shoulder, worse with any movement. His right arm is flexed and internally rotated for comfort.

Vitals: T 98.6 HR 95 BP 143/91  RR 14 O2 98% on RA

A bedside ultrasound of the right shoulder is performed, what is the next best step in management?

Screen Shot 2017-11-18 at 11.09.45 AM

Answer and Learning Points

Answer

Shoulder dislocation reduction. The ultrasound image shows anterior displacement of the humeral head with respect to the glenoid fossa consistent with an anterior shoulder dislocation. A hematoma is also noted within the joint space which is very commonly associated with a traumatic shoulder dislocation. 

Ultrasound diagnosis of anterior shoulder dislocation

Learning Points

    • Ultrasound is useful for both the initial diagnosis and reduction confirmation of a shoulder dislocation, as well as for intra-articular injection of local anesthetic; however in a traumatic dislocation, an initial x-ray should be obtained to evaluate for any associated fracture.
    • To perform the exam, a low frequency curvilinear transducer should be used. The operator should stand behind the patient, on the side of the affected shoulder, and place the ultrasound system directly in front of the patient for easy visualization. The probe should be placed on the posterior aspect of the scapula, parallel and just inferior to the scapular spine. This will allow direct visualization of the glenohumeral joint.
  • Proper probe placement for evaluation of glenohumeral joint.
    • In a normal shoulder the glenoid and humeral head articulate nicely and this can be appreciated on ultrasound with internal and external rotation of the patient's arm, however with dislocation, the humeral head and glenoid will not be aligned. In anterior dislocation, the humeral head will be deep to the glenoid, while in a posterior dislocation, the humeral head will be more superficial to the glenoid.
  • Normal glenohumeral ultrasound anatomy
    • Ultrasound is especially useful to confirm successful shoulder relocation and prevent both a prolonged stay in the emergency department waiting for a post reduction x-ray, as well as re-sedation if this was required for a difficult shoulder reduction.
    • Lastly, this same ultrasound view can be used for in-plane needle guidance to provide intra-articular anesthesia using a lateral needle entry approach.
    • For a 5 minute video tutorial on  ultrasound for shoulder dislocation , click here to watch this excellent video at 5 Minute Sono.
In vivo shoulder reduction!

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.