Testicular torsion this month – a surgical emergency with good outcomes if operated on less than 6 hours since the pain started.
Also, links to helpful health and well being websites for young people and to good ECG CPD for psychiatrists and GPs. A bit more on ADHD and a round up of neck lumps in infants, assessment and management.
Do leave comments below.
Please do leave comments below.
Remote assessment of children the Wessex way this month, tight foreskins, difficult airways and a journal club discussion around the likelihood of meningitis in neonatal UTI. Do leave comments below…
April 2020: The start of “surgical paediatric pearls” series this month, a reminder that the NHS is open for children during the COVID period, DKA update and frontline assessment of anorexia nervosa. Do leave comments below:
March 2016: a few odds and ends on asthma this month and assessing a child in an acute exacerbation, Childline survey, Meningococcus W and paediatric neck lumps. Do leave comments below:
BCG Lymphadenitis with thanks to Dr Mujahid Hassan
Lymphadenitis is the most common complication of BCG vaccination, and is of two types – suppurative and non-suppurative.
Normal course post-vaccination:
Intradermal injection -> local multiplication of vaccine -> transport to lymphatics via lymph glands -> haematogenous dissemination of BCG.
No clear definition of ‘BCG lymphadenitis,’ proposed definition is when it becomes palpable or concerning for parents.
Can appear as early as two weeks after vaccination, most within 6 months and almost all cases will be within 24 months.
Normally ipsilateral with one or two palpable lymph nodes, but can involve multiple nodes. Normally axillary but can be with cervical/supraclavicular.
Diagnosis:
Non-suppurative will resolve within a few weeks – this is a normal reaction and most of these are sub-clinical so go unnoticed.
Suppurative involves an enlarging lymph node with fluctuant appearances, oedema and erythema. Happens in ’30-80%’ of cases of lymphadenitis.
Treatment of suppurative lymphadenitis:
Antibiotics: Previously erythromycin/rifampicin/isoniazid have been used but their clinical role is of dubious significance, so are not used routinely.
Reassurance and followup are what is needed.
Fine Needle Aspiration: Suppurative lymphadenitis can result in spontaneous perforation and sinus formation, which can result in several unpleasant months of dressing and wound care. FNA is thus recommended to prevent this and reduce time for healing.
Surgical excision: Risks of general anaesthesia – other than in extreme cases of failed FNA/multiloculated lymph nodes – far outweigh the potential benefits.
Non-suppurative
Suppurative
Management pathway and images courtesy of:
WM Chan, YW Kwan, CW Leung. Management of Bacillus Calmette-Guérin Lymphadenitis, Hong Kong Journal of Paediatrics (New Series). Vol 16. No. 2, 2011, available via http://www.hkjpaed.org/details.asp?id=782&show=1234
References:
J Goraya and V Virdi, Bacille Calmette-Guérin lymphadenitis, Postgrad Med J. 2002 June; 78(920): 327–329,
available via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742390/pdf/v078p00327.pdf
Neglect and emotional abuse is the safeguarding topic this month. ED advice on the management of minor head injuries, a report from BPSU in hypocalcaemic fits secondary to vitamin D deficiency, the new UK immunisation poster and a bit on crying babies. Hope you find it all helpful. Comments welcome below
A timely reminder of an albeit old guideline on otitis media this month, continuation of our minor injuries series and introduction to a new series on sleep disorders. Also a link to a new Whipps “1st afebrile fit” guideline and a bit of background on hypospadias.
With thanks to Dr Nikolina Kyprianou for this article and to Mr Devesh Misra, consultant paediatric urologist at the Royal London Hospital, for checking it.
Hypospadias is a congenital abnormality where the male urethral opening is displaced ventrally. It may be displaced anywhere within the glans, the shaft of the penis, the scrotum, or the perineum. It results from failure of the urethral folds to close during fetal development and it is often associated with abnormal penile curvature (chordee) due to disrupted development of the penile shaft. Males with severe uncorrected forms of hypospadias may have difficulties in controlling their urinary stream which may require urination in a sitting position. They can also have erectile dysfunction and infertility (due to impaired semen delivery).
Severity
The location of the urethral meatus classifies the hypospadias and its severity.
Figure 1. Different types of hypospadias
3 classes of severity:
Pathogenesis
Hypospadias results due to disruption of the androgenic stimulation that is required for the normal male external genitalia to develop. Environmental factors have been found to be associated with hypospadias suggesting a multifactorial aetiology. These include:
Incidence
Hypospadias is one of the most common congenital abnormalities with an incidence from 0.3 to 0.7% in live male births. It is more common in the Caucasian population and in those of Jewish and Italian descent.
Diagnosis
The diagnosis is usually made during the newborn examination. Physical findings include:
In 6% of cases the foreskin is normal and the urethral abnormality only becomes evident during/after circumcision when the glans of the penis is visualised.
Evaluation
Isolated hypospadias: this is only rarely associated with upper genitourinary tract abnormalities and therefore there is no need to
routinely perform imaging studies of the tract.
Cryptorchidism and hypospadias: these patients have an increased risk of disorders of sex development. Cryptorchidism is present in 10% of
patients with hypospadias and is higher in patients with proximal hypospadias (eg. scrotal or perineal urethral meatus). Proximal hypospadias on its own is also associated with disorders of sex development. These patients should be referred to a specialist so that they can have the following investigations:
Hypospadias with other organ system anomalies eg. Congenital cardiac disease, imperforate anus, limb malformations, or cleft lip. These patients require renal and bladder USS because they are at risk of upper tract abnormalities. They should be referred to a specialist who will also perform genetic testing.
Management
Parents should be advised not to circumcise their baby in order to preserve the foreskin and optimise later surgical choices. These patients need to be referred to the local paediatric urologist who will determine the severity of the hypospadias and the need and timing for surgical correction.
The goal of surgery is to create a straight penis by repairing any curvature (orthoplasty), to create a urethra with its meatus at the tip of the penis (urethroplasty), to reform the glans into a more natural conical configuration (glansplasty), to achieve cosmetically acceptable penile skin coverage, and to create a normal-appearing scrotum. Surgery is usually performed within the first year of life because early correction is associated with improved wound
healing, reduced rate of complications and improved emotional and psychological result. The repair is usually planned as a single-stage procedure, but in infants with severe hypospadias a two-stage repair may be necessary.
Prognosis
With the use of modern instruments, sutures and antibiotics and by performing the procedure at a younger age, the repair of hypospadias has been successful.
For a useful leaflet for parents please follow link and download the PDF document: http://www.patient.co.uk/health/Hypospadias.htm
References:
Baskin LS, Erol A, Li YW, Cunha GR. Anatomical studies of hypospadias. J Urol 1998; 160:1108.
Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg 2006; 41:463.
Carlson WH, Kisely SR, MacLellan DL. Maternal and fetal risk factors associated with severity of hypospadias: a comparison of mild and severe cases. J Pediatr Urol 2009; 5:283.
Brouwers MM, Feitz WF, Roelofs LA, et al. Risk factors for hypospadias. Eur J Pediatr 2007; 166:671.
With thanks to Dr Jess Spedding for the continuation of her minor injuries series….
Minor Injuries Series, part 2: The Elbow Xray and Supracondylar fracture:
The elbow xray typically strikes fear into the heart of clinicians as there are so many centres of ossification which appear at different stages of a
child’s development and can quite easily be mistaken for bony injury. Remember that the smooth rounded appearance of a centre of ossification does not often mimic the typically sharp edges of a new fracture fragment, but even saying this, distinction can be very difficult. If you have the CRITOL (or CRITOE) acronym in your mind, it will help you to interpret the xray with a sensible approach. The image below highlights each of the six ossification centres with the typical age of the child when each centre appears:
Note: Lateral / External epicondyle are interchangeable terms, giving either CRITOL or CRITOE
Work through in order the centres of ossification – each may appear at slightly different ages in different children, but the sequence in which they
appear should always be C,R,I,T,O,L. For example in a 6 year old you would not expect the lateral condyle to have appeared yet, so if there is a bony fragment at that site, it is suggestive of a fracture.
Supracondylar Fractures:
The supracondylar fracture (of the distal humerus) is the most common upper limb fracture in young school age children. It presents almost always as
a FOOSH (fall on the outstretched hand). They are likely to be in a lot of pain, and may need strong analgesia and immobilisation (with a splint or
sling) before assessment is possible. (A good example of a strong, rapid acting, well tolerated analgesic that can be used in the Emergency Department is intranasal diamorhpine, which is made up with saline into a small volume of fluid and then given as nose drops with a syringe.)
You may well see bruising and swelling around the elbow, with tenderness around the distal humerus, but remember to check the whole limb including
clavicle (and the whole of their body if the mechanism of injury could have caused other serious injuries!)
The elbow contains numerous important neurovascular structures – your assessment must document presence of radial pulse, capillary refill time in
fingertips and function of ulnar, median and radial nerves (not possible formally in younger children, so watch to see if they will hold a toy or parents hand
and be suspicious if the xray shows a displaced fracture). Any concerns about neurovascular compromise require the fracture to be urgently reduced, either by the Emergency Department team or referral to Orthopaedics. This initial reduction is to relieve mechanical pressure of displaced bony fragments on the
neurovascular structures and will not provide the stability required for neatly aligned healing, so a trip to theatre for fixation will happen soon after.
A common classification system for supracondylar fractures is the Gartland classification. In this there are three categories of supracondylar fractures based on their radiological appearance on the lateral elbow view:
1: undisplaced – recognised as clinical suspicion plus xray evidence of fluid in the elbow joint elbow (as demonstrated by a raised anterior fat pad or
the presence of a posterior fat pad) and possibly loss of anterior humeral line (normal is when line along anterior humerus intersects middle third of
capitellum)
2. visible fracture which is hinging on the posterior edge
3. totally displaced
Type 1 can usually be managed conservatively with an above elbow cast and sling, whilst 2 and 3 require operative fixation.
All should be followed up by Orthopaedics in fracture clinic – typical progress is evidence of union at 4 weeks, and then the patient is encouraged to
gradually do away with the sling, to allow mobilisation without too much discomfort.
A rare but debilitating late complication of supracondylar fractures is Volkmann’s ischaemic contracture (when the brachial artery is damaged and months later the patient develops clawing of the thumb and fingers and forearm wasting).