BELL'S PALSY

A 29-year-old woman presents to the ED with a complaint of sudden onset of left facial weakness that was noticed by her coworker. She denies fever, rash, or any other symptoms. On physical examination, she has no other neurologic deficits other than what is shown . When asked to shut her left eye, she cannot. Which of the following is the most likely diagnosis?
A. Bell palsy
B. Malingering
C. Ramsay Hunt syndrome
D. Brain tumor

answer: A. Bells palsy.

The woman in the image demonstrates a Bell smile. Bell palsy is paralysis of the facial nerve and is one of the most common neuropathies of the cranial nerves. It typically occurs with abrupt onset, and is usually unilateral. Cranial nerve VII, the facial nerve, has 2 components, both of which may be affected. One portion comprises efferent fibers that stimulate the muscles of facial expression. The other portion contains taste fibers to the anterior two thirds of the tongue, and secretomotor fibers to the lacrimal and salivary glands. The path of the facial nerve is complex; which makes it vulnerable to injury. The definition of Bell palsy is mononeuropathy of the facial nerve, although other cranial nerves are sometimes affected. This paralysis is believed to be a result of inflammation of the nerve, possibly secondary to infection from Lyme or herpes zoster. Weakness and paralysis involves the entire face on the affected side. In supranuclear lesions (upper motor neuron) such as a cortical stroke, the upper third of the face is spared although the lower two thirds are paralyzed. This is because the orbicularis, frontalis, and corrugator muscles are innervated bilaterally. In addition, Bell palsy may cause decreased lacrimation, salivation, and decreased taste (ageusia). Treatment includes high-dose steroids in a short burst followed by tapering with lower doses. Treatment is most effective if administered within 48 hours. The addition of acyclovir may decrease resolution time. It is also important to have the patient tape his or her eyelid shut during sleep and to use liquid tears during the day to prevent drying and injury to the cornea. (B) Malingering is the intentional production of
false or exaggerated symptoms motivated by primary or secondary gain, such as to obtain compensation or drugs, to avoid work or military duty, or to evade criminal prosecution. (C) Acute facial paralysis that occurs in association with herpetic blisters of the skin of the ear canal, auricle, or both is referred to as Ramsay Hunt syndrome, or herpes zoster oticus. (D) Brain tumors typically cause central nervous system (CNS) defects. (E) Because a cerebrovascular event is centrally occurring, sparring of the upper third of the face is seen.

BOUTTONIERE DEFORMITY.

A 33-year-old chef presents to the ED with a complaint
of a deformity in his finger. He states that a few weeks ago he sustained a deep laceration over the dorsum of his finger but never sought medical attention for it. On examination, the wound is
well-healed, but there is an obvious deformity as shown in the pic below. Which of the following is the most likely diagnosis?
A. Swan-neck deformity
B. Boutonniere deformity
C. Bell-clapper deformity
D. Mallet finger deformity

 answer: B. Boutonniere deformity may manifest acutely following trauma, but most are found weeks
following the injury or as the result of progressive arthritis. 
The proximal interphalangeal (PIP) joint of the finger is flexed, and the distal interphalangeal (DIP) joint is hyperextended.
The deformity is due to a disruption of the central slip, which is the main component of the
extensor mechanism at the PIP joint. Weakening or disruption of the central slip, with compromise of
the triangular ligament results in volar migration of the lateral bands of the PIP joint. As the deformity
progresses, the newly dominant flexor superficialis creates constant flexion at the PIP joint. As
the intrinsic muscles (lumbrical and interosseous) lose their insertion into the middle phalanx due to
the incompetent central slip, their force is diverted entirely through the lateral bands. Over time, these
lateral bands migrate palmarly and contract. This is accompanied by secondary shortening of the
oblique retinacular ligaments. Subsequently, these changes cause hyperextension at the DIP joint.
(A) A swan-neck deformity, typically defined as PIP joint hyperextension with concurrent DIP joint
flexion that occurs in ~50% of patients with rheumatoid arthritis.
(D) A Mallet finger occurs when the extensor tendon of a finger is either forcibly stretched or avulsed from the distal phalanx and tdistal portion of the finger hangs in flexion.
 (C) A bell-clapper deformity occurs when there is failure of normal posterior anchoring of the gubernaculum, epididymis, and testis. The bell-clapper deformity allows the testicle to twist spontaneously on the spermatic cord that causes venous occlusion and engorgement, with subsequent arterial ischemia causing infarction of the testicle. It is not relevant to orthopedic injuries.