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This is Pediatrics week five case one and

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the diagnosis were considering is testicular torsion.

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This is a scrotal ultrasound

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and this is a teenage patient

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with pain.

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And concern for torsion. And so this is the first line

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Imaging modality. It's sufficient to

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make the diagnosis and decide whether the patient

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needs to go to surgery with the urologists or maybe merely

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receive some medication or conservative management. So

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we're going to scroll through our very first image here reveals

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a lot of fluid in the scrotum. So we know we have at least

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a hydrocele. This is a sign of inflammation. Something is not happy

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in this scrotum and we're gonna scroll through

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we're gonna get some images of the right testicle and one of the things

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that I notice right away about this testicle is it's a demitus

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in fact, if you bear with me and look

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at a very magnified view of the testicle, there's

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lots of little hypochoic lines

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zigzagging through the echo texture

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of the testicle. I'm going to zoom back out, but basically

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what's happening is there's fluid infiltrating

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in between the parenchyma of

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this testicle. So it's swollen and that's a

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sign of inflammation. It's also just

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Just a little more hypoechoic. It's

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a little darker than I'd like to see and when we put Doppler

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signal on it. We're really not seeing any we see

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some Doppler signal over here. We see some over there. This is

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artifacts this motion artifact and I wouldn't take that too seriously.

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and here we've got a couple of

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images demonstrating the grayscale with the color

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Doppler see our color bar here, but there's no color signal on

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that testicle. So we're concerned. We've got seemingly no

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blood flow an indemnus testicle fluid

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infiltrating. It's enlarged. It's

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swollen. So what happens when the testicle twists the

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first thing as you rotate around

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that testicle the first thing that gets pinched off is the

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lymphatic channels and then the second thing is the paniform Venus

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plexus. So it's possible to have partial torsion where

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fluid can work its way into the testicle

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via the arteries but not back out and that's

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why the edema occurs and as you continue to twist

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that testicle even the arteries are occluded they're

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pinched off.

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Once all three of the arteries supplying the

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testicle are gone are occluded then we

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start to see the risk of necrosis. So at

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this point, I don't see signs of necrosis. I see an

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endemitous testicle. It's an at-risk testicle, but it might

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still be salvageable. So this is a surgical emergency and we're

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just going to take a few more pictures. We can see fluid

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and look at this the spermatic chord.

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Look at this almost.

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Swirled pattern where you see layers and

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layers of circle. This has been described as the snail

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sign. So bear with me it's sort of

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a circular kind of swirling pattern here.

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And that is the twisting of the spermatic cord

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in the vessels. And that's exactly why they're occluded the lymphatics

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the veins we can see some vessels in

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there. There's blood pumping in there but not making it all the way to the

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testicle. So we've got cream hysteric artery probably

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the the least significant vascular Supply then

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we've got the gonadle testicular artery. That's a big

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one and it's being occluded and then we have the differential artery

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the artery to the vast deferens. That's probably

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my favorite of the three differential artery seems

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like it opens the door for everyone and is very humble and submissive. That's

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a dad joke. I'm gonna move along. Anyway, all

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three arteries are gone and we have no

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blood flow. If you look at the other testicle on the other side we've

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got

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Not nearly the same degree. Let's get over to

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the left side. Here we go. Not nearly the same degree of Edema. We

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can see the mediastinum testis. We

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can see not really significant fluid around

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it. And then when we put Doppler flow on this testicle, it

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looks just fine. So this is a unilateral right testicular

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torsion. If we were doing a physical exam, we

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would expect that tourist testicle to be higher and it

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needs to go to surgery right away. That's the end

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of the case.