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Chapter 13. Emergency Medicine

eFigure 13-1
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Algorithm for the management of fever without localizing source in patients 0 to 2 months of age. (Adapted from Texas Children's Hospital: Evidenced based clinical guideline on fever without localizing signs 0–60 days old).

eFigure 13–2
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Algorithm for the management of fever without localizing signs in patients 2 to 36 months of age. (Adapted from Texas Children's Hospital: Evidenced based clinical guideline on fever without localizing signs in 2–36 mo.)

Comparison of Testicular Torsion, Epididymitis, and Torsion of Testicular Appendage

eFigure 13–3
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Algorithm for differential diagnosis and treatment of fever with petechiae/purpura. (Adapted from http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5270.)

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Differential diagnosis of scrotal swelling.

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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†

  • Prepubertal: Most commonly no antibiotics required; may consider Trimethoprim–sulfamethoxazole
  • Sexually active: Ceftriaxone + azithromycin/doxycycline

Scrotal support (briefs) NSAID

Resolves within 2–12 days

*Relief of pain with elevation of testicle.

†Etiologic agents include coliform bacteria, viruses in prepubertal boys and Neisseria gonorrhea, Chlamydia in adolescents.

  • Definition: Uneven alteration in natural gait (secondary to pain, weakness, deformity).
  • Etiology: Trauma is the most common cause of limp. See the table below for causes of limp when there is no history of trauma.

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% 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%

*Adapted from: J Bone ...

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