Tag Archives: trauma

child abuse and head injuries

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This summarises the Core-info leaflet on head and spinal injuries in children. Full details are available at www.core-info.cardiff.ac.uk.

**PLEASE REFER ALL SUSPECTED INFLICTED HEAD AND SPINAL INJURIES TO PAEDIATRICS **

Inflicted head injuries

  • can arise from shaking and/or impact
  • occurs most commonly in the under 2’s
  • are the leading cause of death among children who have been abused
  • survivors may have significant long term disabilities
  • must be treated promptly to minimise long term consequences
  • victims often have been subject to previous physical abuse

Signs of inflicted head injury

  • may be obvious eg. loss of consciousness, fitting, paralysis, irritability
  • can be more subtle eg. poor feeding, excessive crying, increasing OFC
  • particular features include retinal haemorrhages, rib fractures, bruising to the head and/or neck and apnoeas
  • also look for other injuries including bites, fractures, oral injuries

If inflicted head injury is suspected

  • a CT head, skull X-ray and/or MRI brain should be performed
  • neuro-imaging findings include subdural haemorrhages +/- subarachnoid haemorrhages (extradural haemorrhages are
    more common in non-inflicted injuries)
  • needs thorough examination including ophthalmology and skeletal survey
  • co-existing spinal injuries should be considered
  • any child with an unexplained brain injury need a full investigation eg. for metabolic and haematological conditions, before a diagnosis of abuse can be made

The following diagram comes from http://www.primary-surgery.org:

 

 

These CT images are from http://www.hawaii.edu/medicine/pediatrics/pemxray/v5c07.html:

 

EXTRADURAL (or epidural) haematoma

 

 

SUBDURAL haemorrhages in a 4 month old

SUBARACHNOID haemorrhage in a 14 month old

Neuro-imaging for inflicted brain injury should be performed in

  • any infant with abusive injuries
  • any child with abusive injuries and signs and symptoms of brain injury

Inflicted spinal injuries

  • come in 2 categories : neck injuries, and chest or lower back injuries
  • neck injuries are most common under 4 months
  • neck injuries are often associated with brain injury and/or retinal haemorrhages
  • chest or lower back injuries are most common in older toddlers over 9 months
  • if a spinal fracture is seen on X-ray or a spinal cord injury is suspected, an MRI should be performed

 

August 2012 PDF digest

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August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog.  A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter.  Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures.  Do leave comments…

Fractures in child abuse

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Metaphyseal fractures, also known as a bucket handle, chip or corner fracture, occur at the growing end of the bone and only in children. Recent fractures are very difficult to see on x-ray and they are often not associated with any clinical sign of soft tissue swelling or bruising.  They may become more obvious radiographically after 11 to 14 days. They are thought to happen when the baby has been pulled or swung violently and the relatively weaker growing point of the bone breaks.  They have been noted to occur accidentally following birth injuries, following serial casting of talipes or as a consequence of appropriate physiotherapy to newborn babies. (Source: Core-info leaflet)

The picture of a metaphyseal fracture of an infant’s wrist below comes from a 2000 paper on the orthopaedic aspects of child abuse by Kocher et al and published in the Journal of the American Academy of Orthopaedic Surgeons (http://www.jaaos.org/content/8/1/10.abstract):

 

A spiral fracture refers to the direction in which the bone is fractured.  It implies that there has been a twisting force to cause the fracture. Spiral fractures can also occur accidentally in the femur once the child is walking. (Source: Core-info leaflet)

The picture below of a spiral fracture of the femur in a 2 month old comes from http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c02.html (same website has a wealth of other paediatric radiological images on it if you are interested):

 

 

A supracondylar fracture is one in the upper arm immediately above the elbow and is highly suggestive of accidental injury.  The picture below comes from http://www.kidsfractures.com/, a site put together by 2 American orthopaedic surgeons who say their aim was to make parents’ experience of having a child with a broken bone a little less traumatic but I think much of the language and many of the pictures are more suited to a medical audience.

 

A simple linear skull fracture is a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone.  They are equally prevalent in NAI and in accidental injury.  The picture below is of a linear right parietal skull fracture and comes from a Rumanian educational website, http://www.medandlife.ro/medandlife602.html.

 

This compares with a complex skull fracture which is variously defined as:

• a depressed fracture (where the skull is pushed in)

• two or more fractures of the skull

• fractures that cross the sutures (natural joining edges of skull bones) or those that are widening. (Source: Core-info leaflet)

The picture below of a complex skull fracture is from http://www.childabuseconsulting.com/child-abuse-fractures.html which houses other not-very-subtle images of non-accidental burns and bite marks as well.

 

Rib fractures in infants, particularly posterior ribs, with no history of major trauma are suspicious.  The picture below is taken from http://www.learningradiology.com/notes/bonenotes/childabusepage.htm and shows multiple rib fractures with callous formation, the ones of the left 2nd and 6th posterior ribs being the easiest to identify:

 

Paediatric Pearls for February 2012

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Click here for this month’s PDF digest!  It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter.  I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners.  Many thanks to my colleagues who have contributed this month.  The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty.  Do leave comments, questions, suggestions!

Pulled elbow

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Dr Furqan Ahmed is an Emergency Medicine middle grade doctor seconded to paediatrics for a few months as part of his training.  I hope he is learning from us, we are certainly picking up things from him.  He has put together the following guide to “pulled elbow” or “radial head subluxation” for Paediatric Pearls.

Pulled elbow, Nursemaid’s elbow, is a dislocation of the elbow joint caused by a sudden pull on the extended, pronated arm. The technical term for the injury is radial head subluxation.

Pathophysiology:

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.

Causes, incidence, and risk factors

Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 4 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children’s joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.

The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm (eg. when trying to lift the child over a curb or high step).

Other ways this injury may happen include:

  • Breaking a fall with the arm
  • Rolling over in an unusual way
  • Swinging a young child from the arms while playing

 

Signs and symptoms

When the injury occurs, the child usually begins crying right away and refuses to use the arm because of elbow pain.

  • The child may hold the arm slightly bent (flexed at 15-20 degrees) at the elbow and pressed up against the abdominal area (pronated).
  • The child will move the shoulder, but not the elbow. Some children stop crying as the first pain goes away, but continue to refuse to move the elbow.
  • Tenderness at the head of the radius may be present.
  • Erythema, warmth, oedema, or signs of trauma are absent.
  • Distal circulation, sensation, and motor activity are normal

Treatment

Inform child and caregiver that the reduction may be uncomfortable, but the discomfort will end quickly after reduction. Parents should not attempt these manoeuvres at home unless advised by a physician.

To resolve the problem, the affected arm must be held with one hand/finger on the radial head and the other grasping the hand making sure the elbow is in 90° of flexion. While applying compression between these two hands, the forearm of the patient is gently supinated and the arm flexed. The manipulator will usually feel a “click” if the manoeuvre is done properly, the child will feel momentary pain, and usually within 5 minutes, the forearm will be functioning well and painlessly.  NB: although a ‘click’ signifies reduction, absence of a ‘click’ is noted in some successful reductions.

Differential diagnoses:

  • Fracture, Elbow
  • Fracture, Wrist
  • Hand Injury, Soft Tissue

 

Indication for xray:

Child not using arm 30 minutes after a reduction.  External signs of trauma such as swelling, abrasions, or ecchymoses.

Consultations

If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated in 1-2 days time.

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%.  Those 24 months and younger may have the greatest risk of recurrence.

 

References

  1. ^ Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW (2012). “Manipulative interventions for reducing pulled elbow in young children”. Cochrane Database Syst Rev (1): CD007759. doi:10.1002/14651858.CD007759.pub3. PMID 22258973. 
  2. ^ Toupin P, Osmond MH, Correll R, Plint A (September 2007). “Radial head subluxation: how long do children wait in the emergency department before reduction?”. CJEM 9 (5): 333–7. PMID 17935648. http://www.cjem-online.ca/v9/n5/p333. 
  3. ^ Kaplan, RE; Lillis, KA (2002 Jul). “Recurrent nursemaid’s elbow (annular ligament displacement) treatment via telephone.”. Pediatrics 110 (1 Pt 1): 171–4. PMID 12093966. 
  4. ^ Macias CG, Bothner J, Wiebe R (July 1998). “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations”. Pediatrics 102 (1): e10. PMID 9651462. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=9651462.

Paediatric pain

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We currently use 2 recognised pain scores in our Emergency Department, depending on the age of the patient.  The FLACC score (ref) was put together at the end of the 1990’s and has been validated for use in pre-verbal children aged 2 months to 7 years.  The Wong Baker (“smiley faces”) score is for use in the over 3’s.  We also ask older children to give us a mark out of 10 on their pain with 10 being the worst they have ever felt and 1 being not too bad.  Our local pain protocol suggests what the health professional should do with the information gleaned and when the child should be reassessed.  I have reproduced that table for you here.  The UK Department of Health National Service Framework for young people and maternity services says that the prevention, assessment and control of pain in children should be subject to regular audit.

GP May 2011!

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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.

Limping child guideline

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Limping Child Guideline

(with thanks to Dr Rajashree Ravindran)

Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]

The history should include

  1. pain characteristics
  2. trauma (recent/remote)
  3. mechanical symptoms (catching, clicking, snapping, worse during or after activity)
  4. systemic symptoms (fever, irritability, weight loss, anorexia)
  5. inflammatory symptoms (morning stiffness)
  6. neurological symptoms (weakness, altered sensation)
  7. gait (limp or not weight bearing)
  8. effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
  9. The current level of function of the child and development

 

Examination:

  1. Temperature and vital signs.
  2. Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
  3. A CNS examination is also vital to exclude any neurological pathology.
  4. Look for abdominal masses(Neoplasias in children can present with a simple limp)
  5. Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
  6. Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.

 

Common differential diagnosis of limp by age:[2] 

0-3 years 3-10years 10-15 years
Septic arthritis or OsteomyelitisDevelopmental dysplasia of hip(usually does not present with pain)Fracture or soft tissue injury (toddler fractures or non accidental injury) Transient synovitis (Irritable hip)Septic arthritis or osteomyelitisPerthes’ diseaseFracture or soft tissue injury Slipped Upper Femoral epiphyses(SUFE)Septic arthritis or OsteomyelitisPerthes’ diseaseFracture or soft tissue injury

 

Also consider: Neoplasms, Neurological/ neuromuscular causes, Rheumatological disease such as Juvenile idiopathic arthritis

 

Investigations:

Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.

Atraumatic limp: The algorithm as below can be used for guidance.  You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.

Algorithm for Child presenting with an atraumatic limp

Parent information leaflet

REFERENCES

1.            Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.

2.            Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.

3.            Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.

4.            Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

5.            Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.

6.            Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.

7.            Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.

8.            Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.