Varicoceles and Jones Fractures

Hey Team,

Two quick items from yesterday!

Varicoceles

• Anatomy and why laterality matters

  • Varicoceles are dilated pampiniform plexus veins.

  • Left-sided varicoceles are far more common because the left gonadal vein drains into the left renal vein at a right angle, creating higher venous pressure.

  • The nutcracker effect (compression of the left renal vein between the SMA and aorta) further increases left-sided venous pressure and explains why most varicoceles are unilateral left or bilateral.

  • Right-sided isolated varicoceles are uncommon, since the right gonadal vein drains directly into the IVC, a low-pressure system.

See how the left gonadal vein takes a hard turn into the left renal vein and then gets squished a bit by the SMA? The right gonadal vein has a smooth shot back into the IVC. This is what makes right-sided varicoceles rarer and more concerning. Source: Step 1 Medbullets

• Clinical features

  • “Bag of worms” fullness above the testis, more prominent when standing or with Valsalva, and decompresses when supine.

  • May cause dull, aching scrotal discomfort; often asymptomatic.

  • Can be associated with left testicular atrophy due to increased temperature impairing spermatogenesis.

  • Possible association with subfertility

• Diagnosis in the ED

  • Primarily clinical. Consider bedside ultrasound when the exam is unclear or to evaluate acute scrotal pain.

  • Diagnostic US findings: dilated veins ≥3 mm, increased caliber with Valsalva, and assessment of testicular volume.

• When EM clinicians should worry

  • Isolated right-sided varicocele, especially if: new in onset, large or nonreducible, associated with systemic symptoms

  • These raise concern for retroperitoneal obstruction, thrombosis, or mass effect (including renal malignancy).

  • Initial step is scrotal US; if confirmed and suspicious, consider CT or MRI abdomen/pelvis.

• Relevance to fertility

  • Chronic increased scrotal temperature can impair spermatogenesis.

  • Nonurgent outpatient urology follow-up is appropriate for fertility counseling

References:

• Shridharani A, Lockwood G, Sadeghi-Nejad H. Varicocele: Clinical presentation, evaluation, and management. Rev Urol. 2017;19(2):83-89.

• Leslie SW, Sajjad H, Siref LE. Varicocele. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2025-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448113/

• UpToDate. Nonacute scrotal conditions in adults. Available from: https://www.uptodate.com/contents/nonacute-scrotal-conditions-in-adults?search=varicocele&source=search_result&selectedTitle=1~15

Jones vs Pseudo-Jones

Source: Zones of the 5th Metatarsal (wikifoundry.com)

• Pseudo-Jones (Zone 1 – Tuberosity Avulsion)

  • Avulsion off the 5th metatarsal tuberosity.

  • Good blood supply; low risk of nonunion.

  • Management

    • Walking boot or hard-soled shoe

    • Weight bearing as tolerated

    • Routine outpatient follow-up

• Jones Fracture (Zone 2 – Metaphyseal-Diaphyseal Junction)

  • Fracture at the watershed vascular zone 1–2 cm distal to the tuberosity.

  • High risk of delayed union/nonunion due to poor blood supply.

  • Management

    • Non-weight bearing

    • Posterior splint or CAM boot

    • Ortho follow-up (early referral for athletes or high-demand patients

• Misclassification often leads to premature weight bearing and failed healing.

Vascular Watershed Zone (orthobullets.com)

For more information—take a look at Orthobullets – 5th Metatarsal Base Fractures and CORE EM

Cheers,

Dillon