Most of the deaths from rabies in North America are due to bat bites. The bites can be very inconspicuous. Awakening from a deep sleep with bats in the room, or a mentally disabled or intoxicated person left unattended and found in the presence of bats is an indication for post-exposure prophylaxis.

If the patient had been previously vaccinated for rabies, additional vaccine booster would suffice.

If the animal was a known neighbourhood pet (dog, cat, ferret) and could be observed for 10 days, no immediate treatment would be required beyond wound irrigation, unless the animal were to display signs of rabies.

Ribavirin is part of the Milwaukee protocol which is a last-ditch effort when people start to develop signs and symptoms of rabies. The protocol is not very effective.

This patient requires the full post-exposure prophylaxis protocol of HRIG and vaccination (5 doses).

Some tips to decrease the pain associated with injecting local anesthetic:

1) Use a fine gauge needle (27 or 30)
2) Inject slowly. This way the anesthetic is able to numb the pain of stretching caused by the injection.
3) Add sodium bicarbonate to the anesthetic in a 10:1 ratio
4) Poke perpendicular to the skin rather than at an angle
5) Inject into tissues before advancing the needle through them

Using these techniques its possible to freeze a relatively large area without discomfort. Ideally the patient should only feel slight pain from the initial poke.

ECRL inserts into the base of the second metacarpal. ECRB inserts into the base of the third metacarpal.

The first step in the management of this patient should be to attempt closed reduction under local anesthesia.

In general, indications for operative treatment include open fracture, irreducible fracture, unstable fracture following closed reduction.

Nail bed injuries are common with distal phalanx fractures because of the close proximity of both structures. If a subungual hematoma greater than 50% is seen, one should consider exploration and repair of the nail bed (some sources say greater than 25%).

This injury, the mallet finger, results when the extensor mechanism is disrupted, either by avulsion from the distal phalanx or tendon rupture. If untreated it may lead to a swan-neck deformity in susceptible individuals (those who have hyperextensible PIP joints). Splinting the DIP joint in full extension is the treatment of choice, although K-wire fixation may also be used. Tendinous injuries require 6-8 weeks of continuous immobilization, and bony avulsion injuries (evident on X-ray) require 4-5 weeks of immobilization.

http://emedicine.medscape.com/article/1242305-overview

The ideal answer for treatment of mallet finger is spling the DIP joint in extension for 6 WEEKS. The duration of splinting is the most important and is not included in the answer.

The lateral bands insert on the distal phalanx and when disrupted result in a mallet deformity (hyperflexion of DIP joint). The swan neck deformity is flexion of the DIPJ and hyperextension of the PIPJ. The boutonniere deformity is hyperextension of the DIPJ and flexion of the PIPJ.

ECRB is the prime wrist extensor and it is most centrally located, so the transferred tendon is sutured into it. Pronator teres works very reliably and is the classic transfer for restoring wrist extension.

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This question is correct but I just wanted to mention that we should not loose focus on the goal of this website. This is a very advnaced question:) Tendon transfers are >PGY-3 level and our population is medical students and family physicians.

The patient underwent a Hall-Findlay type breast reduction (vertical skin resection, medially based pedicle). As with any technique that involves vertical skin resection, it is normal for the skin to pucker at the inferior end of the incision. No mistake was made. The pucker should settle down with time, but if it does not a revision may be considered at one year post-op. At only 5 months post-op it is likely premature to commit to a revision.

The facial nerve emerges from the stylomastoid foramen, so you may use the styloid and mastoid processes as landmarks.

The facial nerve crosses over the retromandibular vein, so you may locate the nerve by following the vein.

Tracing backwards from a branch works. Probing at random locations throughout the parotid with a nerve stimulator is not an effective way to locate the facial nerve.