Humeral shaft injuries

Cite this article as:
PJ Whooley. Humeral shaft injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29682

Six-year-old Rosie was running in from the back yard when she just tripped over the skateboard that her mum had told her to tidy up. She landed directly onto her left arm. She was brought to the ED and it was noted she was unable to extend her left wrist and she had pins and needles over the back of her hand. 

Humeral shaft fractures are uncommon, accounting for less than 10% of paediatric fractures. Children have a great ability to remodel and heal with little or no deformity despite significant displacement and angulation therefore most of these fractures can be managed with simple immobilization. 

Anatomy

The thick periosteal sleeve of the humerus limits the displacement of humeral fractures and promotes excellent healing. The main anatomical feature that is important to remember is the radial nerve, which curves around the back of the mid humerus and is at risk of injury. That said, injuries of the radial nerve secondary to humeral fractures are rarely associated with long-term deficits with the majority being temporary neuropraxia.

Mechanism of injury

Neonates – hyper extension or rotation as they pass through the birth canal. The typical fracture is a transverse midshaft fracture. 

Older children – Fall on an outstretched hand (FOOSH), a direct blow to the upper arm or high energy trauma such as a motor vehicle collision. 

Adapted from Orthobullets.com 

Pathological fracture – suggested when a midshaft humeral fracture occurs after only minimal trauma. The humerus is a common site for bone cysts and other benign lesions. These occur most commonly in children 3-12 years of age. 

Case courtesy of Dr. Hani Makky Al-Salam, Radiopaedia.org. From the case rID: 13537

Non accidental injury – Is the mechanism inconsistent with the injury or is there a fracture in a healthy child younger than 3 years? This should raise concern for child abuse. These fractures can be transverse fractures from a direct blow or an oblique or spiral fracture caused by traction with humeral twisting. 

Evaluation

These injuries often present with mid arm pain and swelling. If a humeral fracture is present with no visible deformity, it is typically minimally displaced. 

Determine if there is any distal neurovascular compromise (check out the elbow examination post for some top tips on neurovascular assessment in upper limb injuries). Vascular injuries are extremely rare but midshaft fractures are associated with radial nerve injuries in 5% of fractures. This will be evident with paraesthesia / numbness in the dorsum of the hand between the 1st and 2nd metacarpal and motor deficit with reduced thumb and wrist extension and reduced forearm supination. 

Radiology

Typical Anterior-posterior (AP) and lateral views are sufficient. A prominent vascular groove in the distal humerus is commonly seen on plain film and should not be confused with a fracture line. 

Case courtesy of Kellie Grant, Radiopaedia.org. From the case rID: 39526

Describing humeral fractures

There are four key descriptors of humeral fractures:

  1. Anatomical location: proximal, middle or distal third
  2. Fracture pattern: spiral, short oblique, transverse or comminuted
  3. Degree of displacement and angulation
  4. Presence of soft tissue damage: is the fracture open or closed?

Analgesia and immobilisation

Give early analgesia. These are sore and children often require opiate analgesia such as intranasal fentanyl or diamorphine, which are safe to give if there is no facial trauma or signs of head injury present. 

Immobilization in a sling and swathe or shoulder immobilizer enhances patient comfort and reduces the chance of further fracture displacement. Be sure to check for and document any neurovascular deficit pre and post immobilization.

Infants – sling and a swathe for 4 weeks is sufficient regardless of the degree of displacement.

Older children – In incomplete fractures then a sling and swathe, a collar and cuff sling or a shoulder immobiliser can be used. 

Complete and moderately displaced fractures are better managed in a hanging U-slab. This uses gravity to decrease the deformity by relaxing the muscles and also improves the child’s comfort. Provided there is no radial nerve injury, the fracture can be reduced under procedural sedation to improve clinical alignment. After reduction, the child is placed in a U-slab or coaptation splint for 2 weeks. In the fracture clinic, they will then be reassessed and braced in a functional clamshell brace until approximately 4 weeks.

Hanging U-slab

Refer for orthopaedic assessment in ED if there are any of the following features present:

  • Compound fracture with neurovascular compromise
  • Open fracture
  • 100% displacement
  • Fracture with clinical deformity 
  • Angulation more than 20° in children and 10° in adolescents
  • Compartment syndrome (rare in midshaft humeral fractures)

Operative management involves open reduction and internal fixation. It is indicated in many of the above but also the multiply injured patient to aid in early ambulation including concomitant forearm fractures resulting in a “floating elbow”.  

‘Floating elbow’ in a child with concomitant humeral and forearm fractures. Image from Orthobullets.com

Outcomes

  • Malunion is common, but there’s usually little functional loss. These remodel well.
  • Initial fracture shortening may be compensated for by later overgrowth
  • Nonunion is uncommon
  • Radial nerve palsy is less common, and when occurs, is usually a temporary neuropraxia

Rosie was brought to theatre for an open reduction of her left midshaft humerus fracture. The radial nerve was trapped in the fracture line but not severed. After a few weeks of physio Rosie has regained full movement of her wrist and hand and she loves the fact that she has a scar on her arm. Skateboards have been banned from the house…

References

  1. JC. Cheng, JY. Shen. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15
  2. S. Carson, DP. Woolridge, J. Colletti, K. Kilgore, Pediatric upper extremity injuries. Pediatr Clin North Am. 2006 Feb;53(1):41-67, v.
  3. Figure 3 – Case courtesy of Dr Hani Salam, <ahref=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <ahref=”https://radiopaedia.org/cases/13537″>rID: 13537</a>
  4. https://emedicine.medscape.com/article/1231103-overview
  5. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/

Septic for sure…

Cite this article as:
Deirdre Philbin. Septic for sure…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31704

Febrile children can pose a real challenge to clinicians in the Emergency Department. Identifying and trying to predict those who are at high risk of serious or invasive bacterial infection is particularly important as there are huge implications for altering the course of their illness, as well as for resource allocation and research initiatives. 

There are many clinical scores in use but, so far, their predictive performance for poor outcomes in undifferentiated febrile children is unknown.

Long E, Solan T, Stephens DJ, et al. Febrile children in the Emergency Department: Frequency and predictors of poor outcome. Acta Paediatr. 2020; 00: 1– 10 

What was the aim of this study?

This retrospective, observational study set out to determine the frequency of poor outcomes in undifferentiated children presenting to the ED with fever as well as evaluate predictors of poor outcome. The authors defined  ’poor outcome’ as the development of new organ dysfunction and the requirement for organ support therapy. They included initial vital signs, initial blood tests, and clinical scores as predictor variables.

What was the study design?

This is a retrospective cohort study. It was conducted in the ED in a large tertiary referral centre (single centre study) and full ethical approval was obtained.

Who were the study participants?

All children with ‘fever’ in their triage description or an initial triage temperature of >38.0°C were included, with no exclusion criteria.

How was the study performed?

Data was extracted from electronic medical records. This included demographic data, vital signs, blood test results, diagnosis, disposition, organ support therapies, organ dysfunction scores for patients admitted to PICU and mortality.

To ensure accuracy, one hundred electronic medical records were randomly selected and manually checked. 

What were the study team looking for?

The primary outcome of this study was the frequency of new organ dysfunction and requirement for organ support therapy in the study population, two indicators of severe illness. 

The study team examined the following variables to see if any could predict children at risk of poor outcome:

  • vital signs: heart rate, respiratory rate, blood pressure, and GCS
  • blood tests: venous lactate, creatinine, white cell count, platelet count, and INR
  • clinical scores: SIRS, qSOFA, and qPELOD-2

What kind of statistics did they use?

The chart above can be really helpful when thinking about statistical analysis. The type of data collected determines the most appropriate means of analysis. This study included both continuous and categorical variables.

For continuous variables, descriptive statistics were used i.e.  data was reported using median and inter-quartile ranges. 

In this study, continuous variables refer to demographic data such as age, sex, weight, vital signs (temperature, heart rate, blood pressure, respiratory rate, Glasgow coma score) and blood results (including lactate, creatinine, INR, platelet count and white cell count). The use of median and inter-quartile ranges is most appropriate for this type of data. The median is the value that is in the “middle” of the distribution, with 50% of the scores having a value larger than the median, and 50% of the scores having a value smaller than the median. The interquartile range (IQR) is the range of values within which reside in the middle 50% of the data. 

Frequency with percentage was used for categorical variables

For this study, categorical variables refer to the clinical scores used i.e. SIRS, qSOFA and qPELOD scores. Describing the data in this way is appropriate as it means the frequency that the data occurred may be expressed as a percentage. 

The association between initial vital signs, blood tests, clinical scores and the development of new organ dysfunction and requirement for organ support therapy were reported as odds ratios (OR) with 95% confidence intervals (CI). 

Odds ratios are usually used to compare the relative odds of the occurrence of the outcome of interest (e.g. development of new organ dysfunction), given exposure to the variable of interest (e.g. initial vital signs). The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The confidence interval (CI)  is used to estimate the precision of the odds ratio and may be thought of as a way to measure how well your sample represents  the population you are studying.  A large CI indicates a low level of precision of the OR, whereas a small CI indicates a higher precision of the OR. This study uses 95% confidence intervals which means that there is a 95% probability that the confidence interval will contain the true population mean and in practice, is often used. 

The discriminative ability of predictor variables was measured using the area under the receiver operating characteristics curve (AUROC), with sensitivity and specificity calculated for each variable. i.e. vital signs, blood tests and clinical scores. 

The Receiver Operating Characteristic (ROC) curve is commonly used in statistics and can be confusing. Put simply, the curve is used to plot sensitivity versus false positive rate for several values of a diagnostic test. It is a graphical measure which illustrates the trade-off between sensitivity and specificity in tests that produce results on a numerical scale, rather than as an absolute positive or negative result. In this study, the AUROC is used to determine the sensitivity and specificity of each of the variables used. 

What were the results? 

Over the 6-month study period, 6217 (13.8%) children presented to the ED with a febrile illness. This represented  just over one-eighth of the overall presentations to the ED. Approximately two-thirds of these children were discharged home (65.4%), a third were admitted to hospital (34.6%), with 0.5% (32 of the 6217 children in the study) admitted to PICU. Slightly more than half of the children, at 58.3%, were under the age of 3. 

New organ dysfunction was very rare, in (0.4% or 27 children). 10 required organ support therapy (inotropes for 0.2%, mechanical ventilation in 6, renal replacement therapy in 1, and extra-corporeal life support in 1). 

The best performing ED predictors of new organ dysfunction were: GCS <11, INR≥ 1.2, lactate ≥ 4.0mmol/L, and qPELOD-2 (SBP) score ≥ 1.

The best performing predictors of the requirement for inotropic support were: initial hypotension using qPELOD 2 (SBP), lactate ≥4mmol/L, INR ≥ 1.2, and qPELOD (SBP) score ≥  1

The best predictors of the requirement for mechanical ventilation were: GCS <11, lactate ≥4mmol/L, INR ≥ 1.2 and qSOFA=3.

The bottom line

The bottom line from this study was that all predictor variables had poor test characteristics for the development of new organ dysfunction and the requirement for organ support therapy.

This is a good study; the results are easy to follow and, importantly, they meet the study aims.  The sample size is large, giving this study good internal validity, i.e. the extent to which the observed results represent the truth. 

Overall, this study supports our clinical experience. Poor outcomes in febrile children are, thankfully, rare. Less than half a percent of children in this study developed new organ dysfunction. Even fewer required organ support therapy. The infrequency of these outcomes in the study population however means that the use of “predictor variables” is not particularly helpful. A few take-home messages:

Vital signs – Elevated heart rate and respiratory rate were common findings in undifferentiated febrile children. This did not confer an increased risk for the development of organ dysfunction or the requirement for organ support therapy.

Take abnormal GCS seriously though – in this study, very few children had a GCS <11, but when it was low, GCS score was a strong predictor of the requirement for mechanical ventilation.

Blood tests – Remember to check lactate! Elevated venous lactate significantly increased the odds for the development of new organ dysfunction and the requirement for organ support therapy (both mechanical ventilation and inotropic support), with increasing risk the higher the lactate climbed. Elevated initial creatinine and initial INR also signified increasing severity of illness. 

Clinical scores – in this study, clinical scores performed variably. They can be helpful but may be more useful in the PICU setting. 

The external validity of this study is also strong; the results seem to be generalisable to our own population. Given the lack of exclusion criteria, the results of this study may be applied to any setting where undifferentiated febrile children are cared for. 

Were there any limitations to this study?

This is a retrospective, observational, single centre study using data extracted from an electronic medical record. Retrospective studies may be subject to information bias (by missing information) or by selection bias (because individuals are selected after the outcome has occurred). This study limited selection bias however by including all patients with fever. 


In addition, a single centre study may be limited by the use of local policies and guidelines rather than disease severity, reducing external validity / generalisability of the findings. 

The outcomes measured in this study are rare, but the authors attempted to overcome this by using a large sample size of over 6000 children. However, because the outcomes were so uncommon, the predictor variables had wide confidence intervals. 

Will this study change my practice?

This study is unlikely to change our practice. However, it does provide food for thought. It is in keeping with our clinical experience that the development of new organ dysfunction and the requirement for organ support therapy is rare among febrile children presenting to the ED. 

This study emphasises that predicting poor outcome in this patient group is difficult. Vital signs, blood tests and clinical scores were poor predictors. This highlights the importance of remaining particularly vigilant with respect to undifferentiated febrile children. 

A final comment from the authors – Elliott Long and Franz Babl

Thank-you for the opportunity to comment on our article titled ‘Febrile children in the Emergency Department: frequency and predictors of poor outcome’. The associated review covered all of the major aspects of the study.

A few additional points that may have been buried in the data: 

  • Though the study was primarily focused on severe infection (sepsis), we included a broader cohort of undifferentiated children with febrile illness presenting to the ED. This was somewhat exploratory, as we suspected that many children would be treated for sepsis (i.e.- admitted to hospital for IV antibiotics and one or more fluid bolus), but would not receive the diagnosis of sepsis. Interestingly, this was borne out in the study findings. The majority of children treated for sepsis did not receive the diagnosis of sepsis. This included the ‘severe end of the spectrum’ of children admitted to ICU; the most common diagnosis in this group of children was ‘acute febrile illness’. We interpreted this finding as being due to the hesitancy of clinicians to label undifferentiated febrile children with the diagnosis of ‘sepsis’ early in their treatment. Prospectively, we all hope kids will ‘turn the corner’ and physiologically improve after basic resuscitative measures… until they don’t! Also, children with more specific diagnoses, such as appendicitis or pneumonia, were more likely to receive these as working (admission) diagnoses even when at the severe end of the spectrum and receiving treatment consistent with sepsis. 
  • The majority of febrile children admitted to ICU did not require (new) organ support. These children included those with meningitis <2months of age, children with croup requiring multiple doses of nebulised adrenaline, children with pneumonia with large pleural effusions, and children on ventricular assist devices. These ICU admissions were based on local policy and procedure, and may not be generalisable to other health services. Studies using ICU admission as an outcome measure should be interpreted with this in mind. 

From a ‘big picture’ perspective, this study highlights two major issues for clinicians and researchers when dealing with sepsis.

  • Clinicians caring for children with febrile illness at different stages of their hospitalisation have different frames on the same disease that we all call sepsis. From an ED and acute care perspective, children with fever are un-differentiated, the majority have a mild, self-limited illness, and can be safely discharged home. The challenge for front line clinicians is early recognition of severe disease- finding the needle in the haystack. From an ICU perspective, children with fever are differentiated, the majority have severe disease and require close monitoring and/or organ support. The challenge in ICU is risk stratification. Understanding these differences in perspective is crucial for communication between clinicians caring for children at different stages of their hospital journey, and for researchers designing studies involving children with sepsis. 
  • As a result of poor outcomes being so rare, interventional trials that aim to capture patients at the entry point of acute care – before they are differentiated – will need to be pragmatic, large, and use composite outcomes. An example of such a study is PROMPT Bolus, which compares 0.9% saline to balanced fluids for sepsis resuscitation and initial maintenance. The study will include pragmatic entry criteria: patients receiving treatment for sepsis (IV antibiotics and >1 fluid bolus). The study will enrol >8000 patients from 3 research networks (PECARN in the United States, PREDICT in Australia / New Zealand, and PERC in Canada), and will use the composite outcome of Major Adverse Kidney Events on day 30 (MAKE30) as the primary outcome. This is probably the model that will be required to answer fundamental questions regarding early sepsis therapies in future.

How to… perform a lumbar puncture

Cite this article as:
Taryn Miller. How to… perform a lumbar puncture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31106

Performing a neonatal or paediatric lumbar puncture can be a daunting procedure but is an important part of the initial investigations of an unwell patient. However, it’s important to remember that a lumbar puncture should never delay administration of antibiotics that could be life-saving to a patient with suspected bacterial meningitis. 

Before the start of any procedure always ask, “Why are we doing this procedure? Are there any contraindications?”. 

The Royal Children’s hospital in Melbourne outline the indications and contraindications to performing a lumbar puncture as follows:

Indications

  • Suspected meningitis or encephalitis 
  • Suspected subarachnoid haemorrhage in the context of a normal CT scan 
  • To assist with the diagnosis of other CNS or neurometabolic conditions 

Contraindications

  • The febrile child with purpura where meningococcal infection is suspected 
  • Cardiovascular compromise/ shock 
  • Respiratory compromise 
  • Signs of raised intracranial pressure (diplopia, abnormal pupillary responses, abnormal motor posturing or papilledema) 
  • Coma: Absent or non-purposeful response to pain. 
  • Focal neurological signs or seizures 
  • Recent seizures 
  • Local infection around the area where the LP would be performed 
  • Coagulopathy/ thrombocytopenia 

The next important step is to gain verbal consent from the parents by explaining the procedure, risks and complications. 

Stop – As a parent, an initial septic workup of an unwell child can be an extremely stressful time. Try and explain the procedure with the risks and complications as concisely and clearly as you can without using medical jargon. It can be useful to think… if I were a parent what would I want to know?

It is useful to have your departments recommended lumbar puncture leaflet printed to give to the parents to read after the conversation. 

We would like to perform an investigation known as a lumbar puncture on your child. We do not perform this investigation unless it is absolutely necessary, and we think this is necessary to perform on your child today. 

This is a test that involves a small needle that is inserted into the back of your babies/ child’s spine to obtain a sample of the fluid that runs around the brain and the spinal cord. We usually do this test to identify whether your child has meningitis (infection of the lining of the brain). Sometimes we occasionally think your child is too ill to have a lumbar puncture and we will give antibiotics straight away to cover the most common types of bugs that cause meningitis. However, if possible, we like to perform a lumbar puncture that helps us identify: 1 ) if your child has meningitis by looking at the cells in the fluid, and 2) what type of bug is causing your child’s meningitis. This helps us choose the correct type of antibiotic and how long it is needed for. 

The procedure can be an uncomfortable procedure similar to performing a blood test. Most babies will be upset by being held in one position more than by the procedure itself. To minimise discomfort we will give pain relief such as sucrose or a pacifier to help. The procedure usually takes 30 minutes to perform. 

This can be a distressing procedure for parents to watch and we often offer parents not to be present while we perform the procedure. This can help increase the chance of success as it is a difficult procedure to perform. However, you are always more than welcome to be present. 

A lumbar puncture is a safe test and the risk of any serious complications such as bleeding, infection or damage to the nerves is extremely low. More common risks are that we are not able to get the sample we need or having to try more than once. Today we will only try twice and then stop if we are unsuccessful. 

Remember the parents may refuse a lumbar puncture and this should prompt us to think again and take some more time to re-discuss this with a senior and / or the parents. 

The procedure

Gather equipment and personnel 0:13  

Ensure that at least two people (the person performing the lumbar puncture and an assistant to hold) are present. It is often useful to have a third person to help as an assistant or with any other problems during the procedure. 

Equipment

  • Drapes or a sterile dressings pack 
  • Sterile gloves 
  • Sterile Gown 
  • Mask 
  • Spinal needle – 22G or 25G bevelled spinal needle with a stylet* 
  • Specimen pots x 2/3 
  • Chlorhexidine 0.5% in 70% alcohol solution with tint (chloraprep 3mls skin cleaning applicator) or your local alternative 
  • Local anaesthetic and/or sucrose 
  • Specimen pots x 2 
  • Labels 
  • Tegaderm for the site following removal of the needle 

For some more information on how to choose a correct spinal needle for the patient check this post from Henry.

Position 0:35

Position is everything for a paediatric lumbar puncture. A calm, cool and collected assistant who is confident in maintaining an adequate position is essential for improving the likelihood of success. 

You: Decide whether you are going to sit or stand for the procedure and set the bed height accordingly 

Patient: 

  • Position the patient in the left or right lateral position with their knees to their chest. Avoid over flexing the neck as this can cause respiratory compromise especially in younger neonatal patients. 
  • Position the patient so that the plane of their back is exactly perpendicular (90 degrees) to the bed. 
Lateral position for lumbar puncture

Landmarks: 

You are aiming for approximately the L3-L4 or L4-5 interspace. In neonates you can feel the ASIS and in older children you can feel the PSIS.  Invision a straight line between the top of the iliac crests intersecting your target area L3/4. 

Analgesia, anaesthesia, and sedation  1:15

  • All children should have a form of local anaesthetic used which can include: 
  • For the neonatal population oral sucrose can be used. 
Layers of the spine

The procedure 1:36

  • Prep the trolley by cleaning with a detergent wipe and allow it to dry before the procedure set up 
  • Open the dressings pack onto the clean trolley and using a non-touch technique drop the sterile gloves, cleaning solution and lumbar puncture needle into the sterile area. 
  • Wash hands and don sterile gloves 
  • Put a sterile drape under the patient’s buttocks, on the right and left side of the desired site and at the top leaving the spine exposed. It’s a good idea to keep the nappy on a neonate during the procedure and pull it slightly further down to prevent faeces accidentally sliding into the sterile field during the procedure. 
  • Clean the area using the chlorhexidine solution to disinfect the skin around the procedure site. Do not place the used swab on the sterile field but dispose of immediately in the bin. Wait for the skin to dry 
  • Take the tops off the specimen pots and keep them on your sterile field ready 
  • Identify the desired space as described above  
  • If using lignocaine infiltrate at this step 
  • Position the needle with the bevel facing up towards the ceiling
  • Direct the needle towards the umbilicus 
  • Resistance will be met often felt as the needle moves through the ligamentum flavum
  • Keep advancing slowly – a pop may be felt as the epidural space is now crossed and the subarachnoid space is entered a few millimetres more. 
  • Remove the stylet and check for CSF 
  • If CSF fluid Is present collect 6-10 drops of CSF in each container. Number the container depending on analyses required. 
  • Re-insert the stylet (to reduce the risk of head) and in one swift manoeuvre, remove the needle and stylet. 
  • Apply pressure to the site 
  • Use a tegaderm dressing so that the site is visible to staff to assess for infection 

Trouble-shooting

  • If, when you initially insert the needle the neonate or child moves, do not advance, keep the needle in place and wait. Allow the child to settle, and re-check the position, then continue to advance. 
  • If the CSF is blood stained this can still be collected for culture and if it runs clear can be collected for a cell count at this point.

For More useful tips for LP’s check out this post by dftb Ben Lawton. Pro tips for LPs in kids, Don’t Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7969

References 

Other references 

  1. https://www.rch.org.au/kidsinfo/fact_sheets/Lumbar_puncture/ 

Midshaft radius and ulna fractures

Cite this article as:
Rie Yoshida. Midshaft radius and ulna fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.21902

Alvaro is a 12-year-old boy who presents to the ED with a painful and swollen right arm. He was trying out his new skateboard and fell whilst trying to master the kickflip. (He tells you it’s not cool to say he’s been skateboarding: “It’s skating, but not the on-ice kind, that’s not cool either.”)

On examination, he is tender in the middle third of his right forearm with swelling and some mild deformity.  There are no open wounds. There is pain on forearm rotation with limited pronation and supination but a good range of movement at the wrist and elbow.  There are no signs of neurovascular compromise or compartment syndrome. 

You top him up with some intranasal fentanyl and send him for an x-ray. His AP film shows a greenstick in the middle third of the ulna. 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

But when you look at his lateral you do a double-take. There’s pretty significant angulation with radial bowing. You always make sure you look at both x-ray views but this really shows why that’s so important.

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

You know that ulna fractures can be associated with radial head dislocations as part of the Monteggia fracture-dislocation pattern so send Alvaro back for an elbow x-ray.  Radio-capitellar alignment is maintained so you’re happy this isn’t a Monteggia injury but given the significant ulna angulation, you give your orthopaedic on-call colleague a ring.

 

Epidemiology

Forearm fractures are the most common fractures in children, representing 40% of all childhood fractures. Although the majority of these occur at the distal end of the forearm, 20% are located at the midshaft and often involve both bones.  Peak incidence occurs between ages 10-14.

 

Anatomy

The radius and ulna are connected by an interosseous membrane and meet at the distal and proximal radioulnar joints at the wrist and elbow.  Due to these connections, a break in one bone is often accompanied by a break in the other.  It is also important to look at the proximal and distal radioulnar joints to identify Monteggia and Galeazzi fracture-dislocations.

Mechanism

Midshaft radius and ulna fractures usually occur due to a fall from a height onto the forearm or an outstretched hand or direct blow to the forearm.

 

Examination findings

Examine the forearm, wrist and elbow joint.  You may find swelling and possible deformity with tenderness of the forearm. Check for any open wounds and check the tetanus status of the child.

The range of movement will be reduced, particularly with forearm pronation and supination. Check for signs of neurovascular compromise or compartment syndrome.

 

Investigations

For all midshaft forearm injuries, order true AP and lateral x-rays of the forearm including the wrist and elbow (including distal humerus). Note: 5% of forearm fractures are associated with supracondylar fractures.

In a true AP x-ray, the distal radius (R) and ulna (U) should be visualized with minimal overlap. The trochlea (T) and capitellum (C) should be seen in profile, as long as the child is old enough for them to have both to have ossified.

In a true lateral, the distal radius (R) and ulna (U) will be superimposed at the wrist.  If there is no plastic deformity the posterior border of the ulna is straight, sitting on an imaginary horizontal line, and the radius is bowed. The trochlea and capitellum will be superimposed at the elbow (denoted by *).

True AP: Case courtesy of Dr. Aditya Shetty, Radiopedia.org, rID:31106 True lateral: Case courtesy of Dr. James Hayes and Dr. Aditya Shetty, Radiopedia.org, rID:31107

 

Classification

The Rule of Fours can be used to describe the fracture and identify the correct fracture pattern.

There are 4 types of fracture patterns:

  • Plastic deformation: there is bowing of the bone with no cortex disruption. It’s most commonly seen in the ulna and is easily missed on x-ray. A top tip for spotting on x-ray: on the lateral view, a normal ulna has a straight posterior border.  But if the posterior border does not sit nicely on a horizontal line there is plastic deformation.

  • Greenstick fractures: there is a break on one side of one bone that does not extend all the way through the bone.
  • Complete fractures: there is a fracture through both cortices of the radius and/or ulna, often with displacement.
  • Comminuted fractures: these are fractures with multiple bony fragments. They are uncommon in midshaft fractures in children.

 

Treatment

The vast majority of paediatric forearm fractures can be managed non-operatively, with closed reduction and casting.

Firstly, check whether the fracture needs to be referred to the orthopaedic team. Any fracture with complications, either a plastic, comminuted or open fracture or one with neurovascular compromise, compartment syndrome or associated Monteggia or Galeazzi dislocation, must be referred to the on-call orthopaedic clinician.

Next, assess the degree of angulation. If the child is under 5 years of age, up to 20 degrees angulation is acceptable; aged 5 – 9 up to 15 degrees is allowable; and in children 10 years and older fractures with angulation of up to 10 degrees will remodel without manipulation. Fractures that are more angulated than this will need to be reduced.

Closed reduction should be performed by an experienced ED practitioner or clinician or by the orthopaedic team.  It may be done either under procedural sedation in the ED or in theatre with image intensification if this fails (or if the fracture is complicated).  Always, always, reassess neurovascular status and repeat an x-ray after manipulation to reassess the degree of angulation and ensure no further complication has arisen. And finally, an above-elbow (long arm) cast should be applied with follow-up in fracture clinic within a week.

 

Indications for orthopaedic referral

  • Open fracture
  • Neurovascular compromise
  • Compartment syndrome
  • Comminuted fracture
  • Monteggia or Galeazzi fracture
  • Failed reduction or unable to perform in the ED

 

Top tips

  • Always check both lateral and AP films. Alignment can look deceptively good in one plain and very angulated in another.
  • If a break in one forearm bone is identified, remember to look at the other bone and the radioulnar joints. Don’t forget forearm fractures are associated with supracondylar fractures and can be complicated by Monteggia or Galeazzi fracture-dislocations.

 

Alvaro’s ulna greenstick fracture had over 10 degrees of angulation and you and your orthopaedic colleague agree a closed reduction in ED is called for.  You manage Alvaro’s procedural sedation while the orthopaedic doctor re-moulds the fracture and places Alvaro in an above elbow backslab.  Post-reduction films show good alignment.  A few months later you’re walking past the local skate park and you smile to yourself as you see Alvaro with his skateboard (correction, on his board). He gives you a grin as he spins into a kickflip.

 

Selected References

Vopat, Matthew L et al. “Treatment of diaphyseal forearm fractures in children.” Orthopedic reviews vol. 6,2 5325. 24 Jun. 2014, doi:10.4081/or.2014.5325

Orthobullets Both Bone Forearm Fracture – Pediatric https://www.orthobullets.com/pediatrics/4126/both-bone-forearm-fracture–pediatric

Schweich P. Midshaft forearm fractures in children. Post TW (Ed). UpToDate, Waltham, MA. 2019.

Price CT. Acceptable alignment of forearm fractures in children: Open reduction indications. J Pediat Ortho 2010; 30: S82-4.

Chest compressions in traumatic cardiac arrest

Cite this article as:
Karl Kavanagh and Nuala Quinn. Chest compressions in traumatic cardiac arrest, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31093

Traumatic cardiac arrest (TCA) is an infrequent event in paediatrics, and a cause of significant stress in the busy trauma resuscitation room. Outcomes are similar in both paediatric and adult arrests, with poor survival rates in both. There are now international guidelines on the management of traumatic cardiac arrest. A traumatic cardiac arrest (TCA) is traumatic not just for patients but also for staff and all those involved. The guidelines were published in 2016, however, the role of chest compressions is still a source of confusion for medical and nursing staff alike. Advanced Paediatric Life Support algorithms and supporting medical evidence have correctly engrained chest compressions into medical management of life threats. However, there is a paucity of studies examining trauma-induced hypovolaemic arrests to base the decision to change the “normal practice”. It is counter-intuitive for medical staff to not start compressions when an arrest is presented to you and withholding them inevitably leads to the question “Well, what can I do then?”.

Haemorrhage is one of the three common causes of early preventable death in trauma. This paper, from Sarah Watts et al, sought to determine whether compressions are beneficial and with what fluid the patient should be resuscitated with (if at all). Of course there are ethical and practical issues with a prospective randomised control study involving children as the subjects. Instead, this animal study is a helpful surrogate for analysis of the question surrounding the role of chest compressions in haemorrhage-induced traumatic cardiac arrest.

Disclaimer: not suitable for vegetarians!

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

PICO image

Population

39 pigs were enrolled and treated as per UK Animals (Scientific Procedures) Act 1986 ethics standards. The baseline data of all animals involved were within normal ranges and differences between them was not clinically significant. Each subjects’ vital signs were invasively monitored throughout the study.

Intervention

There were 5 phases through which all participants/subjects went.

  • Injury phase
  • Shock phase
  • TCA phase
  • Resuscitation phase
  • Post-resuscitation phase

Each subject was anaesthetised and the same injury was reproduced in each. Subjects were allowed to exsanguinate in a controlled pattern. Once terminal hypovolaemia was declared, three rounds of resuscitation were commenced. After resuscitation, subjects were categorised according to MAP and Study End was defined as 15 minutes after the end of the third resuscitation cycle.

Patients were blindly randomised into 5 different groups:

  1. Closed chest compressions(CCC)
  2. Whole blood (WB)
  3. 0.9% Saline (NaCl)
  4. WB+ CCC
  5. NaCl+ CCC

Outcome

The primary outcome was achievement of ROSC at study end.

Secondary outcomes were differences in survival and attainment and maintenance of ROSC during the resuscitation and post-resuscitation phases.

Results

To summarise the numerous results:

  1. All the subjects in compressions only group died.
  2. All the subjects that received whole blood only survived.
  3. Resuscitation with blood had improved outcomes over normal saline.
  4. Addition of compressions had a detrimental effect on fluid resuscitation.
  5. Subjects that received any combination of CCC showed a more significant metabolic acidosis, reflecting increased tissue ischaemia.
  6. In the group that received both CCC and WB, 5 of 8 subjects achieved partial ROSC (MAP 20-50mmHg). Once partial ROSC was ascertained, CCC’s ceased and fluid resuscitation alone was continued. This led to the subjects improving to such a degree that there was no longer a difference between this group and that resuscitated by WB alone from the beginning.
  7. All results can be attributed to the groups’ interventions as confounding variables were minimised and the initial injury reproduced in each case.

Discussion

While this is a small population study, it has become a sentinel paper as it demonstrates clear evidence that chest compressions in a TCA are detrimental and that our reflexive management of medical arrests is not transferable. We need to shift our focus to optimising fluid resuscitation. It shows a clinically relevant outcome that is internationally applicable. It is important to note that it was terminal hypovolaemia, not true cardiac arrest with no output, which was being measured. However terminal hypovolaemia is an imminent precursor of cardiac arrest.

Reflections from Nuala Quinn

I have listened to Dr Sarah Watts present this paper and listening to her reinforced my opinion that this paper is superb. It challenges the dogma and forces us to push beyond traditional management strategies in what is arguably the most stressful paediatric emergency: major trauma.

Closed chest compressions are a mainstay of medical management. They are firmly embedded in resuscitation culture and indeed have become a mainstay of civilian culture. When healthcare practitioners hear the word “arrest” they automatically move into the “chest compressions” mindset. However medical cardiac arrest and traumatic cardiac arrest are two completely different entities with ensuing separate management. Anecdotally it is difficult to separate the two and advising a team that no-one needs to do chest compressions in an arrest causes anxiety and confusion. This happened only recently in our department where advising one of our staff that we didn’t need to do chest compressions as a priority was met with “but it says in APLS so we need to do them”. 

So how do we get around this? In my mind we do this in two ways: 

Firstly, we use and promote the life-saving bundle of interventions for TCA and keep it as a completely separate entity. When leading a TCA, as the pre-brief I will usually start with This is a Traumatic Cardiac Arrest which will need the bundle of life-saving interventions before anything else”. I write the bundle of life-saving interventions on the adjacent whiteboard and assign specific people to them. I focus on the bundle, rather than ABCDE. Focusing the team on the bundle, rather than the “arrest” per se, helps to separate the medical arrest from the traumatic arrest. 

Nuala's priorities for traumatic cardiac arrests
Team priorities in a traumatic cardiac arrest

I follow the PERUKI guideline which can be found here. The bundle needs to be prioritised over chest compressions and defibrillation. For revision, here is the bundle:

Secondly, we use the evidence and this is where papers like Watts et al come in. Evidence is fluid, it changes all the time. It takes years for resuscitation courses and bodies to update manuals and so it is our responsibility to use emerging evidence and use it sensibly and progressively. Watts’ paper helps me to educate and challenge dogma, particularly with compressions and saline resuscitation. Again, anecdotally the practice of giving saline as the initial resuscitation fluid in trauma exists.  We seem to be hesitant to give blood immediately, with view that to try with saline first is better, to not waste blood. The literature is now abound with papers describing the deleterious effects of saline in trauma, particularly with regard to its dilutional effects and role in worsening trauma coagulopathy. Again, this paper supports the choice of whole blood over saline and is in keeping with the life-saving bundle.  This paper cements for me, the reasons for the importance of the life-saving bundle before anything else and should empower us to make better decisions in the trauma reception and resuscitation:

Should we just give a saline bolus first?

Should we just get someone to do chest compressions as they have no pulse?

The answer here should always be no, and this paper is evidence to support that. The TCA algorithms are almost exactly the same, between adults and paediatrics and in institutions all over the world. This has really helped to standardize the management of TCA and have people trust the bundle, rather than revert back to what feels safe for them (compressions and saline in most instances). 

As to our case above, I wasn’t team-leading and with 10min to the patient’s arrival, didn’t want to push the issue, so the plan for compressions went ahead and the role was assigned. However, at the end of the trauma resuscitation, I realised that the chest compressions hadn’t actually been performed. So in that clinician’s subconscious, there was an understanding and mutual trust in the process of changing and progressing how we better manage traumatic cardiac arrest. Watts and PERUKI are leading the way. It is up to us to follow them.

Selected references

Watts S, Smith JE, Gwyther R and Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation. 2019; 140:37-42. Doi: 10.1016/j.resuscitation.2019.04.048

Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, et al. Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Emerg Med J. 2018;35(7):434-9.

Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Emerg Med J. 2018;35(11):669-74.

(ANZCOR) AaNZCoR. Australian Resuscitation Council Guidelines 2016 [Available from: https://resus.org.au/guidelines/.]

Fish hook removal

Cite this article as:
Cliona Begley. Fish hook removal, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29788

Sean, a 14-year-old boy, was out fishing with friends. While tidying away his gear, a used barbed fishhook became lodged in his second finger on his right (dominant) hand. Sean and his friends attempted to remove the hook but were unsuccessful. Sean feels otherwise well, has no long-term medical problems and is unsure when his last vaccinations were. 

Is this a common problem?

Depending on where your Emergency Department is situated, a child with a fisk hook lodged somewhere can be an exceedingly rare or pretty common presentation. Most hooks will be embedded superficially in fingers or feet and be easily removed by an easy-to-master technique. However, some hooks can become lodged in eyes/ eyelids or have penetrated deeper. These may warrant a surgical referral. Let’s have a look at how we can evaluate which fishhooks can be removed in the ED and which ones we might be more cautious about.

What type of hook are we dealing with?

There are many different types of hooks. They vary both in size and the number of hooks or barbs present. 

The most important thing for us to know as clinicians is whether the hook is barbed or not. 

Lots of different fish hooks
The anatomy of a fish hook

The most common type of hook has an eyelet at one end, a straight shank, and a curved belly that ends in a barbed point on the inner curve that points away from the hook’s tip as shown above.

Some fishhooks may be multi-hooked or have a lure (an artificial fishing bait) attached. These will need to be clipped from the main shank prior to removal. Some hooks will have multiple barbs along the shank. These hooks cause greater tissue damage. 

What should we be looking out for?

When evaluating a lodged fishhook and its suitability for removal in the Emergency Department, consider the following:-

Important aspects in the history:

  • Where the incident occurred i.e freshwater vs salt water?
  • Whether or not the hook has been used?
  • Vaccination status as they will require a tetanus booster if not up to date. 
  • History of immunocompromise and bleeding disorders.

Your examination should include:

  • Site and depth of penetration. Most hooks will lodge superficially in fingers or hands, and less frequently in feet, the face or the head. These can be safely removed in the ED. Subspecialty consultation should be obtained for fish hooks lodged in the eye or eyelid, vascular structures, the genital area or if there is clinical evidence of neurovascular compromise. Careful assessment of the depth of penetration and integrity of surrounding structures and joints is important.
  • Type of fishhook. See techniques below.
  • Wound. Assess for active bleeding or evidence of gross contamination that may need management in theatre.
Case courtesy of Dr Yair Glick, Radiopaedia.org. From the case rID: 73822

How are we going to get it out?

First off, good analgesia to manage the pain is paramount. Generally, local infiltrative anaesthesia is highly effective in older, cooperative patients. Younger children may require procedural sedation to facilitate this.

Next, think about the child’s tetanus status and give prophylaxis as indicated.

And thirdly, think carefully about your removal techniques. Five techniques of fishhook removal are described. Your choice of technique depends on: 

  • Type of hook
  • Depth of entrapped point
  • Body part involved

Regardless of the method used, all wounds should be cleaned and prepped prior to removal.   If the hook is multi-hooked or if there is a lure attached, clip off the end before you attempt removal to minimise tissue damage. The objective of each technique is to disengage the barb with as little tissue trauma as possible. Let’s take a look at the five techniques.

The back-out technique

The back-out technique can only be used with a barbless fishhook. Simply grasp the shank of the hook and back the hook out of the wound. 

Hook in finger
The problem

The push-through technique

This technique can be used for superficially embedded barbed hooks where the point of the hook is close to the skin. To avoid injury from the barb, you should always wear protective equipment. 

Cutting out the hook
The push through

The string method

The string technique can be used for single barbed hooks that are embedded in a body part that can be firmly secured so that it does not move during the procedure. It fails if the force isn’t sudden enough so don’t be afraid to give the string a good pull.

Pull the string to release the hook
The string method

The needle technique

This technique works well with larger hooks that are superficially embedded. A needle is used to cover the barb therefore the hook can be backed out the entry wound. It can be difficult and is only to be used once other techniques have failed. 

The needle acts as a barb guard
The needle technique

Cut it out

When all other techniques have failed, you may consider cutting out the hook. Under adequate anaesthesia, an incision is made along the body of the hook and the hook is removed. 

What about once the hook has been removed?

The name of the game here is to minimise the risk of infection. Firstly, thoroughly irrigate the wound with normal saline.

Should I give empiric antibiotics?

No clinical trial to date has addressed the need for empirical antibiotics in fishhook wounds. In general, empirical antibiotics are prescribed.

If the hook was not contaminated, empiric antibiotics for skin flora is recommended. Treat as if there might be uncomplicated cellulitis and follow local guidelines.

If the hook was contaminated, consider other pathogens including Aeromonas, Edwardsiella tarda, Vibrio vulnificus and Mycobacterium marimun. Use an oral first-generation cephalosporin or, in patients with acephalosporin allergy, oral clindamycin, plus an oral fluoroquinolone such as levofloxacin. If there is seawater exposure, add doxycycline to cover for Vibrio (although avoid in children under 8 as it causes teeth discolouration and enamel hypoplasia). If there was soil contamination or exposure to sewage-contaminated water, add metronidazole to cover for anaerobes, unless you are already using clindamycin.

Sean’s hooked was embedded superficially in the finger pulp, with no evidence of damage to deeper structures. It was removed with ease in the Emergency Department using the push-through technique. His wound was thoroughly cleaned and he was discharged with a prescription for prophylactic antibiotics. He was given a tetanus booster and educated on the signs and symptoms of wound infection. 

Selected references

Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992;99(6):862. 1630774

Malitz DI. Fish-hook injuries. Ophthalmology. 1993;100(1):3. 8433823

Su, E. Removal of a barbed fishhook. In: Illustrated Textbook of Pediatric Emergency and Critical Care Procedures, Diekema, RA, Fiser, DH, Selbst, SM (Eds), Mosby, St. Louis 1997. p.727

https://www.uptodate.com/contents/fish-hook-removal-techniques#H3

Searching for sepsis

Cite this article as:
Anna Peters. Searching for sepsis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31160

The child with “fever” is one of the most common paediatric presentations to the emergency department. Most of these children are managed conservatively with parental reassurance and discharged home with a safety net identifying red flags. However, failing to identify those with “sepsis” has devastating consequences. How often do we get it wrong or worry about getting it wrong? We’d all love an evidence-based clear cut path for flagging and managing febrile children at risk of sepsis. Currently the approach in the UK is predicated on the NICE SEPSIS (NG 51) screening system which has anecdotally performed poorly with concerns it is poorly specific (i.e lots of false positives). Nijman and colleagues aimed to objectively assess the impact of the NICE Sepsis screening approach in children.

Nijman RG, Jorgensen R, Levin M, Herberg J and Maconochie IK. Management of Children With Fever at Risk for Paediatric Sepsis: A Prospective Study in Paediatric Emergency Care. Frontiers in Pediatric Care 2020; 8:548154. doi: 10.3389/fped.2020.548154

The lead authors looked at the various warning signs of serious infections in febrile children presenting to PED. Their aim was to then determine these children’s risk of having sepsis and to evaluate their subsequent management.

Who did they study?

Over 5000 children (5156 to be exact) aged 1 month to 16 years old presenting with fever over a period of 9 months from June 2014–March 2015 in a single PED at St Mary’s Hospital, UK were analysed.  Febrile children with no warning signs of sepsis were then excluded from the final cohort. The second largest group excluded from the final cohort was children with a complex medical history (n=119).  The decision to exclude this particular cohort is important given that ‘complex medical patients’ are more likely to have sepsis. The authors make the valid point that this group has features very different from the intended cohort, such as having different management plans in the context of fever. After these exclusions, plus a few further exclusions (lack of consent, lack of complete data or excluded because the child didn’t have any warning signs) the final cohort was of 1551 children. 

What did they do?

They first looked at the numbers of febrile children with tachycardia and tachypnea by using APLS and NICE (the National Institute of Healthcare Excellence) thresholds.  Subsequently, they looked at the numbers of febrile children fulfilling sepsis criteria by using well-known sepsis screening tools (NICE traffic light guidelines, SIRS, qSOFA, Sepsis Trust UK trigger criteria).

All the data for this study (vital signs, clinical signs and symptoms, tests, working diagnosis, need for hospital admission, timeliness of interventions) were collected electronically, having been recorded prospectively for all febrile children.

What did they look for? 

As a primary outcome the study determined:

  1. The incidence of febrile children who present with warning signs of sepsis 
  2. How often these children fulfilled paediatric sepsis criteria 
  3. How frequent invasive bacterial infections (IBIs) occurred in this population 
  4. How frequent PICU admissions occurred in this population.

Secondary outcomes included the compliance of clinicians with the paediatric sepsis 6 care bundle (PS6), what clinical interventions were and were not used from this care bundle and the timeliness of the interventions that were undertaken

What did they find? 

Almost a third of children aged 1 month to 16 years who presented to the PED had fever (28% to be exact).

41% of these febrile children had one or more warning signs (our study population).

The incidence of IBI was 0.39%. Of these children, only 0.3% required PICU admission.

This meant that using the sepsis guideline recommendations, 256 children would need to be treated to catch one IBI. Another way of saying this is the number needed to treat was 256. NNT for any serious outcome was 141.

How did the sepsis guidelines fare?

The thresholds for tachycardia and tachypnoea yielded a high false positive rate.

Adding sepsis criteria to predict the presence of a serious bacterial infection (SBI), IBI or PICU admission was also unreliable, with a lot of false positives.

Lactate levels were not significantly associated with the decision to give IV fluid bolus or presence of SBI, IBI or PICU admission. There WAS, however, a significant association between lactate levels and hospital admission.

Looking at the Paediatric Sepsis 6 Interventions, although many children triggered, two-thirds (65%) of the children with PS6 warning signs had none of PS6 interventions. And when it came to the ‘golden hour? Only a third (36%) of children with IBI or PICU admission received all PS6 interventions in the ‘golden hour with only 39 children (2%) receiving a fluid bolus

What does this all mean?

It is important to note that this study was only conducted in one single PED and in a time period that was before the NICE sepsis guidelines were formally implemented into practice.  The data was collected for this study via an electronic interface. While large amounts of data can be collected rapidly there can sometimes be gaps, either due to extraction issues or brevity on the behalf of clinicians that don’t give a comprehensive picture. Data were also only taken from initial triage and not from any clinical deterioration in the ED.  Given that acuity changes over time, especially in children with fever, this may have missed subsequent clinical change although is a pragmatic approach given the way that sepsis screening tools are applied in nearly all Emergency Departments. 

Numbers needed to treat were exceptionally high. Despite the allure of a protocol-based screening and management pathway,  the benefits of catching true sepsis early must be weighed against the possible unwanted effects of overtreating or overdiagnosing mostly well children in a potentially resource-stretched PED. The study really does highlight the difficulties we face when screening for a septic child in a generally well cohort, the ‘needle in a haystack’.

Essentially, what this study shows us is that serious infections are rare and most children who are categorised as ‘at risk of sepsis’ can in fact be managed conservatively with little intervention other than observation. It is clear that our current guidelines have very poor specificity; and while they tell us to investigate and treat lots of children, a lot of the time we as clinicians choose to rely on our clinical judgement and essentially ‘do nothing’. Observation and good clear red flagging must not be underestimated.  Instead of continuing to research more and better early predictors of sepsis, such as point of care biomarkers, perhaps we should be looking at this from another angle. The focus of the lens can also be flipped; we also need more research on how it can be safe NOT to do anything too. 

We’ll end with some thoughts from the authors

The Infections in Children in the Emergency Department (ICED) study is a single centre, prospective observational study. The study describes unique and carefully curated clinical data of febrile children with warning signs of sepsis, from a period prior to the implementation of the NICE sepsis guidelines. 

Our results confirm what many paediatricians dealing with acutely unwell febrile children already suspected: that many febrile children have warning signs of sepsis, but that the large majority have non-life threatening infections. 

Our findings will hopefully contribute to ongoing discussions about the use of sepsis screening tools in paediatric emergency medicine. Our study makes it clear that current tools lead to a high number of false positive cases, and their usefulness in routine clinical care in paediatric emergency medicine should be questioned. Escalation to senior decision makers of all children with warning signs of sepsis should be aspired, but is seldomly feasible in clinical practice and with unproven impact on reducing missed cases and optimising clinical care for the total cohort of febrile children. 

Although all children with serious infections would have been detected by the various sepsis tools, it is now evident that we need better tools to more selectively identify children at the highest risk of sepsis. Future studies should explore the utility of machine learning as well as the potential of combining clinical signs and symptoms with point of care biomarkers.

Ruud Nijman

Intraosseous access

Cite this article as:
Gavin Hoey and Owen Keane. Intraosseous access, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31005

It is 15.50 hrs on a Tuesday when the call comes in. A 3-year-old female is in cardiac arrest.

When it is an adult patient, we can manage this without even breaking stride…but as you begin to formulate your action plan, your brain now needs to focus on areas that you don’t tend to dwell on when it comes to a grown-up patient – How will I gain access? What are my medication doses? What are those novel airway features again? While we are more confident and experienced managing adult patients in cardiac arrest, it is important to remember that – Familiarity Breeds Contempt” – and this is different.

We are weaving in and out of rush hour traffic while deriving our WETFAG when we get updated information that an FBAO* may have led to this arrest.

*EM/prehospital speak for foreign body airway obstruction

My colleague and I discuss a plan of action:  we allocate roles, make a difficult airway plan, and agree to ensure that exceptional high-quality Basic Life Support is delivered in the first instance. We know that fundamentals matter most.

We discuss access options:

  • Intravenous (IV) – but will it be possible?
  • Intraosseous (IO) – we know that this is both possible and effective.

On arrival we find a 3-year-old old girl lying in a playroom. She is being tended to by a crew of firefighter-paramedics who have arrived just ahead of us.

I can see she is unresponsive but breathing. Her breathing does not look normal. She looks very unwell.

I get a handover from those on scene while Simon gets straight to work with airway assessment.

We voice our plan to the team:

  • Team role allocation reaffirmed.
  • Assess and manage the airway.
  • Assess and assist breathing.
  • Get access.
  • Complete a rapid A-E assessment to ensure we are not missing vital information.
  • Maximise team dynamics, performance, and optimise management of scene environment.

The decision to proceed with vascular access in paediatric patients is not an easy (or common) one to make for pre-hospital practitioners. Knowing that this patient was “Big Sick” makes the decision somewhat easier, but not so the challenge.  

When to IO?

Intraosseous (IO) is a rapid and effective method for accessing non-collapsible marrow veins without sacrificing pharmacokinetics.

Any delay in establishing vascular access can be potentially life threatening.

The Royal Children’s Hospital Melbourne states In decompensated shock IO access should be established if IV failed or is going to be longer than 90 seconds”.

The decision to gain IO access should be considered in the following scenarios

Selecting the site

How do we choose a site for placing an IO line and what can influence our decision?

Is the case medical or trauma? If it is a trauma, where are the injuries? Fractures at, or above, the insertion site can compromise the integrity of the underlying anatomic structures. Importantly, what sites are practical and accessible to me in this case right now?

Having never attempted IO access on a paediatric patient before, I stuck with what I had done most frequently in training and decided on “proximal tibia” as my site for IO insertion.

“In the pre-hospital environment, it is sometimes as important to know when not to do something as it is to know when to do something”

Justification for tibial IO access in this not-arrested patient was based on the following case elements for me:

  • IV access had failed.
  • I had a small child, obtunded and unresponsive, requiring airway and breathing support, tachycardic, tachypnoeic, and hypoxic. Big Sick.
  • Activities “up top” were busy, very busy – although the airway did not appear to have a FBAO, it did require my colleague to maintain a good seal. I did not feel positioning for humeral IO was viable at this moment.
  • This was a medical case with no apparent lower limb or pelvic trauma.

Of course, one must always consider contraindications before proceeding with IO access.

Contraindications

  • Fractures at (or above) the insertion site
  • Crush Injuries
  • Ipsilateral vascular injury
  • Illness or anomalies to the underlying bone e.g. osteomyelitis, osteogenesis imperfecta, osteoporosis.
  • Previous failed IO attempts at this location
  • Overlying skin infection
  • Pain associated with infusion may be considered a reason not to continue using the line if it cannot be controlled.

Landmarks

I considered all potential options for IO insertion before choosing the site most familiar to me– proximal tibia. Other possible sites included:

  • Distal tibia
  • Distal femur
  • Humeral head
Intraosseous insertion sites

Anatomical landmarks for the insertion site depend on whether you can palpate the tibial tuberosity or not. The tibial tuberosity does not develop until around 2 years of age. If you cannot feel the tibial tuberosity in the smaller child, palpate two fingerbreadths down from the inferior border of the patella, then one finger breath medial to this point. Where the tuberosity is palpable, just go one fingerbreadth medial to it.

Target flat bone and pinch the tibia (especially in the very young patient) to reduce bone mobility, and to prevent the skin rotating with the driver before starting needle insertion.

Surface anatomy for insertion around knee
Landmarks for proximal tibial insertion

This is a small child. While it might seem like there is no time to hesitate; training, planning, awareness, and observation are vital I recalled the phrase “Power and Pressure”. This was not going to require as much force as I usually use in adult IO insertion. “Let the driver do the work” and be careful not to overshoot through the bone.

Placing the needle over the landmark site at 90 degrees, I visualised the line I wanted to drill. After careful, but firm, passing of the needle through the skin, I pressed the trigger. After the first pop, I was careful not to overshoot. Anticipation here is key so avoid putting too much pressure on the driver. Similarly, be careful to avoid excessive recoil when you feel you have reached the medullary space as this can result in dislodgement of the needle.

But am I in the right space?

Attempt to aspirate marrow from your line (though it might not always be present). Flushing saline through with little to no resistance is very reassuring. No Flush = No Flow!

The line needs to be secured in place and the extension tubing attached properly with no identifiable leak points. What we give through the line should generate a physiological response – if it does not, always consider if the line has become displaced.

The proximal tibial site may not always be an option, so we where else can we go?

Medial view of ankle
Landmarks for distal tibial insertion

Distal Tibia

Place one finger directly over the medial malleolus; move approximately 3 cm or 2 fingerbreadths proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. 

Distal femur surface anatomy
Landmarks for distal femoral site of insertion

Distal Femur

Midline, 2-3 cm above the external condyle or two fingerbreadths above the superior border of the patella. This is often an accessible site due to children having less muscle bulk. To ensure you avoid the growth plate, the leg should be outstretched when performing your landmarking’s above and aim about 15 degrees cephalad too.

Landmarks of the humeral head for IO insertion
Landmarks for insertion in the proximal humerus

Humeral Head:

The humeral head represents an excellent access point for large proximal vasculature (lies closer to the heart). Flow rates may be higher here too due to lower intramedullary pressures. The greater tuberosity secondary ossification centre doesn’t appear until about 5 years of age making palpation of this landmark more of a challenge in the younger child.  For this reason, it is more often used in older children, typically over 7 years of age or only in those in whom the anatomy can be readily identified.

You may need to consider using a longer needle here due to the larger amount of soft tissue over this axillary area.

The insertion site is located directly on the most prominent aspect of the greater tubercle. 1 cm above the surgical neck. The surgical neck is where the bone juts out slightly – you will find this by running a thumb up the anterior aspect of the humerus until you feel a prominence. This is the greater tuberosity. The insertion site is approximately 1cm above this.

It is important to position the arm correctly.

hand on belly or thumb to bum position for humeral IO
Positioning the arm for humeral IO

Humeral IO placement techniques:

  • Thumb to Bum – Move the patient’s hand (on the targeted arm) so that the patient’s thumb and dorsal aspect of hand rest against the hip (“thumb-to-bum”).
  • Palm to umbilicus – Move the patient’s hand (on the targeted arm) so that the palm rests over the umbilicus, while still maintaining the elbow close to the body.

Site versus flow

As mentioned above, the proximal humerus is very close to the heart and this, coupled with seemingly lower intramedullary pressures, lends itself to higher flow rates when compared to the lower limb sites.

Important to note, however, that any abduction or external rotation of the arm during resuscitative efforts (easy to picture this happening when moving your patient from scene to ambulance!) can lead to dislodgment of you IO. Nice and easy does it.

An awake IO?

The sound of the driver buzzing brings back dentist chair memories for all of us. No less so for your patient who, if conscious during the insertion, will be particularly anxious and upset. Anticipate this and control anxiety with reassurance, distraction, and parental explanation if you can.

Pain in the conscious patient with an IO in situ can be from the area around the insertion site as well as the volume expansion caused by infusion. A small volume of 2% lidocaine can be given through the line prior to commencing the infusion to help with pain – this is slowly infused over 120 seconds, left for 60 seconds, then flushed with 2-5ml of saline.

Always consider line dislodgment or compartment syndrome with gross discomfort and inspect/flush the line to ensure it is still functioning adequately.

Size of IO – credit to Tim Horeczko

What about the gear itself?

The EZ-IO 10 driver and needle Set is a semi-automatic intraosseous placement device commonly found in our EDs. All needle catheters are 15 gauge giving gravity flow rates of approximately 60-100ml/min. The use of pressure bags can greatly increase these rates. It is important to make sure you pre-flush the connector set to ensure no residual air can be injected after attachment.

Fail to Prepare, Prepare to Fail”. Practice really makes perfect and so frequent familiarisation sessions are encouraged to get used to both the IO equipment and identifying the various access sites and their relevant anatomy.

A recent study by Mori et al (2020) showed a high rate of successful placement at 92.7%. This paper also described the complications encountered with the use of EZ-IO in a paediatric population in a paediatric ED. The complication rate seems to be consistent across all needle sizes at around 21%. Complications (particularly the more commonly occurring extravasation and skin) are important considerations for PEM IO training programmes.

Potential complications

  • Extravasation or subperiosteal infusion – the highest reported complication in the Mori paper was 17% of all IO insertions. This occurs if you fail to enter the bone marrow or happen to go through the entire bone itself and overshoot the medullary canal. Dislodgement of a well-placed IO line during resuscitation can lead to this occurring too.
  • Dermal abrasion4% in Mori study. A more recently described complication of using the semi-automatic IO approach, these injuries can occur due to friction from the rotating plastic base surrounding the EZ-IO needle. While these all seemed to settle with conservative treatment it is important to watch out for this during insertion.
  • Compartment syndrome – rare…but the smaller the patient the higher the risk.
  • Fracture or physeal plate injury.
  • Osteomyelitis – very rare, reported as 0.6% (Rosetti et al).
  • Fat embolus

The use of POCUS to rapidly confirm intraosseous line placement and reduce the risk of misplacement with extravasation has been discussed in recent times. This paper by Tsung et al in 2009 comments on its feasibility and describes using colour Doppler signal with a saline flush to identify flow in the bone around the IO to confirm placement. Misplacement may also be identified if flow is seen in the soft tissues rather than bone.  

The Super Smallies

Achieving safe and reliable intraosseous access in the neonate or infant can be a big challenge as they have smaller medullary canal diameters. Higher risks of misplacement and extravasation also put this group at risk of compartment syndrome. Case reports of limb amputation secondary to iatrogenic compartment syndrome from IO misplacement are almost exclusively in neonates and small infants.

A case report by Suominen et al. in 2015 described proximal tibia mean medullary diameters on x-ray as 7mm in neonates, 10mm in 1-12-month infants, and 12mm in 3-4-year old children. The EZ-IO needle set for this group is 15mm in length and 12mm in length once the needle stylet is removed. This leaves a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle.

With the measurements above, it makes sense that one would need to stop a few mm short to avoid throuugh-and-through insertion and subsequent extravasation. Stopping short like this could make the line more difficult to protect…Scott Wingart and Rebecca Engelman outline some neat tricks to “SEAL THE HECK OUT OF…” these delicate lines over here.

The systematic review by Scrivens et al in 2019 describe IO as an important consideration for timely access in neonatal resuscitation practice. They comment on the importance of incorporating IO insertion techniques into neonatology training. While a more recent study of IO access in neonatal resuscitation by Mileder et al reports lower success rates for insertion at 75%, clearly further studies are needed to scrutinise this access modality in neonates and whether it can be considered as a standard reliable and fast alternative to umbilical vein access in a time-critical scenario.

What are the take homes?

  • Have a vascular access plan before arriving at the scene for every paediatric patient – consider adding this to the end of you WETFLAG.
  • There are clinical scenarios outside of the patient in cardiac arrest where IO placement may be necessary – the decision to IO after failed IV should be rapid in the shocked child.
  • Familiarise yourself with the equipment, needle sizes and gauge, and be aware of the age-related anatomical considerations when landmarking sites for IO insertion.
  • Let the driver do the work – nice and easy does it!
  • Complications can occur and are not always rare – extravasation from dislodgement or misplacement, as well as skin abrasions, are well reported.
  • The smaller the patient, the higher the risk of through-and-through misplacement – these “super smallies” are at a greater risk of compartment syndrome. 
  • Keep it simple….“No Flush = No Flow!”. POCUS may be used to confirm satisfactory line placement too.

References

Arrow EZ-IO Intraosseous Vascular Access System. 2017 The Science and Fundamentals of Intraosseous Vascular Access. Available at: https://www.teleflex.com/usa/en/clinical-resources/ez-io/documents/EZ-IO_Science_Fundamentals_MC-003266-Rev1-1.pdf#search=’flow%20rates’

Ellemunter H, Simma B, Trawöger R, et al. Intraosseous lines in preterm and full-term neonates. Archives of Disease in Childhood – Fetal and Neonatal Edition 1999;80:F74-F75.

Santa Barbara County Emergency Medical Services Agency Intraosseous (IO) Vascular. https://countyofsb.org/uploadedFiles/phd/PROGRAMS/Emergency_Medical_Services/Policies_and_Procedures/Policy%20538A.pdf.

Royal Children’s Hospital Clinical Practice Guideline – Intraosseous Access. https://www.rch.org.au/clinicalguide/guideline_index/Intraosseous_access/

Advanced Paediatric Life Support, Australia & New Zealand: The Practical Approach, 5th Edition Published October 2012.

Weingart et al. How to place and secure an IO in a peds patient. https://emcrit.org/emcrit/how-to-secure-an-io-in-a-peds-patient

Wade, T. Intraosseous Access in Neonates, Infants and Children. 2019. https://www.tomwademd.net/intraosseous-access-in-neonates-infants-and-children/

Mori, T., Takei, H., Sasaoka, Y., Nomura, O. and Ihara, T. (2020), Semi‐automatic intraosseous device (EZ‐IO) in a paediatric emergency department. J Paediatr Child Health, 56: 1376-1381. doi:10.1111/jpc.14940. Available at: https://onlinelibrary.wiley.com/doi/10.1111/jpc.14940

Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: An alternative route of pediatric intravascular access. Ann. Emerg. Med. 1985; 14: 885–8.

Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009;2(3):155-160. Published 2009 Aug 11. doi:10.1007/s12245-009-0116-9.Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/

Tsung JW, Blaivas M, Stone MB. Feasibility of point-of-care colour Doppler ultrasound confirmation of intraosseous needle placement during resuscitation. Resuscitation. 2009 Jun;80(6):665-8. doi: 10.1016/j.resuscitation.2009.03.009. Epub 2009 Apr 22. PMID: 19395142. Available at: https://pubmed.ncbi.nlm.nih.gov/19395142/

Suominen PK, Nurmi E, Lauerma K. Intraosseous access in neonates and infants: risk of severe complications – a case report. Acta Anaesthesiol Scand. 2015 Nov;59(10):1389-93. doi: 10.1111/aas.12602. Epub 2015 Aug 24. PMID: 26300243.Available at: https://pubmed.ncbi.nlm.nih.gov/26300243.

Intraosseous (IO) – Salford Royal NHS Foundation Trust.  https://www.srft.nhs.uk/EasysiteWeb/getresource.axd?AssetID=45337&type=full&servicetype=Inline

Mileder LP, Urlesberger B, Schwaberger B. Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr. 2020 Sep 18;8:571285. doi: 10.3389/fped.2020.571285. PMID: 33042930; PMCID: PMC7530188 Available at: https://pubmed.ncbi.nlm.nih.gov/33042930/.

Scrivens A, Reynolds PR, Emery FE, Roberts CT, Polglase GR, Hooper SB, Roehr CC. Use of Intraosseous Needles in Neonates: A Systematic Review. Neonatology. 2019;116(4):305-314. doi: 10.1159/000502212. Epub 2019 Oct 28. PMID: 31658465. Available at: https://www.karger.com/Article/FullText/502212.

Lefèvre Y, Journeau P, Angelliaume A, Bouty A, Dobremez E. Proximal humerus fractures in children and adolescents. Orthop Traumatol Surg Res. 2014 Feb;100(1 Suppl):S149-56. doi: 10.1016/j.otsr.2013.06.010. Epub 2014 Jan 4. PMID: 24394917. Available at: https://pubmed.ncbi.nlm.nih.gov/24394917/.

Acromio-clavicular joint injuries

Cite this article as:
PJ Whooley. Acromio-clavicular joint injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29623

John went in for the ball but was tackled off it and ended up falling onto his shoulder to the ground. He was able to finish the game but had a lot of pain when he stretched his arm across the front of his chest.

AC joint anatomy

The acromioclavicular (AC) joint combines the distal clavicle and the acromion (the superolateral part of the scapula). The joint is supported by a ligament complex as well as the surrounding fascia and muscles. The main ligaments involved are the acromioclavicular ligaments and the coracoclavicular (CC) ligament. The CC ligament is made up of the lateral trapezoid ligament and the medial conoid ligament. 

Mechanism of injury

Injury to the AC joint means disruption of the AC ligaments with or without disruption of the CC ligament. It occurs in up to 10% shoulder girdle injuries and is more common in athletes. Injury typically occurs from a direct blow or following a fall onto the superior or lateral part of the shoulder with the arm adducted. This results in the acromion being forced inferiorly and medially to the clavicle. Injury with a low force causes an AC sprain, with progressively increased force causing AC ligament rupture and then additional sprain and rupture of the CC ligaments. 

Examination 

AC joint injury presents with pain and tenderness over a possibly swollen AC joint. The pain may also be referred to the trapezius muscle. When compared to the contralateral side there may be an abnormal contour. 

If the diagnosis is in doubt you can perform the crossbody ADDuction (Scarf test) to compress the AC Joint. If this is painful, this is suggests AC joint injury. A careful distal neurovascular exam of the involved extremity shoulder be performed, documenting radial, ulnar and median nerve function (take a look at the examining paediatric elbow post for top tips on conducting a proper neurovascular assessment in upper limb injuries).

Young boy trying to hurt his sister (and failing)

It is important to rule out atraumatic distal clavicle osteolysis, a repetitive stress injury in young athletes who do high level upper weight training.

AC injury infographic

Radiology

There are two approaches to plain film imaging in suspected AC joint injury:

  • a single AP view including both AC joints 
  • one AP view of each shoulder comparing affected with the unaffected side

This image from Orthobullets.com shows AC joint widening on the left compared to a normal AC joint on the right.

If there is still some doubt the AC joints can be better seen on Zanca views using a 10-15 degrees of cephalic tilt. Stress views are often used with weights in each hand to determine AC joint instability. This is important also to out-rule coracoid fractures often seen in stress overuse as in young athletes who do repetitive weight training.

Zanca views of the left shoulder. In these images, the ACJ has not become widened on weight-bearing indicating a normal AC joint, with no injury. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 68155

Look carefully at the clavicle for any associated occult clavicle fractures.

Classification

Paediatric AC joint injuries are classified as grades I – VI by the Rockwood classification

In the ED, the most common injuries, occurring after minor trauma, are types I to III, ranging from stretching of the AC ligament to complete tear with clavicle lifting: 

  • I – AC ligament sprain with intact periosteal sleeve
  • II – Partial periosteal sleeve disruption with AC Joint widening (CC distance <25% contralateral side)
  • III – Disrupted periosteal sleeve with superior (upwards) displacement of the clavicle, with between 25 – 100% displacement

Types IV to VI typically occur after high energy trauma and need surgical intervention:

  • IV – Distal clavicle displaced posteriorly through the trapezius
  • V – Deltoid and trapezius detachment and clavicle displacement >100%
  • VI – Clavicle displaced inferiorly under the coracoid

Management

Rockwood Grades I – III AC joint injuries: Non-operative management is the mainstay as these are low energy injuries. Analgesia, ice and rest in a sling or figure-of-eight braces followed by gentle range of motion exercise once the pain has settled. Early rehabilitation with cautious exercise results in earlier return of normal shoulder range of motion, with functional motion by 6 weeks and normal activity by 12 weeks. The lower the grade the earlier the return to normal function. Caution needs to be taken to avoid manoeuvres that that strain the ligaments and cause pain. Avoid cross-body ADDuction, extreme internal rotation (i.e. behind the back) and overhead movements.

Rockwood Grades IV to VI injuries: Operative management is indicated in grades IV to VI but also in Grade III that have failed non operative treatment or in elite athletes and for cosmesis.

Complications

Up to 30 – 50% of patients with AC joint injuries complain of residual pain. 

John thankfully only had a Grade II AC joint injury and wore a shoulder immobilizer for 3 weeks. He’s already back training but is a little more cautious when he goes in for the tackle. 

References

AD. Mazzocca, RA. Arciero, J. Bicos. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35:316-329.

JD. Gorbaty, JE Hsu. AO. Gee.  Classifications in Brief: Rockwood Classification of Acromioclavicular Joint Separations. Clin Orthop Relat Res. 2017 Jan; 475(1): 283–

S. Evrim. N. Aydin, OM. Topkar. Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT Open Rev 2018;3:426-433

Talk ortho like a pro

Talk ortho like a pro

Cite this article as:
Orla Callender. Talk ortho like a pro, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30463

Clear and structured communication between the emergency and orthopaedic team is paramount to ensuring a smooth transfer of care for children with fractures and traumatic injuries. Use this checklist to structure your referrals to ortho like a pro, and test your x-ray interpretation skills with the quiz below.

History

Injury is force meets child; child is damaged. Force causes an easy-to-remember event – shock, pain, ‘crack’, blood, fear – so there will always be a history of an injury. When taking a history, remember the six honest men: when, how, where, what, who and why.

In addition to a full history of presenting complaint and past medical, vaccination and developmental history, a trauma history should include:

  • Date and time of injury
  • Exact mechanism of injury when possible, preferably in parent’s or child’s own words
  • Environment in which the injury occurred
  • Symptoms at time of injury and subsequently
  • Hand dominance for upper limb injury
  • Analgesia administered
  • Fasting status
  • Relevant past medical history such as bleeding disorders

Sadly, we must always remain vigilant for signs of non-accidental injury (NAI). The presenting injury needs to reasonably fit with the account as to the mechanism of injury.

Examination

Whilst the majority of the examination of a traumatic injury is centred on the affected site, the examination must always include:

The examination should be broken down into:

  • Inspection
  • Palpation
  • Movements and gait
  • Neurovascular status
  • Special tests

Imaging

Fractures can generally be identified on an AP and lateral radiograph. Use a systematic approach and apply the rule of two’s.

Apply rule of two’s:

  • Two views as standard; occasionally other views may be required
  • Two joints viewed
  • Two sides where comparison of normal is necessary
  • Two occasions before and after procedures or in specific instances (such as when a scaphoid fracture is suspected)

A fracture may appear as a lucency (black line) where a fracture results in separation of bone fragments or as a dense (white) line where fragments overlap. If bone fragments are impacted, then increased density occurs which may be the only radiological evidence that a fracture exists.

Sometimes, there is no direct evidence of a fracture and instead, we need to rely on indirect evidence. Looking for radiological soft tissue signs can provide clues to fractures. These include displacement of the elbow fat pads or the presence of a fluid level.

The AABCS approach, described by Touquet in 1995, can be used to carry out a structured interpretation of a limb x-ray.

Key points:
•   Examine the entire radiograph in detail before concentrating on the area of concern – Look at the whole x-ray and the x-ray as a whole
•   Remind yourself of mechanism of injury – Are the radiographic findings relevant to patient history? How do the findings correlate with clinical findings? Do you need to re-examine the patient?
•   Take an x-ray before and after procedures
•   Get help – If the x-ray doesn’t look right ask someone else, and ensure there is a backup reporting system in place
•   Document both what you see and what you don’t see on the x-ray

Describing fractures

Fractures are described systematically. Start with the site (name and part/portion of bone), then extent (fracture type/line, open/closed, articular involvement), then describe the distal fragment (displacement and angulation). Describe any involvement of the skin and damage to related tendons and structures such as nerves or blood vessels.

Describing the site

Long bones are often described based on thirds: proximal, middle (diaphyseal) and distal segment. Including nearby anatomical landmarks (head, neck, body /shaft, base, condyle, epicondyle, trochanter, tuberosity etc.) helps describe the area of interest.

In paediatrics, fractures are described including the anatomical divisions of the bone segments: the epiphysis, the epiphyseal plate, the metaphysis and the diaphysis.

  • The diaphysis is the shaft of the bone
  • The physis is the growth plate. Also known as the epiphyseal plate, the physis occurs only in skeletally immature patients and is a hyaline cartilage plate in the metaphysis, at the end of a long bone.
  • The metaphysis lies between the diaphysis and the physis. An easy way to remember this is to think of the word metamorphosis – a change; the metaphysis is the area of change between the physis – the growth plate – and the diaphysis – the shaft. The metaphysis is only used to describe a bone before it matures – it is the growing end of the long bone. Metaphyseal fractures are almost pathognomonic of NAI. They are also known as corner fractures, bucket handle fractures or metaphyseal lesions
  • The epiphysis sits above the growth plate – epi (Greek for over or upon – like the epidermis) – physis – upon the physis

Describing the extent

For revision of specific terms to use to describe the type of fracture, see the fracture terminology glossary below. Key characteristics to add include whether the fracture is open or closed, and whether the fracture is intra-articular (inside the joint capsule) or extra-articular. Extra-articular fractures are usually less complicated.

Describing the distal fragment

There is a convention to ensure that the same injury is described in the same way: angulation, displacement, and dislocation are described by where the distal fracture fragment is in relation to the proximal fragment, or in the direction of the fracture apex.

Displacement is the loss of axial alignment: dorsal (posterior), volar (anterior) or lateral displacement of the distal fragment with respect to the proximal fragment. The degree of displacement can be roughly estimated from the percentage of the fracture surfaces in contact. Where none of the fracture surfaces are in contact, the fracture is described as having ‘no bony opposition’ or being ‘completely off-ended’, and are potentially unstable. Displacement is usually accompanied by some degree of angulation, rotation or change in bone length.

Angulation is the angle created between the distal fragment and the proximal fragment as a result of the fracture. The anatomical reference point is the long axis. Angulation is described using words like: dorsal / palmar; varus / valgus; radial /ulnar. It may be described either by reference to the direction in which the apex of the fracture points (apex volar or apex dorsal) or by indicating the direction of the tilt of the distal fragment. Medial angulation can be termed ‘varus’, and lateral angulation can be termed ‘valgus’. To measure angulation, one line is drawn through the midline of the shaft. A second line is then drawn through the midline of the fragment and the angle can now be measured.

Rotation is present when a fracture fragment has rotated on its long axis relative to the other. It may be with or without accompanying displacement or angulation. It is more readily diagnosed on clinical examination.

Finally, perfecting your referral

Referrals to the orthopaedic team, using a framework like the ISBAR tool, should start with the child’s name, hospital number and who is attending with the patient. Then proceed to give a history, including a full history of the presentation, hand dominance, fasting status and any relevant clinical risk factors such as bleeding disorders. Describe your clinical findings, including neurovascular examination, and then the radiological findings in the order of:

  • the bone(s) involved
  • part of bone
  • type of fracture
  • fracture line
  • extent of deformity and angulation
  • and any associated clinical findings

Describe any other investigations, management to date and on-going treatment. Summarise events that have occurred before referral – analgesia, backslab casts, splints, antibiotics, tetanus boosters, wound cleansing, dressings etc.

As with any good referral, be clear about why the child is being referred. It may be reasonable to transfer full care of a child. Or, the referral may simply be to gain a second opinion on the diagnosis followed by management. Be clear about the type of care expected. And finally, discuss whether you feel the referral is urgent or not. It should be stated how quickly you expect the patient to be seen. Do you feel they need to be seen urgently, soon or routinely?

At this stage, a management plan and expected outcome can be discussed and agreed. This information can then be reiterated to the child and family. Make sure everything is clearly and concisely documented.

Done!

Fracture terminology

Non-displaced fracture: A fracture where the pieces of the bone line-up.

Displaced fracture: The pieces of the bone are out of line.

Closed fracture: Either the skin is intact or, if there are wounds, these are superficial or unrelated to the fracture.

Open / compound fracture: A wound is in continuity with the fracture site.

Unstable fracture: A fracture with a tendency to displace after reduction.

Complete fracture: The fracture line extends across the bone from one cortex to the other separating the bone into two complete and separate fragments.

Greenstick fracture: Only one cortex is fractured.

Torus / buckle: Buckling of the cortex with no break.

Comminuted: There are more than two fragments.

Transverse fracture: A fracture across the bone.

Oblique fracture: A fracture at an angle to the length of the bone.

Spiral fracture: A fracture that curves around the bone diameter.

Depressed: A portion of bone is forced below the level of the surrounding bone.

Avulsion fracture: The muscle have torn off the portion of bone to which is attached.

Stress fracture: Tiny cracks in the bone caused by repetitive injuries. A cortical break is not always seen but there is greying of the cortex due to callus formation.

Pathological fracture: A fracture arising within abnormal bone weakened by benign or malignant cysts or tumours.

Impacted fractures: One fracture fragment is driven into the other.

Plastic deformation: Deformation of bone without fracture of the cortex.

Epiphyseal fractures: A fracture to the growing end of a juvenile bone that involves the growth plate. Use the Salter-Harris classification if the fracture involves the epiphyseal plate.

Fractures don’t always occur in isolation – a joint may be involved.

Fracture-dislocation: A dislocation is complicated by a fracture of one of the bony components of the joint, such as a Galeazzi or Monteggia fracture-dislocation.

Subluxation: The articulating surfaces of a joint are no longer congruous, but loss of contact is not complete.

Dislocation: Complete loss of contact between the articulating surface of a joint. Displacement of one or more bones at a joint.

References

Bickley S. & Szilagyi P. (2003) Bates’ Guide to Physical Examination and History Taking (8th edn.) Philadelphia. J.B. Lippincott, Philadelphia.

Davis, F.C.W., 2003. Minor Trauma in Children. A pocket guide. London: Arnold.

Duderstadt, K. 2006. Pediatric Physical Examination. Mosby. Elsevier.

Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh: Churchill Livingstone.

Larsen, D. & Morris, P. 2006. Limb X-ray Interpretation. Whurr Publishers Limited.

McRae, R. 2003. Pocketbook of Orthopaedics and Fractures. 3rd ed. Edinburgh: Churchill Livingstone.

Raby, N., Berman, L. & De Lacey, G., 2001. Accident & Emergency Radiology. A Survival Guide. Edinburgh: W.B. Saunders.

Touquet et al, 1995. The 10 Commandments of Accident and Emergency Radiology. BMJ 1995; 311: 571.

Image source for final quiz case: https://radiopaedia.org/cases/2c1840c5145638e56f599031f23dd0c8?lang=us

Wrist x-rays

Cite this article as:
Sian Edwards. Wrist x-rays, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29082

The wrist is one of the most commonly requested X-Rays in the children’s emergency department. Wrist views are requested when injury to the distal radius/ulna or carpal bones are suspected. Below is a systematic approach to interpretation.

The wrist series examines the carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate), the radiocarpal joint and the distal radius and ulna. 

There are eight carpal bones present and each one is named according to its shape:

  1. Scaphoid (boat-shaped)
  2. Lunate (crescent moon-shaped)
  3. Triquetrum (pyramidal)
  4. Pisiform (pea-shaped)
  5. Trapezium (irregular trapezium-shaped)
  6. Trapezoid (wedge-shaped)
  7. Capitate (head-shaped) – *the largest of the carpal bones
  8. Hamate (wedge-shaped with a bony extension, or ‘hook’)
Labelled XR of carpus
AP
Proximal carpal rowDistal carpal row
ScaphoidTrapezium
LunateTrapezoid
TriquetrumCapitate
PisiformHamate

How to best remember the carpal bones

There are many mnemonics around – some too rude for mention here! You will need to find the one that works for you… here’s one that’s super suited for clinicians working with kids:

Sam Likes To Push The Toy Car Hard

Failing that, save an image to your phone for quick reference!

Mnemonic for remembering carpal bones

Ossification

The carpal bones are formed entirely from cartilage at birth – this is important from a radiological viewpoint as it means they are not visible on x-ray initially. They begin to ossify from about 1-2 months of age and are fully developed by the age of 8-12 years. Although there is variability in the timing, the order is always the same.

  1. Capitate 1-3 months
  2. Hamate 2-4 months
  3. Triquetrum 2-3 years
  4. Lunate 2-4 years
  5. Scaphoid 4-6 years
  6. Trapezium 4-6 years
  7. Trapezoid 4-6 years
  8. Pisiform – 8-12 years

Generally, on x-ray, one carpal bone is visible every year until full development – this acts as a handy (pun intended) ageing tool!

On requesting wrist X-Rays, most commonly you will receive posteroanterior and lateral projections, with oblique views forming part of the series usually when carpal injury is suspected.

1. Check the soft tissues

Look for signs of swelling or any incidental findings.

2. Trace the bony cortices

Trace each bone in turn to look for breaks or irregularities in the cortex.

Look closely at the distal radius, proximal carpal row (especially the scaphoid) and the proximal metacarpals. Disruptions in the cortex may be very subtle as in the case of this torus fracture (aka a buckle fracture)

Buckle fracture of radius
Buckle fracture

3. Check bony alignment

On the AP view:

The distal radial articular surface should curve round the carpals with the articular surface getting more distal towards the ulnar styloid. The articular surfaces of the proximal and distal carpal rows should form three smooth arcs – these can be traced on the AP film.

The spacing between all carpal bones should be 1-2mm.

If the arc is broken or there is widening or lack of uniformity between the spaces, think about carpal dislocation.

The articular cortex at the base of each metacarpal parallels the articular surface of the adjacent carpal bone.

The carpo-metacarpo (CMC) joint spaces should be clearly seen and of uniform width (1-2mm).

The 2nd to 5th CMC joints are visualised as a zigzag tram line – on a normal view, there will always be the “light of day” seen between the bases of the 4th and 5th metacarpals and the hamate bone. If this is narrowed, think dislocation of the 4th or 5th metacarpal.

Labelled AP view of wrist
AP view

On the lateral view:

The distal radius, lunate and capitate should articulate with each other in a straight line on the lateral x-ray – the apple, cup, saucer analogy – the cup of the lunate should never be empty.

Lateral view of carpus
Normal capitate – lunate – radius alignment. Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947

If the cup is empty, this suggests a perilunate dislocation.

Perilunate dislocation
Perilunate dislocation. Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46714
The apple and cup model of perilunate dislocation
The slipped cup of the perilunate dislocation

References

https://radiopaedia.org/articles/wrist-radiograph-an-approach?lang=gb

Galeazzi fracture-dislocations

Cite this article as:
Rie Yoshida. Galeazzi fracture-dislocations, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21150

Patrick is a 15-year-old boy who presents to the Emergency Department with a painful left arm.  He tells you he fell off his bicycle, putting out his left hand out to break the fall.  On examination, his left forearm is deformed at the wrist.  There are no open wounds and no signs of compartment syndrome. The limb is neurovascularly intact.  

He has declined analgesia in triage but you convince him to take paracetamol and ibuprofen prior to his x-ray. You order a lateral and AP film of his left forearm including the wrist and elbow.  

Th. Zimmermann [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
His x-ray shows a distal radial fracture.  Whilst you are assessing the degree of angulation, a medical student leans over your shoulder and asks, ‘Should the head of the ulnar be sticking out like that?’. You nearly missed it but Patrick has a rare Galeazzi fracture-dislocation! 

Galeazzi fracture-dislocations consist of a fracture of the radius with dislocation of the distal radio-ulnar joint.  The fracture usually affects the distal third of the radius.

Galeazzi injuries are very rare in children (more commonly seen in the adult population).  The mechanism of injury is usually due to a fall on an outstretched hand with forearm rotation.

Examination findings

Examine the forearm, wrist and elbow joint.

Inspection and palpation: swelling, tenderness and likely deformity of the distal forearm and wrist. Check for any open wounds.

Range of movement: Maybe reduced at the wrist joint.

Check for signs of neurovascular compromise or compartment syndrome.  Ulnar nerve injury is uncommon.

Investigations

True AP and lateral X-rays of the forearm including the wrist and elbow (including distal humerus).

The key point here is if a distal to mid-shaft radial fracture is seen on  X-ray, have a good look for signs of distal radioulnar joint disruption.

Classification 

Galeazzi fractures are classified according to the direction of ulna displacement.

Galeazzi-equivalent fracture

A Galeazzi-equivalent fracture may occur in children.  This characterised by both

  • fracture of the distal radius
  • fracture of the growth plate of the ulna (separation of the ulnar physis), as opposed to dislocation of the distal radio-ulnar joint, DRUJ.

Treatment

All Galeazzi fracture-dislocations should be referred to orthopaedics on-call as a surgical intervention may be required for unstable or irreducible fractures.  The usual approach in children is conservative management with closed reduction and immobilisation in an above-elbow cast.  They should be followed up in the fracture clinic in 7 days.  Complications include malunion, compartment syndrome and nerve injury but these are more common in adults and if the diagnosis is delayed.  Children tend to have good outcomes with closed reduction and casting, even if the diagnosis is initially missed.

You are congratulated by the ED consultant for identifying Patrick’s Galeazzi fracture-dislocation.  You call the Orthopaedic surgeons.  It is a stable fracture and he has a successful closed reduction performed under procedural sedation in ED.  An above-elbow back slab is applied.  A few hours later, Patrick is ready to go home as he has recovered from the sedation.  On their way out, his mother asks you if he will recover fully.  You explain that he will be followed-up in the fracture clinic in 7 days but that his outcome should be good as the fracture was identified early and the post-reduction x-ray shows good alignment.  On your next day off, you decide to make a table of the differences between Monteggia and Galeazzi fracture-dislocations to aid your memory. 

[wpsm_comparison_table id=”10″ class=””]

*One way of remembering that both Monteggia and Galeazzi require review by orthopaedic surgeons is to remember that both fracture types are named after Italian surgeons!

Top tips

  • If you identify a distal to mid-shaft radial fracture, look for signs of distal radioulnar joint disruption or ulna physis disruption.
  • A useful mnemonic to remember the key differences between Monteggia and Galeazzi fracture-dislocations is MUGR (Monteggia fractured Ulna, Galeazzi fractured Radius)

Selected references

Eberl, R., Singer, G., Schalamon, J., Petnehazy, T. and Hoellwarth, M.E., 2008. Galeazzi lesions in children and adolescents: treatment and outcome. Clinical orthopaedics and related research466(7), pp.1705-1709.

Johnson NP, Smolensky A. Galeazzi Fractures. [Updated 2019 May 2]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470188/