436 Emergency Medicine
to help decrease swelling. In addition, a dorsal penile nerve block can be used
for analgesia making it easier to perform a manual reduction.
Dorsal slit or circumcision (b)should be considered after the initial
attempts at manual reduction have failed and typically in consultation with
a urologist. Topical lidocaine (c)is not described for treatment of this con-
dition. Topical steroids (e)can be considered in the treatment of phimosis,
not paraphimosis. Catheterization (d)is rarely indicated as most paraphi-
moses are retractable in the ED and urinary retention is uncommon.
396.The answer is a.(Fleischer and Ludwig, pp1614-1617. Rosen, pp 2606-
2608.)The patient’s clinical presentation is consistent with malrotation
with midgut volvulus.Malrotation occurs when there is an inappropriate
fixation of the intestines at the ligament of Treitz during fetal life. The inci-
dence is uncertain but it is believed to approximate 1 in 500 live births with
a male to female ratio of 2:1. Signs and symptoms of malrotation may be
nonspecific and include vomiting, which is characteristically bilious, and
abdominal distension. Up to 25% of cases present after 1 year of age. The
most catastrophic presentation of malrotation occurs when the abnormally
fixed mesentery twists around itself and the superior mesenteric artery lead-
ing to bowel infarction, shock, sepsis, and death. All of which can all occur
within a few hours. The definitive diagnostic study of choiceis an upper
GI series.Contrast in the gut will fail to demonstrate the classic “C-loop” of
the four parts of the duodenum and instead show the “corkscrew” appear-
ance classic of this condition. Some physicians begin the workup with a plain
film of the abdomen looking for air fluid levels, dilated loops, or pneumatosis
coli that can be seen in patients with severe distention. The classic plain film
finding is that of the “double bubble”. However, plain films are less sensitive
and specific than an upper GI series.
Ultrasound(b)is not the imaging modality of choice for malrotation.
It is commonly used to diagnose pyloric stenosis. Physical findings (c)are
nonspecific and cannot be relied on to make the diagnosis. CBC, elec-
trolytes, and urine analysis (d)will not provide sufficient information to
rule this disease out but may show electrolyte abnormalities, dehydration,
leukocytosis, and elevated specific gravity. Serum lactate (e)rises late in the
disease process and is an indicator of ischemia.
397.The answer is e.(Fleischer and Ludwig, pp 1538-1544.)The patient’s
presentation and radiographic findings are consistent with a supracondy-
lar fracture.Supracondylar fractures are the most common type of elbow