Talipes (Neonatal Clubfoot) with thanks to Dr Mujahid Hasan and the paediatric physiotherapy department at Barts Health
Newborn babies can present with one of two types of Talipes:
Click here for the Whipps Cross physiotherapists and Muj’s complete, illustrated article.
The information for this topic is taken from a recent comprehensive review (August 2012) that appeared in www.UpToDate.com. Bartshealth employees can access the full text via a link from the intranet.
Ingested foreign bodies (UptoDate.com article, August 2012)
Coins — Coins are by far the most common foreign body ingested by children. Approximately two-thirds of ingested coins are in the stomach by the time of x-ray but those that lodge in the oesophagus for 24 hours after ingestion may need to be removed endoscopically as only 20-30% of these will pass into the stomach on their own. Coins that reach the stomach can be managed expectantly, and most will be passed within one to two weeks. A child who develops any signs or symptoms of obstruction, abdominal pain, vomiting, or fever, needs to come back to the ED urgently.
Button batteries — ingestions of “button” batteries are increasing and are associated with significant morbidity. Animal studies have demonstrated mucosal necrosis within one hour of ingestion and ulceration within two hours, with perforation as early as eight hours after ingestion. It may be difficult to differentiate between a disk battery and a coin on a radiograph. This distinction is most important when the foreign body is in the oesophagus, since batteries require immediate removal whereas coins may not.
Magnets — also increasing. Many of the children with complications from multiple magnet ingestion had underlying developmental delay or autism. In one case, an older child inadvertently swallowed these magnets while using them to imitate a pierced tongue. Two or more strong magnets, especially if ingested at different times, may attract across layers of bowel leading to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction. Radiographs of the neck and abdomen should be performed, including a lateral view. X-rays cannot usually determine whether bowel wall is compressed between the magnets, although the finding of magnets that appear to be stacked but are slightly separated is suggestive. Management depends on the number, location and type of magnets, and on the timing of the ingestion. Ingestion of a single magnet can generally be managed conservatively with serial radiographs while multiple magnets need removing. Laxatives may help with faster bowel emptying if they are not in a place easily accessible with the endoscope.
References at www.uptodate.com.
Torticollis / Wry Neck / Sternomastoid tumour of infancy with thanks to Dr Katie Knight
(From Latin tortus = twisted + collum = neck)
Torticollis can be congenital or acquired, but this article will focus mostly on the congenital form, affecting 0.3% of infants and usually presenting in the first 6 months of life [1]. It is the third most common reason for referral to orthopaedics in this age group. The overwhelming majority of cases seen are due to a benign muscular problem, but some more sinister diagnoses can also present in a similar way, so it is crucial to be aware of these.
What causes torticollis?
Muscular damage:
Most cases of congenital torticollis are the result of damage to the sternocleidomastoid muscle (SCM) at birth (for example in instrumental delivery) or in the uterus (restricted movement or abnormal positioning causing muscle damage).
Damage to the SCM causes it to shorten or contract as fibrosis affects the area. Fibrotic change in the damaged muscle is felt as a hard lump – the ‘pseudotumour’ of torticollis, as it is sometimes called.
This shortening of the muscle in turn makes it difficult for the infant to turn their head, resulting in neck stiffness and a fixed head position, with very limited neck movement.
Risk of muscular torticollis is increased in intrauterine constraint (eg breech presentation or oligohydramnios [2]), and it is also associated with other minor positional deformities. 10% of babies with torticollis have hip dysplasia. [3] One study looking at 1001 babies found that 10% had one or more postural deformities (in decreasing order of frequency: plagiocephaly or torticollis; congenital scoliosis or pelvic obliquity; adduction contracture of a hip and/or malpositions of the knees or feet [4]. This study found that all these deformities were more likely to be observed in:
With these presenting symptoms described above and nothing else of note, torticollis is clearly the first diagnosis that springs to mind. HOWEVER – to play the devil’s advocate – a baby who presents with ‘a lump in the neck’ and ‘abnormal neurology’ certainly demands a careful history and examination.
Uncommon causes of torticollis
Congenital vertebral abnormalities:
The SCM is supplied by the accessory nerve (CN XI), which exits the skull through the jugular foramen. Anything affecting the structure of the upper cervical spine or skull base could compress the nerve root of CN XI and cause torticollis.
Congenital vertebral abnormalities often come along with other congenital abnormalities, as part of a syndrome (two examples are briefly described below, for interest). For this reason a child presenting with torticollis who is known to have other congenital abnormalities should be carefully examined with the possibility of an unusual syndrome kept in mind. [5]
MURCS syndrome (Müllerian duct/renal aplasia/cervicothoracic somite dysplasia) is a rare condition affecting 1 in 5000 female infants that has been associated with congenital torticollis in some cases due to aplasia of the posterior vertebral arch [6]
Klippel-Feil syndrome – cervical spine fusion is seen along with a host of other symptoms [7]
Posterior fossa tumours, tumours of the cervical spine, atlas and axis – these are very rare and should be part of the differential in older children who present with acquired torticollis. [8, 9] Posterior fossa tumours, when they present with torticollis, usually have accompanying symptoms of intracranial pathology (headache, nausea, vomiting, eye signs) [10]
‘Mimics’ of torticollis
‘Ocular torticollis’ occurs when there is 4th cranial nerve palsy. The superior oblique muscle, supplied by CN IV, causes the eye to look inwards and downwards. Paralysis of the muscle means the eye cannot adduct or internally rotate, and this causes torsional diplopia, which the child ‘corrects’ by tilting the head position. Adopting this position over a long period of time eventually causes contracture of the SCM. [11] This condition can be ruled out by using the cover test (watch a 7 minute long Youtube video with a rather disconcerting picture of a huge eye in the background here). When the affected eye is covered, the child should spontaneously correct their head position (in the early stages, before muscle contracture has occurred).
Examination
Appearance (see image): The head is tilted to one side (to the side of the affected muscle), and the chin is turned to the other side. There is stiffness, from the lack of movement, so there may be pain when the neck position is passively corrected.
A lump may be felt in the distal SCM.
|
|
Investigation
The key is to differentiate between muscular torticollis (ie common, benign, easily correctible) and non-muscular torticollis (ie possibly secondary to neurological, ocular or vertebral pathology, and needing further investigation.
If there is a lump palpable in the SCM, it needs to be differentiated from other causes of a lump in the neck. Ultrasound is the best first line investigation – it detects fibrosis of the muscle (diagnosing torticollis) but would also pick up abnormal lymph nodes or masses.
Fine needle aspiration would be the next step if there was any uncertainty of the diagnosis, but this is rarely needed.
Treatment
Once muscular torticollis is confirmed:
Physiotherapy is the mainstay of treatment. Even when there is severe fibrosis of the SCM, physio is effective in 98% [12]
(The above advice adapted from ‘Physio Questions’ [13], a blog by an Australian physio – torticollis featured as a blog entry in August 2010)
Surgical treatment is very rarely needed – only in instances where conservative management has failed after 6 months of treatment. When surgery is performed, the operation is a bipolar release of the SCM, and this has been found to be highly successful, even in patients older than 5 years [14] and into adulthood [15]
Alternatives to surgery?
A recent successful non-surgical development in treating cases resistant to physio is using botox injection. [16] The evidence for chiropractic treatment is weak, isolated successful cases have been described, [17] but there has been no randomised controlled trial. There are also reports of infants with torticollis caused by neurogenic tumours being treated (unsuccessfully) by a chiropractor before the correct diagnosis was made, [18] so it is imperative that parents have consulted a doctor before they choose to seek chiropractic help.
References:
The ED version of May 2011’s “Pearls” is available here! NICE on otitis media with effusion, inguinal hernias, measles, the child with a limp and the significance of a high anion gap. Do leave comments below.
May 2011 GP version available here! Can you tell the difference between septic arthritis and transient synovitis? We have a new algorithm to help you. Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding. Do leave comments below.
with thanks to Dr Jemma Say for putting the following information together:
Inguinal Hernias
An indirect inguinal hernia is a protrusion of abdominal contents into the inguinoscrotal or labial canal via an open deep inguinal ring due to the failure of obliteration of the processus vaginalis.
In fetal life the descent of the testis into the inguinal canal and scrotum is preceded by a small pouch of peritoneum; the processus vaginalis. After birth this peritoneal communication is obliterated, failure to do so results in either a hydrocele or hernia, depending on the degree of fusion.
Indirect hernias are more commonly seen in a paediatric population, as opposed to direct inguinal hernias in adult patients, where the musculature is weak and abdominal contents protrude through the wall of the inguinal canal.
Epidemiology
The incidence is 1-2%, occurring 9 times more commonly in males. The majority are found on the right (60%), 15% are bilateral, more commonly with a family history. Presentation is most frequently in infancy.
Increased Incidence
The diagnosis is clinical, although USS can play a role in older children with indeterminate pain. Surgery is indicated for all paediatric patients with inguinal hernia.
The risks of not performing surgery include bowel incarceration or necrosis, and testicular or ovarian compromise and necrosis. This risk is greatest in early infancy; premature infants have an incarceration risk of up to 30%, and therefore often warrant treatment prior to discharge. Some surgeons keep under close review for a few weeks post discharge so that these still very small babies put on a bit of weight before the operation.
If a patient presents with incarceration, an attempt at reduction should be made and urgent surgery is required, as the risk of reincarceration is as high as 15% if surgery is delayed more than 5 days.
Referral Pathway
All inguinal hernias should be referred, paediatric patients >1 year can be referred to Mr Brearley at Whipps Cross while those <1 should be referred to the Royal London Hospital. Surgery involves either open or laparoscopic techniques (tranperitoneal or preperitoneal approaches). The majority are performed as an outpatient with normal activity resuming within 48 hours.
References
IPEG guidelines for Inguinal Hernia and Hydrocele, Nov 2009. http://www.ipeg.org/education/guidelines/hernia.html
Ashcraft’s Paediatric Surgery, Holcomb G W, Murphy. J P
ABC of General Paediatric Surgery: Inguinal hernia, hydrocele and the undescended testis: BMJ 1996 312:564
Patient Information Leaflets
http://www.patient.co.uk/doctor/Inguinal-Hernias.htm
http://www.bch.nhs.uk/acrobat/PDF%20for%20Web/Inguinal%20Hernia%20Repair.pdf
Video information
Distinguishing indirect and direct inguinal hernia
http://www.youtube.com/watch?v=wAzXSqGybvE
Indirect inguinal hernia repair
http://www.medicalvideos.us/play.php?vid=1108
NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED. We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult! Umbilical hernias are common and benign, inguinal hernias may not be. Read all about it here!
The April 2011 version is now published. I have covered the recently reviewed NICE guideline on depression in children and young people. We continue with the 6 week check series with some information on umbilical hernias and granulomas. And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.
I thought it might be useful to outline the sort of paediatric surgery Whipps offers. This post is being put together with the help of my surgical colleagues who are keen to continue receiving appropriate paediatric referrals from GPs. I will be updating it as and when I get the information from the different specialties.
A word from the anaesthetists: As a general rule all of our consultants on the on-call rota are currently able to anaesthetise any child, 3 years or above presenting as an emergency as long as they are ASA 1 or 2 and needing non body cavity surgery (appendicectomy excepted) with an expected duration of less than 2 hours. (“ASA 1 and 2” are children who are previously fit and well and those with a mild underlying systemic illness such as mild asthma.) We have three consultants who have had advanced training in paediatric anaesthesia (Drs. Williams, Singh and Radhakrishnan) who undertake regular elective paediatric lists who are happy to anaesthetise younger children.
GENERAL SURGERY (Mr Stephen Brearley) AND UROLOGY (elective surgery from 1 year of age, emergency surgery from 3 years of age):
Hernias (all types)
Foreskins
Undescended testicles
Lumps of all types
Tongue ties
Thyroglossal cyst
Emergency work in children over the age of 3 eg. suspected appendicitis
Please refer such things as in-grown toenails and verrucae to podiatrists rather than surgeons.
ENT:
(elective work from 6 months of age, emergency work from 3 years of age):
Lead Clinician, Mr. Sam Jayaraj
Dedicated Paediatric ENT clinics at WX:
Mr Jayaraj 3 per month at WX and 2 per month at Forest Medical Centre, Loughton (WX outreach clinic)
Mr Patel 2 per month at WX
Mr Kenyon 1 per month at WX.
N.B. We are in the process of setting up a Paediatric ENT Specialist Community Clinic (SCC) in conjunction with Dr Watkin and our audiological colleagues at Wood Street Clinic – watch this space!
ENT Surgical procedures offered at WX
Tonsillectomy
Adenoidectomy
Oral cavity lesions
Turbinate reduction
Obstructive sleep apnoea assessment
Nasal bone manipulation following trauma
Nasal cautery
Peri-orbital abcess drainage
Middle ear ventilation tubes (Grommets)
Pre-auricular sinus excision
Pinnaplasty (Mr Jayaraj and Mr Kenyon)
Myringoplasty/tympanoplasty
Mastoidectomy (Mr Nitesh Patel)
Cervical lymph node excision
Thyroglossal cyst excision
Branchial cyst excision
Tongue tie division
Thyroid surgery (Mr Papesch)
Tertiary paediatric ENT services not available at WX (these are rare conditions which require highly specialised nursing, anaesthetic and allied therapies support):
Cleft lip & palate surgery and craniofacial disorders
Paediatric head & neck malignancy
Cochlear implant surgery
Paediatric airway reconstruction surgery (i.e laryngotracheal reconstructive surgery etc)
Currently we refer these patients to our tertiary paediatric ENT colleagues at Great Ormond Street Hospital
OPHTHALMOLOGY:
Strabismus, eyelid, lacrimal, cataract (with infants being referred to Great Ormond Street where our ophthalmologist with a paediatric interest also works).
ORTHOPAEDICS:
MAXILLOFACIAL SURGERY:
This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then. This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition.
There is not much evidence published on what to do with umbilical granulomas. They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue. One theory is that infection has a part to play. I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough! They tend to take a few weeks to months to clear up. There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance. Salt seems to be “in” at the moment. All comments welcome!
