Medial epicondylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Medial epicondylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21036

In this section, we will mainly discuss medial epicondylar fractures. Medial condylar fractures are a rare pattern of fracture and managed in a similar manner to lateral condylar fractures. It is important to differentiate between medial condylar and epicondylar fractures. Condylar fractures are intra-articular and require urgent open reduction and internal fixation.

Lateral condylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21030

Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards, he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…

Epidemiology 

This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.

History 

The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.

Examination

Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.

Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.

It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.

Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.

Investigations

AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.

The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.

The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.

The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.

 Lateral condyle fractures can be classified depending on their x-ray appearances.

Classification

There are several different classification methods. The most common classifications as below.

Milch Classification
Type 1The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.
Milch Classification
Jakob Classification
Stage 1<2mm displacement, which indicates intact cartilaginous hinge 
Stage 22-4mm of displacement 
Stage 3>4mm displacement with rotation of the fragment 
Jakob Classification

Immediate treatment in the ED

Provide immediate adequate analgesia to the child prior to any examination or investigation.

If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.

Keep the child nil by mouth as they may need urgent surgery.

Treatment following imaging

Treatment depends on the degree of displacement of the fracture.

Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.

Jakob classificationTreatment optionFollow up
Stage 1 (<2mm of displacement)Conservative management with immobilisation with above elbow cast to 90 degrees.Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation)These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation.3-6 weeks in above-elbow cast and orthopaedic follow up.

Areas of controversy

Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.

Potential complications

This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.

The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:

  • Stiffness is the most common complication, usually fully resolving by 48 weeks.
  • Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
  • Non-union is more likely when delayed union occurs.
  • Cubitus valgus deformity occurs with lateral physeal growth arrest.
  • Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
  • Avascular necrosis may develop 1-3 years after the fracture.
Image from wikimedia.org

Do not miss bits

Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.

William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.

References

Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.

Finger injuries: basics and bones

Cite this article as:
Sinead Fox. Finger injuries: basics and bones, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27577

Introduction

Injuries to the hand are frequent in the paediatric population and are a common reason for presentation to the PED. Despite the frequency of these presentations, assessment and management of hand and finger injuries can be challenging. But never fear! DFTB have come to the rescue with a comprehensive two-part series related to the assessment and management of paediatric hand and finger injuries including some handy tips.

This first post will cover an overview of the basic anatomy of the hand, professional lingo as well as history taking and the clinical examination. Documentation essentials and common phalangeal and metacarpal fractures seen in PED will also be covered.  

First, let’s take a look at the basic anatomy of the bones of the hand.

Professional Lingo: Get to know your pinkie from your pointer!

Although it is helpful to know your pinkie from your pointer when talking to children, it is also important to have knowledge of the professional language used to document and describe hand injuries appropriately. This is not only important from a medico-legal point of view but having the ability to describe the exact location of clinical findings in professional terms makes communication and referral to specialist services much easier.

Clinical History/Documentation Essentials: Take a HAND history

H-          How the injury happened? Ask about mechanism of injury including the environment in which the injury was obtained.

              Hobbies. Ask about the child’s hobbies, sports, activities, career aspirations (in older child) as these may impact on management.

A-          Altered sensations. Ask about any altered sensations such as paraesthesia which could indicate a nerve injury.

N-          Needles/Needs Tetanus? Ask about vaccinations, is the child’s Tetanus vaccination up to date, especially relevant if open wounds or animal/human bites are present.

NAI        Like all paediatric injuries consider the possibility of NAI, especially in the younger child. A comprehensive history is essential to detect the possibility of intentional injury from physical abuse or an unintentional injury as a result of neglect. Consider injuries that are self-inflicted in the older child/adolescent age group.

D-          Dominance. Ask and record the child’s hand dominance as this can impact injury management.

Physical exam – look, feel, move

Clinical assessment of hand injuries involves a systematic exam of both hands including inspection, palpation, and range of motion (ROM).

1. Look

  • Once the child has received appropriate analgesia and you have established a rapport with the child and their parent, begin by looking at the hand without touching, observe the child’s hand at rest and play, involve a play specialist if available- they always bring the right amount of magic to get even the sorest of little hands and fingers moving!
  • Look for bruising, swelling, abrasions or open wounds. Assess for nail bed injuries.
  • Check for any clinical deformities including a rotational deformity which may not become apparent until the child makes a fist. Minimally displaced fractures may be clinically significant if they result in a rotational deformity, so it is vital to routinely assess for same. It is good practice to include the presence or absence of a rotational deformity in your documentation.
Rotational deformity – the normal cascade should point to the thenar eminence

2. Feel

  • Examine the child’s unaffected hand first and keep the child chatting throughout the exam, it helps reduce the child’s anxiety and allows the child to build trust in you.
  • Remember to examine the whole hand. It is important to develop a systematic approach to the examination of the hand including palpation of the wrist, carpal bones (including anatomical snuff box and scaphoid tubercle) metacarpals, metacarpophalangeal joints (MCPJs), phalanges, proximal interphalangeal joints (PIPJs) and distal interphalangeal joints (DIPJs).  Systematic palpation of the entire hand can help localise underlying fractures and concomitant injuries.
  • Evaluate and document neurovascular status.

Examination Pearl: The Wrinkle Test

Neurological assessment in young children or children/adolescents with difficulties communicating can be particularly challenging as they may be unable to report the presence or absence of sensation. The wrinkle test measures autonomic function of peripheral nerves via placement of the child’s hand in warm water for 10 minutes, wrinkles on the fingers indicate intact neurological function.

3. Move

  • Getting a child to move an injured hand can be challenging but certain familiar gestures such as high fives, thumbs up or fist bumps can be used to assess active range of movement in a young or uncooperative child.
  • A game of paper, rock, scissors is a fun and systematic way to test peripheral nerves in children with upper limb injuries. 
  • Be vigilant for tendon injuries. Check out the DFTB finger tendon and ligament injuries post for further details and clinical pearls related to the assessment of specific tendon functions. These functional tests should be included in every clinical examination of an injured hand.

Phalangeal Fractures

Approximately 20% of hand injuries in children are fractures. In particular, the phalanges are the most frequently injured bones of the hand with distal phalangeal and proximal phalangeal base fractures being the most commonly diagnosed fractures.

Proximal phalangeal base fractures

It’s a sunny June afternoon and Patrick a 9-year-old boy is brought to your ED by his Dad. Patrick reports it is the last day of school term before the summer holidays, he tells you he was so excited that when the final bell rang he threw his book bag in the air but, as the bag landed his left little finger got caught in the strap. It sounds like his finger was forcefully abducted by the weight of the bag. He shows you his swollen, bruised, and painful pinkie.  

Mechanism

Typically, proximal phalangeal base fractures result from a finger being abducted beyond acceptable limits of the MCP joints.

Presentation

A child with a proximal base phalangeal fracture will typically present with swelling, ecchymosis, and focal tenderness on palpation to base of proximal phalanx. A displaced fracture to the base of the proximal phalanx can cause malrotation of the finger. A significantly displaced fracture or a fracture that causes a rotational deformity requires closed reduction to correct the deformity.

Imaging

Oblique, PA, and lateral X-rays of the injured fingers should be obtained. True lateral X-ray is the most effective way to examine joint congruity. Angulation of proximal phalanx fractures is best seen on the lateral projection.

Salter-Harris Classification

Fractures involving the physis are described by the Salter-Harris Classification system as types I-V.  Salter- Harris type II fractures of the proximal phalanx are a common type of finger fracture in children.

  • Salter-Harris type I fractures involve only the physis and can be difficult to diagnose because X-Rays typically appear normal unless there is displacement.
  • Salter-Harris type II fractures involve extension through the physis and metaphysis.
  • Salter-Harris type III fractures extend through the physis and epiphysis.
  • Salter-Harris type IV fractures extend through the physis, metaphysis and epiphysis.
  • Salter-Harris type V fractures involve crush injuries that shatter the physis. 

Treatment

Non- Operative: Un-displaced or minimally displaced Salter-Harris type I or II fractures of the proximal phalanx without clinical deformity are usually managed with buddy taping to an adjacent finger for support and encouragement of early range of motion, typically for 3-4 weeks.

For displaced Salter Harris type II fractures of the proximal phalanx closed reduction can be carried out in ED. Depending on the age and preference of the child, closed reduction can be performed using a ring block +/- procedural sedation. The proximity of the physis assures a high degree of remodelling. The ED practitioner’s thumb or a cylindrical object such as a pen or pencil can be used to achieve adequate reduction. Post reduction stability is maintained by buddy tapping +/- splinting.

Operative: Severely displaced, unstable or open fractures require evaluation by a hand surgeon.

X-ray shows a displaced Salter-Harris type II fracture to the base of Patrick’s proximal phalanx. There is a rotational deformity on clinical exam. You reduce the fracture in ED using a ring block and Nitrous Oxide. On reassessment post reduction the clinical deformity is corrected and check X-rays are satisfactory. You discharge Patrick home with his finger buddy taped and arrange follow up in an outpatient clinic.  

Phalangeal shaft, neck and condylar fractures

Phalangeal shaft fractures

Treatment for fractures along the shaft of the phalanges is dictated by the orientation of the fracture as well as the degree of angulation on initial presentation. Clinical exam is also extremely important as even innocuous appearing fractures along the phalangeal shaft can be clinically significant if they cause a rotational deformity of the injured digit. A rotational deformity must be corrected as failure to do so can lead to long term functional impairments for the child.

Non operative: For length stable fractures with minimal displacement, buddy taping to an adjacent finger for support and to allow early range of motion can be an effective treatment for approximately 3-4 weeks.

Operative: Oblique or spiral fractures requiring closed reduction need more rigid immobilisation such as an ulnar or radial guttar splint or cast. Alignment of these fractures can be difficult to maintain and fixation is often required; surgical opinion is advised.

Surgery is also indicated in cases of open or severely displaced fractures or where there is instability post-reduction.

X-ray of long oblique proximal phalanx shaft fracture Courtesy of Orthobullets: https://www.orthobullets.com/hand/6114/phalanx-fractures

Phalangeal neck fractures

Neck fractures of the proximal and middle phalanges are classic paediatric injuries, rarely seen in adults. They typically result from a crush injury to the finger such as a child getting the finger caught in a closing door.

Non operative: Non-displaced fractures to the neck of the proximal or middle phalanges can usually be managed safely by immobilizing the digit for 3-4 weeks.

Operative: Surgical consultation is recommended for any displaced neck fractures as these are inherently unstable and require close follow up.

Condylar fractures

The condyles are a pair of tuberosities that form the distal articular surfaces of the proximal and middle phalanges. Condylar fractures are intra-articular fractures and can be unstable, therefore surgical consultation is recommended as these fractures require meticulous reduction to ensure proper joint congruity.

Volar plate avulsion injuries

Tori is a 14-year-old girl and a talented soccer goalie. She reports that while trying to save a penalty, her right middle finger was forcefully hyperextended and is now very painful. She shows you her right middle finger which is swollen and bruised at the PIPJ.

An overview of volar plate injuries

The volar plate lies between the flexor tendons and the palmar PIPJ capsule. It originates from the proximal phalanx and inserts into the middle phalanx. The volar plate contributes to the stability of the PIPJ by preventing hyperextension of the PIPJ.  Volar plate injuries encompass a spectrum of soft tissue injuries and can occur with an avulsion fracture at the volar base of the middle phalanx.  Subluxation or dislocation of the PIPJ may also occur.

Mechanism

Volar plate injuries are commonly caused by forced, sudden hyperextension injuries of the PIPJ, seen typically in older children/adolescents involved in hand/contact sports. Occasionally volar plate injuries can be caused by a crush injury to the digit.

Presentation

Diagnosis of a volar plate injury is based on history and clinical examination. Typically, there is swelling of the PIPJ. Bruising to the volar surface of the PIPJ is sometimes observed. Maximal tenderness on palpation is over the volar PIPJ and the patients may report pain on passive hyperextension of the PIPJ. The collateral ligaments should be tested as with collateral ligament injuries to check stability of the PIPJ.

 X-rays may reveal an avulsion fracture at the base of the volar surface of the middle phalanx and can help identify PIPJ subluxation or dislocation.

Case courtesy of Dr Mohammad A. ElBeialy, Radiopaedia.org. From the case rID: 46050

Treatment

Non- operative: A stable joint without a large avulsion fracture (<40% of articular segment) and/or a reducible fracture with 30 degrees of flexion is usually managed conservatively with splinting. In less severe injuries the injured finger can be buddy taped.

Operative: Surgical opinion should be sought if there is instability of the PIPJ or there is a large avulsion fracture.

When you examine Tori’s hand there is an isolated injury to Tori’s right middle finger as evidenced by swelling, bruising and tenderness to the PIPJ. Although active ROM is painful, Tori is able to fully extend and flex the finger. X-ray demonstrates a small avulsion fracture to the volar base of the middle phalanx on her right middle finger and you correctly diagnose her with a volar plate injury. Tori’s injury is stable and suitable for buddy taping to allow for early range of motion and prevent stiffness.

Distal Phalangeal Fractures

Distal tuft fracture

Khalid is a 2-year-old boy. He is brought to ED by his Mum as he caught his right index finger in the hinge side of a closing door. You examine his hands and note swelling and erythema to the distal phalanx of his right index finger. There is no nail bed injury or open wounds and he is moving the finger freely as you observe him playing with a toy tractor which was kindly supplied by the PED play specialist. His Mum appears more upset than he is, so you calmly reassure her that a serious finger injury is unlikely but an X-ray is required to rule out a fracture.

Mechanism

Distal tuft fractures are common in the toddler or pre-school age groups and typically occur as a result of direct crush injuries such as getting little fingers caught in a closing door.

Presentation

A concomitant nail bed laceration or pulp laceration may be present in children who have a distal tuft fracture. In this case the fracture is classed as an open fracture and opinion should be sought from Plastic Surgery Team. Check out the DFTB post on fingertip injuries for more information related to the assessment and management of nail bed injuries. Be alert for injury to flexor/extensor tendons.

Treatment

Non-Operative: Most children who have a closed distal tuft fracture are treated conservatively with splinting or buddy taping.

Operative: Surgical treatment is reserved for patients with distal tuft fractures who have nail bed injuries, subtotal/total amputations, or an unstable transverse fracture pattern.

X-ray demonstrates an un-displaced tuft fracture. You buddy tape Khalid’s fingers and reassure Mum that the fracture is small and unlikely to cause Khalid any functional problems.

Seymour fractures

Jordan is a 12-year-old boy who is brought to the PED with an injury to his left thumb. During a rugby match he was tackled to the ground and an opposition player stood on his thumb. He shows you a swollen, bruised partially flexed thumb. There is blood at the proximal nail fold and the nail plate is partially avulsed. The finger is visibly contaminated with dirt and soil from the rugby pitch, so you irrigate it with saline prior to X-ray and check that Jordan’s vaccination status is up to date.

Mechanism

A Seymour fracture is an injury unique to children. This fracture pattern is usually caused by a crush injury and results in an angulated Salter-Harris type I or Salter-Harris type II fracture with an associated nail bed injury. It is important to recognise this fracture pattern as early referral to a hand surgeon is important to avoid complications.

Presentation

The typical presentation is a swollen, bruised, and painful finger flexed at the DIPJ. There may be blood under the nail or the nail plate can be completely avulsed proximally causing it to sit superficial to the eponynchial fold (aka proximal nail fold). Soft tissue (often the germinal matrix of the nail) can become interposed in the fracture which prevents fracture reduction and healing.

Imaging

PA X-ray views of the injured finger often appear normal. Lateral view X-ray are used to confirm the diagnosis.

Pro tip! Because of the flexed appearance at the DIPJ, a Seymour fracture can be misinterpreted as bony mallet injury; however a mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not enter DIPJ).

Treatment

Non-Operative: Closed injuries are managed with closed reduction and splinting. The child may be followed up with a weekly X-ray to ensure maintenance of fracture reduction.

Operative: Substantive injuries require open reduction and nail bed repair.

Bottom Line

It is important to seek surgical opinion regarding the management of Seymour fractures as if left untreated possible complications include osteomyelitis, malunion, and pre-closure of the physis.

Jordan’s x-ray shows an angulated Salter-Harris type II fracture to the distal phalanx and you correctly diagnose a Seymour fracture. You refer Jordan to the plastic surgery team who decide to take Jordan to theatre to ensure a thorough washout and repair of the nail bed injury.

Metacarpal Fractures

Katie is a 15-year-old girl who presents to your ED with her father. Her father reports that she had an argument with her Mum and punched a wall at home, he also reports that this is not the first time an incident like this has occurred. Katie shows you her right hand which is grossly swollen and bruised over the dorsal surface. There are no open wounds and she reports focal tenderness on palpation to her 5th metacarpal bone. There is an obvious loss of knuckle height and rotational deformity to her little finger. During the exam she is visibly withdrawn and quiet and you are suspicious that there is more than a hand injury bothering Katie.  

Mechanism

Metacarpal fractures are common in adolescent athletes. The most common type of metacarpal fracture is the so-called ‘‘boxer’s fracture’’, which involves the neck of the ring or small finger metacarpal. This injury usually occurs as a result of direct bony trauma when the child/adolescent strikes a fixed object such as a wall with a closed fist or is struck on a fisted hand with an object such as a bat/hurl/hockey stick for example.

Presentation

The child/adolescent will usually present with bruising, swelling and diffuse pain over the dorsum of the hand. There may be loss of knuckle prominence. Be vigilant for rotational deformity; no degree of malrotation is acceptable.

Ensure to evaluate skin integrity over the injured area, check for and document the presence of open wounds; consider the possibility that these could be so-called ‘’fight bites’’ and will require antibiotics. Substantial injuries or infected open wounds require a surgical opinion as these may require admission for IV antibiotic cover and washout in theatre. Check integrity of flexor/extensor tendons in the presence of open wounds. Remember to check Tetanus vaccination status.

A child/adolescent who presents to the PED with a hand injury because of a fight or an injury mechanism such as puching a wall requires special attention- screening for mental health and/or social problems is paramount. Involvement of medical social worker teams or mental health teams may be necessary. The HEEADSSS screening tool may be useful to guide this line of inquiry.  

Treatment

Treatment is generally based on the level of injury (e.g. head, neck, shaft and base) and clinical findings (rotational deformities, open wounds, fracture stability).  

Un-displaced stable fractures of the neck or shaft (2nd-5th metacarpals)

Non-operative: Can be treated in rest volar splint/back -slab and followed up in clinic

Angulated neck of metacarpal fractures

Most common is fracture of 5th metacarpal or  ‘‘Boxer’s fracture’’

Treatment guided by degree of angulation. Seek surgical opinion

Non-operative: Closed reduction in PED using nerve block +/- procedural sedation and immobilisation in cast

Operative: Surgery may be required in the presence of open wounds, suspected tendon injuries or if angular deformity is substantial and/ or there is a rotational deformity on clinical exam.

Case courtesy of Dr Benoudina Samir, Radiopaedia.org. From the case rID: 23848

Displaced intra articular, unstable, comminuted or unstable fractures

Operative: These fractures all require surgical referral

Metacarpal head fracture (intra-articular) Courtesy of Orthobullets: https://www.orthobullets.com/hand/6037/metacarpal-fractures

Thumb metacarpal fractures

Thumb metacarpal base fractures require surgical opinion. Disruption of carpometacarpal (CMC) joint congruity can result in significant functional impairments for a child/adolescent particularly loss or limitation of pincer or power grip.

Specific names are given to fractures of the base of the 1st metacarpal

  • Bennett fracture: defined as an intra-articular 2-part fracture of the base of 1st metacarpal bone *(see also Reverse Bennett fracture below)
  • Rolando fracture: similar to Bennett fracture but prognosis is worse. Defined as a comminuted intra-articular fracture of the 1st metacarpal, producing at least 3 parts.

X-ray demonstrates a severely angulated fracture to the neck of Katie’s 5th metacarpal bone. Taking this into consideration and the presence of rotational deformity, you refer her to the hand surgery team for management. They decide to admit her for manipulation under anaesthetic (MUA). While awaiting admission you get the opportunity to establish a rapport and talk to Katie about her mental health. You use the HEEADSSS screening tool to guide your inquiry. She reveals information about difficulties at home related to her mother’s substance abuse and reports that she has been missing a lot of school due to bullying. Katie agrees that she needs help dealing with these issues and you refer her to the inpatient mental health team with her permission. Her dad is also informed.

*Reverse Bennett fracture dislocation

An intra-articular fracture dislocation of the base of 5th metacarpal bone is called a reverse Bennett fracture. This fracture pattern is inherently unstable and referral to hand specialist is essential.

Reverse Bennett fracture dislocation Case courtesy of Dr Alborz Jahangiri, https://radiopaedia.org/cases/reverse-bennett-fracture-dislocation-1

References

Andy Neill. AFEM 033 | Hand: Lingo and soft tissues. Retrieved from https://litfl.com/bscc/clinical-anatomy/hand-anatomy/

Abzug, J. M., Dua, K., Bauer, A. S., Cornwall, R., & Wyrick, T. O. (2016). Pediatric phalanx fractures. Journal of the American Academy of Orthopaedic Surgeons24(11), e174-e183.

Sullivan, M. A., Cogan, C. J., & Adkinson, J. M. (2016). Pediatric hand injuries. Plastic Surgical Nursing36(3), 114-120.

Wahba, G., & Cheung, K. (2018). Pediatric hand injuries: Practical approach for primary care physicians. Canadian Family Physician64(11), 803-810.

Weber, D. M., Seiler, M., Subotic, U., Kalisch, M., & Weil, R. (2019). Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. Journal of Hand Surgery (European Volume)44(6), 640-647.

Apophysitis

Cite this article as:
Stephen Gilmartin. Apophysitis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24364

David is a 12-year-old boy who attends the emergency department complaining of bilateral heel pain. His pain has been getting gradually worse over the past month. He is a keen footballer, but his symptoms have gotten to the stage where he is now unable to play through his pain.

 

Apophysitis is a term used to describe a group of overuse traction injuries which commonly cause pain in adolescents. We have all heard of Osgood Schlatter disease. It is the most common form of apophysitis. Other anatomical areas that are commonly affected include the inferior pole of patella (Sinding-Larsen-Johansson), calcaneal tuberosity (Sever’s), medial epicondyle of the elbow (within spectrum of Little League elbow) and various sites on the pelvis. They’re subtly different from osteochondrosis, which is instead due to changes in the epiphyseal ossification centre.

An apophysis is an area of bony growth separate to the ossification centres. It acts as a site of tendon or ligament attachment and will eventually fuse with the bone as the body matures. Rapid growth and relative bone weakness combined with repetitive movements cause increased traction forces at the point of attachment. The apophysis is the weakest point in the muscle-tendon-bone junction; repeated strain at this point leads to bone fragmentation and micro-separation. This abnormal growth leads to swelling and pain at the site. Similar overuse injuries result in tendon and muscle injuries in adults.

Apophysitis is most common during ages of peak growth i.e. between 10-14 years in girls and 12-16 years in boys. Apophysitis is traditionally more common in boys, but the incidence is growing in girls. This is likely linked to increasing sports participation rates among girls of this age. The mean age of onset is younger in girls due to the earlier appearance of the ossification centres. Earlier fusion leads to the cessation of symptoms at a younger age in girls when compared to boys. In lower limb apophysitis, up to 50% of patients will experience bilateral symptoms.



 

Let’s take a look at some x-rays

This 11-year-old male basketball player has been complaining of heel pain. His ankle x-ray shows increased density of the calcaneal apophysis, typically seen in children between 7 and 14 years with Sever’s Disease. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation.

Case courtesy of Dr Dinesh Brand, Radiopaedia.org. From the case rID: 60324

 

This 12-year-old female long-distance runner complains of anterior knee pain, localised to the inferior aspect of her patella. Her lateral knee x-ray shows dystrophic ossification of the inferior patella with subtle thickening of proximal patellar tendon. These changes are consistent with a diagnosis of Sinding-Larsen-Johansson.

Sinding-Larsen-Johansson. Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 6323

 

This 13-year-old female volleyball player presents with progressive pain over her tibial tuberosity. Her pain is exacerbated by jumping. Her lateral knee x-ray shows fragmentation of apophysis with overlying soft tissue swelling, classic for Osgood Schlatter Disease. Some isolated fragmentation can be normal at the tibial tuberosity.

Osgood Schlatter’s Disease. Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9740

 

This 11-year-old boy presents to the ED with worsening elbow pain. He is an avid cricket player and is trying to make his county underage team but finds his pain much worse while bowling. His AP elbow x-ray shows widening of the physis at the medial epicondyle. This is consistent with a diagnosis of Little League Elbow. You may also see fragmentation.

Little League Elbow from Orthobullets

 

This is an MRI of a 14-year-old male long-distance runner complaining of anterior hip pain. His pain is becoming increasingly worse on running and is now affecting his times. MRI shows bone marrow and surrounding soft tissue oedema at the anterior superior iliac spine involving the sartorius muscle origin without separation as may occur in an acute avulsion injury. This is consistent with ASIS (anterior superior iliac spine) apophysitis. Plain radiographs are usually normal or may only show subtle changes of pelvic apophysitis.

ASIS apophysitis. Case courtesy of Dr Chris O’Donnell, Radiopaedia.org. From the case rID: 31877

 

History and exam

Apophysitis has a typical history and the diagnosis is largely based on an accurate history and exam. An adolescent will present with gradual onset focal pain over the involved site. They are typically highly active and may be going through an acute increase in there training levels. They may be currently progressing to higher levels of sport or competing in multiple sports at multiple grades. The initial symptom will be pain present at the start of physical activity. In the early stages the pain will often subside once the child has fully warmed up, only to return once they have cooled down. As the process progresses the child will have persisting symptoms throughout physical activity and the pain will eventually result in total cessation of activity.

Clinical examination will reveal point tenderness over the affected site. There may be mild swelling over the area. Pain will be reproduced by resisted contraction of the affected muscle, e.g. resisted plantar flexion of the ankle in Sever’s disease and resisted knee extension in Osgood-Schlatter’s. A good way to assess this is to ask the patient to demonstrate actions which exacerbate their pain.

 

Differential diagnosis

Alternative diagnoses and investigations should be considered if there are any concerning features on history or exam. Atypical features on presentation are:

  • Sudden onset pain
  • Pyrexia
  • Non-weightbearing
  • History of trauma
  • Point of tenderness or age of patient not typical for apophysitis.

The most common differential diagnoses are osteomyelitis, avulsion fractures, osteochondritis, stress fractures and malignancy. Investigations should be performed in accordance with suspected differential diagnosis.

The below cases and accompanying images highlight the need for you have possible alternative diagnoses in the back of your mind. The patient should be presenting with gradual onset pain, over an apophysis site, at the appropriate age (10-16) for apophysitis. A history which includes high levels or sudden increase in activity can be helpful. Any atypical features should be actively sought out.

 

This elbow x-ray is from a 13-year-old male baseball pitcher attending with sudden onset medial elbow pain. The medial epicondyle is displaced with a sliver adjacent bone, representing a medial epicondyle avulsion fracture. There is marked adjacent soft tissue swelling and joint effusion. Compare this to the Little League elbow x-ray.

Medial epicondyl avulsion fracture. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 41533

 

A 10-year-old female basketball player attended with sudden onset knee pain following a fall. The x-ray shows a bone fragment avulsed from inferior patella at point of tendon insertion with moderate overlying soft tissue swelling: a patella sleeve fracture. This contrasts with the findings of dystrophic ossification of Sinding-Larsen-Johansson.

Patella sleeve fracture. Case courtesy of Dr Yuan Ling, Radiopaedia.org. From the case rID: 69680

 

A 13-year-old female long jumper attends with anterior knee pain following a fall resulting in forced flexion of their flexed knee. She has significant pain and is unable to straight leg raise. Her x-ray shows displacement of tibial tuberosity with significant overlying soft tissue swelling: an avulsion fracture of the tibial tuberosity. Compare this to the typical radiographic features of fragmentation and mild swelling observed in Osgood-Schlatter disease.

Tibial tuberosity avulsion fracture. Case courtesy of Radiopaedia.org. From the case rID: 12022

 

A 13-year-old girl presents with worsening ankle/heel pain over the last week. Her pain is exacerbated on while running and playing football. She has been pyrexic over the past 24 hours and is now unable to weight bear. The x-ray of her ankle shows diffuse soft tissue swelling abutting the distal end of her fibula. There is suspicious erosion of distal fibular cortex. These findings are suspicious for osteomyelitis of the distal fibula.

Osteomyelitis of the distal fibula. Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 10046

 

An 8-year-old boy attends with gradual onset knee pain while running. He begins to notice some associated swelling. His mother feels he is becoming increasingly lethargic. Lateral x-ray shows sclerotic lesion involving the dia-metaphyseal region of the tibia with a wide zone of transition and characteristic “Sunburst ” type of periosteal reaction seen in osteosarcomas.

Osteosarcoma of the tibia. Case courtesy of Dr Iqbal Naseem, Radiopaedia.org. From the case rID: 22814

 

Investigations

Despite the diagnosis being clinical, a baseline x-ray is often useful. An x-ray can help ensure there is no avulsion fracture and a study by Rachel et al found x-rays changed management in up to 5% of patients with Sever’s disease.

Findings of apophysitis can vary on imaging and some patients may not show any radiological changes on plain films. The typical x-ray findings include increased density and fragmentation at secondary ossification centres. Overlying soft tissue swelling can often be seen. MRI will reveal increased fluid signal, apophyseal oedema and fragmentation.

This lateral plain film view shows the calcaneal apophysis with high density and fragmentation consistent with Sever’s disease.

Sever’s on x-ray. Case courtesy of Dr Fateme Hosseinabadi , Radiopaedia.org. From the case rID: 69971

Compare the x-ray to this MRI image showing oedema and fragmentation at the calcaneal apophysis and extending into the adjacent calcaneal tuberosity. These findings are commonly seen in patients with Sever’s disease.

Sever’s on MRI. Case courtesy of Dr Paulo A Noronha, Radiopaedia.org. From the case rID: 63302

 

Treatment

Apophysitis is a self-limiting process. Most patients will return to full activity following 4-6 weeks of rest or reduced activity. Despite successful return to activity, patients may continue to experience some symptoms. The symptoms will cease definitively once growth centres fuse.

The focus of treatment should be to reduce symptoms sufficiently to allow continued sports participation.

Strategies shown to improve recovery are

  • analgesia
  • activity modification
  • muscle stretching and strengthening programmes

Other therapies which have little evidence but may be helpful in some cases include

  • ice application
  • foot orthotics or heel raises in Sever’s disease
  • taping or bracing

There is no place for surgery in the standard treatment of apophysitis. Any short-term benefit observed from surgery cannot be justified when weighed against the potential damage to an immature skeleton. Surgery may be considered an option if there is a displaced avulsion fracture or a loose body in an affected joint.

 

Prevention

Apophysitis is a largely preventable process and as a result recent focus has been placed on both primary and secondary prevention programmes. It can be difficult at an individual level to make changes as these patients tend to be highly active and competitive people. This has seen some youth sport bodies enforcing limits on game participation and mandatory rest to avoid repetitive strain.

Simple advice to give parents and children include:

  1. Encourage 1-2 days off from competitive sport per week
  2. Encourage 2-3 months off from each sport per year
  3. Participate on only one team per sport
  4. Avoid early sport specialisation
  5. Avoid increasing levels of training by more than 10% from one week to the next
  6. Maintain good sleep, hydration and dietary habits.

 

Take home tips

  • Apophysitis has a typical history of gradual onset pain over an apophysis in highly active adolescents.
  • It is a self-limiting process but can cause debilitating pain.
  • Treatment should focus on analgesia, activity modification and muscle stretching programmes.
  • Symptoms will resolve definitively once ossification centres fuse.

 

Not to miss bits

  • Any atypical features should be investigated appropriately. The area around the apophysis is a common site for avulsion fractures, osteomyelitis and malignancy.
  • These patients are high risk for other overuse injuries. All patients should be given secondary prevention advice.

 

And our favourites, the controversies

  • Despite the diagnosis being clinical, baseline x-rays can be useful to out-rule other differential diagnoses.
  • There is little evidence displaying additional benefit for treatment with taping or splints.
  • Custom orthotics can be useful for patients suffering from Sever’s Disease.

 

David undertook a month long physio led programme of activity modification and muscle stretching. He was given secondary prevention advice to avoid overtraining. He is now back to symptom free football participation.  

 

References

Brenner, J. S. (2007). Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics, 119(6), 1242 LP – 1245

Elengard, T., Karlsson, J., & Silbernagel, K. G. (2010). Aspects of treatment for posterior heel pain in young athletes. Open Access Journal of Sports Medicine, 1, 223–232.

Fleisig, G. S., Andrews, J. R., Cutter, G. R., Weber, A., Loftice, J., McMichael, C., Hassell, N., & Lyman, S. (2011). Risk of serious injury for young baseball pitchers: a 10-year prospective study. The American Journal of Sports Medicine, 39(2), 253–257.

Frush, T. J., & Lindenfeld, T. N. (2009). Peri-epiphyseal and Overuse Injuries in Adolescent Athletes. Sports Health, 1(3), 201–211.

Gregory, B., & Nyland, J. (2013). Medial elbow injury in young throwing athletes. Muscles, Ligaments and Tendons Journal, 3(2), 91–100.

Guldhammer, C., Rathleff, M. S., Jensen, H. P., & Holden, S. (2019). Long-term Prognosis and Impact of Osgood-Schlatter Disease 4 Years After Diagnosis: A Retrospective Study. In Orthopaedic Journal of Sports Medicine (Vol. 7, Issue 10, p. 2325967119878136).

James, A. M., Williams, C. M., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review.” Journal of Foot and Ankle Research, 6(1), 16.

Rachel, J. N., Williams, J. B., Sawyer, J. R., Warner, W. C., & Kelly, D. M. (2011). Is Radiographic Evaluation Necessary in Children With a Clinical Diagnosis of Calcaneal Apophysitis (Sever Disease)? Journal of Pediatric Orthopaedics, 31(5).

Ramponi, D. R., & Baker, C. (2019). Sever’s Disease (Calcaneal Apophysitis). Advanced Emergency Nursing Journal, 41(1), 10–14.

Vaishya, R., Azizi, A. T., Agarwal, A. K., & Vijay, V. (2016). Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus, 8(9), e780–e780.

Wiegerinck, J. I., Zwiers, R., Sierevelt, I. N., van Weert, H. C. P. M., van Dijk, C. N., & Struijs, P. A. A. (2016). Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial. Journal of Pediatric Orthopaedics, 36(2).

Cairns G, Owen T, Kluzek S, et al. Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport & Exercise Medicine 2018

Cairns, G., Owen, T., Kluzek, S., Thurley, N., Holden, S., Rathleff, M. S., & Dean, B. J. F. (2018). Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport &amp;Amp; Exercise Medicine, 4(1), e000383.

 

Osteochondrosis

Cite this article as:
Stephen Gilmartin. Osteochondrosis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25054

The Limp family arrive at the emergency department with two of their children. Katie is a 10-year-old complaining of right foot pain.  The pain has been getting worse over the past month and she is now beginning to develop some stiffness.  She is a keen athlete and trains five times per week.  Her younger brother Michael is a six-year-old attending with progressive left hip pain.  Both children’s injuries were atraumatic, and they are systemically well.

 

Introduction

Osteochondrosis is a disorder of bone growth primarily involving the ossification centres at the epiphysis.  It commonly begins in childhood and results in osteonecrosis of the growth plate.  This can lead to altered bone and cartilage formation beyond the growth plate.

Although often confused with apophysitis, which is more clearly due to traction overuse injuries, osteochondrosis is often described as idiopathic osteonecrosis as there has been no definite cause found.  There have been some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis.

 

 

 

History and examination

Osteochondrosis presents in a similar fashion independent of location.  The symptoms will have a subacute onset with one or more of; joint pain, swelling or dysfunction.  The patient may comment on symptoms worsening while stressing the site during activity.  This is typical in throwing or gymnastics for Panner disease and weight-bearing activities such as running and jumping in lower limb osteochondrosis.

The joint involved may have mild swelling and tenderness.  Other common findings are stiffness and a reduced range of motion. Active children will often seek medical attention once their pain and stiffness begin to affect sporting performance.

Important points to establish on history and exam are no sudden pain, absence of temperature and no systemic complaints. This will help you to consider important differentials including osteomyelitis, malignancy and stress fractures.

 

Investigations

X-ray is the diagnostic tool of choice. Findings depend on anatomical location and the stage of disease.  Each location has its own radiological criteria which can be quickly referenced online.  MRI may be required in certain cases if the diagnosis remains unclear following initial imaging. Early typical x-ray findings are potentially normal. Radiological findings tend to show:

Initial findings

  • Irregular epiphyseal growth
  • Flattening of the epiphysis
  • Soft tissue swelling

As disease progresses

  • Sclerosis
  • Fragmentation
  • Joint destruction

Blood tests have no role in the diagnosis of osteochondrosis but will aid the work-up of possible differentials including infection and malignancy.

 

Perthes Disease

A 10-year-old boy presents to the ED with progressive left leg pain.  It has been progressing over the past few months with normal knee x-ray.  The pain is now becoming localised to the hip. He has a hip x-ray performed which shows flattening of the femoral head with widening of the femoral neck.  There is increased joint space and sclerosis at the physis.  His x-ray shows advanced Perthes disease.

Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 5978

 

Panner Disease

A 13-year-old cricket player attends with elbow pain.  The pain started gradually while bowling.  He is now complaining of stiffness and pain which is affecting his performance. His x-ray shows irregularity of the capitellum with associated sclerosis. These findings are consistent with a diagnosis of Panner disease.

Image source Orthobullets.com

 

Freiberg’s Disease

A 15-year-old female runner presents complaining of progressive forefoot pain while training.

Her x-ray shows widening of the metatarsophalangeal joint.  There is flattening of the metatarsal head with cystic lesions.  These findings are seen in Freiberg disease. Progressive disease will show sclerosis and increased cortical thickening.

Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9296

 

Kohler Disease

A 9-year-old presents with worsening left foot pain.  X-ray reveals thinning and sclerosis of the navicular bone.  This is typical for Kohler disease.  You may see fragmentation in advanced cases.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 18657

 

Treatment

Osteochondrosis is self-limiting and the bone will eventually revascularize to a certain extent.  The goal of therapy is to facilitate maximal revascularisation while minimising long term symptoms.

An appropriate treatment plan should be decided on a case by case basis and in conjunction with orthopaedics, physiotherapists and the patient themselves.  Although there is limited evidence to guide the type and length of treatment, there are some factors which can help guide clinicians.

  • Radiological stage: There are radiological staging criteria unique to each form of osteochondrosis. These categorise disease progression on x-ray.
  • Joint function: Patients range of motion and stiffness should be assessed. If there is a significant loss of joint function the patient should be treated more aggressively to prevent progression
  • Patient symptoms: If the patient’s pain is significant, they may need some immobilisation to aid with pain prior to progression of their rehabilitation.
  • Age at presentation: as a rough rule of the thumb, the younger the patient’s bone age the more likely they are to respond to conservative management.

Three broad treatment strategies exist.

Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physiotherapy programme can help to strengthen the area and improve joint function.  This approach is suitable for patients with minimal symptoms and early changes of disease progression on x-ray.

Immobilisation:  Immobilisation can be beneficial for patients with significant pain or more advanced changes on x-ray.  This may be in the form of a cast, walking boot or splint depending on the area involved.  This needs to be weighed up against the risk of worsening joint stiffness.

Surgery:  It is very rare if ever that patients will require surgery.  When used it is only in advanced stages of disease and when appropriate conservative management has proved ineffective. Surgical options include osteotomy, arthroplasty and physeal drilling.

 

Prognosis

Osteochondrosis is a self-limiting pathological process. Patients will usually show full clinical and radiological recovery if diagnosed and treated early. Despite this, some patients will continue to have long term pain and stiffness; this can occur despite appropriate treatment plans.

This is especially true for Perthes Disease patients have a high risk of arthritis and subsequently requiring a total hip replacement. One case series found that >50% of all Perthes Disease patients will require total hip replacement with the mean age of initial total hip replacement of 37.8 years.

Bone age of <6 years and <50% femoral head involvement have been shown to be good prognosticating factors for Perthes.

 

The Limps are delighted with your assessment.  Katie has been diagnosed with Kohler Disease.  You place her in a boot for 4 weeks for symptoms management.  Following this she undergoes a specific return to activity regime to manage her training load and recovery.  She is totally symptom-free at 6 months.

Michael is lucky that his diagnosis of Perthes was made early.  His x-ray shows he is in the early stages with minimal femoral head involvement and good femoral head coverage.  He is started on a physio programme with closely monitored clinical and radiographic assessment until full recovery.

 

Take homes

  • Osteochondrosis is an idiopathic osteonecrosis affecting children
  • It is diagnosed with a combination of accurate history and typical radiograph findings
  • Early diagnosis and treatment can aid a complete recovery
  • Bone age <6 years, <50% of femoral head involved and good femoral head coverage are good prognosticating factors for Perthes disease

Not to miss bits

  • Differential diagnoses including malignancy and infection may present similarly
  • Common systemic causes of osteonecrosis should not be missed i.e. haematological (sickle cell, malignancy), Rheumatological (SLE).
  • Although the pathophysiology of osteochondrosis is self-limited. If not treated promptly it can result in long term morbidity.

Controversies

  • Potential causative factors include genetic links and repetitive activity.
  • There are no firm directives regarding the length of treatments including immobilisation.
  • Benefits of surgery are variable and need to be considered on a case by case basis.

 

Selected references

Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–618.

Claessen, F. M. A. P., Louwerens, J. K. G., Doornberg, J. N., van Dijk, C. N., Eygendaal, D., & van den Bekerom, M. P. J. (2015). Panner’s disease: literature review and treatment recommendations. Journal of Children’s Orthopaedics, 9(1), 9–17.

Terjesen, T., Wiig, O., & Svenningsen, S. (2010). The natural history of Perthes’ disease. Acta Orthopaedica, 81(6), 708–714.

Talusan, P. G., Diaz-Collado, P. J., & Reach, J. S. (2013). Freiberg’s Infraction: Diagnosis and Treatment. Foot & Ankle Specialist, 7(1), 52–56.

Olstad, K., Ekman, S., & Carlson, C. S. (2015). An Update on the Pathogenesis of Osteochondrosis. Veterinary Pathology, 52(5), 785–802.

Joseph, B. (2015). Management of Perthes’ disease. Indian Journal of Orthopaedics, 49(1), 10–16.

Masrouha, K. Z., Callaghan, J. J., & Morcuende, J. A. (2018). Primary Total Hip Arthroplasty for Legg-Calvé-Perthes Syndrome: 20 Year Follow-Up Study. The Iowa Orthopaedic Journal, 38, 197–202.

Chan, J. Y., & Young, J. L. (2019). K&#xf6;hler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.

Foreign bodies

Cite this article as:
Becky Platt. Foreign bodies, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25947

This post is based on a talk I gave for the London School of Paediatrics in June 2020, and will focus on foreign bodies in the nose and ear.  If you’d like to read about ingested foreign bodies, please read this, from Andrew Tagg.

Foreign bodies in the ear or nose

Children often present to the emergency department with something alien in their ear or nose. They’re usually in the pre-school age group and have been experimenting by sticking things in their various orifices. Most children can be found with a finger up their nose on a fairly regular basis, but sometimes other objects too. These can be among the more light-hearted of ED attendances, but only if you have some strategies to deal with them.

4-year-old George comes into your ED with his exasperated mother.  She explains that he’s been telling her he has a phone in his ear for the last 2 days. “Obviously he hasn’t”, she says, “but please would you just have a quick look so I can tell him to stop going on about it”. You have a quick look in his ear, and you see something blue in there.* How will you proceed?

General considerations to aid success

Preparation is key. This means preparing the child, and yourself, for the procedure.

Think of foreign body removal as a one-time offer. You’ll generally have only one good go at it, so preparation is everything. This means getting the right people involved, ideally, a play specialist or someone else whose only role is to distract and calm the child. Make sure they know what is going to happen if they are old enough to understand. If they are unable to keep still, position them appropriately on their parent’s lap or maybe wrapped in a blanket. Foreign body removal is generally not painful (or shouldn’t be) but for children who are able, nitrous oxide can be a useful aid for its anxiolytic properties in addition to distraction.

Prepare yourself. Make sure you use the right technique and equipment for the job. There are several options:

Kissing technique

This is a useful technique for removing FBs from the nose and works especially well for solid objects such as beads. Getting the parent on board with it and briefing them about the technique is key:

  • Sit the child sideways on the parent’s lap with one of the child’s arms tucked away under the parent’s arm
  • Brief the parent that you want them to cover the child’s mouth with their own while you occlude the unaffected nostril
  • Get the parent to deliver a short sharp breath and, hopefully, the FB will shoot out!

For parents who either can’t master the technique, or can’t face it, the same effect can be achieved with a bag-valve-mask: choose a mask that only covers the child’s mouth, and occlude the pop-off valve to increase the pressure. Ask a colleague to hold the mask and the unaffected nostril, while you squeeze the bag sharply.

Other useful tools and techniques

Head torch – this is a game-changer in the world of foreign body removal. It prevents you from having to try to hold a torch in your mouth while holding an ear in one hand and tool in the other.

Head torch

Yankauer suction – good for removing objects with a smooth surface e.g. beads, polystyrene balls. Warn the child it’ll be noisy and let them hear it before you start so they don’t jump away.

Syringe and water – good for items that will float or disintegrate e.g. tissue, play-doh, polystyrene beads. Add a cut-down NG tube on the end to make a smaller nozzle. Fill with warm water (for comfort) and irrigate generously. 

Jobson Horne probe – useful to get behind objects in the ear canal that won’t come out with suction. In this case, it will only work if there’s a little gap and you can actually get behind it.

Wax hook – can be used to get behind foreign bodies, as above, or to hook into softer objects such as bits of tissue or peas. Make sure you don’t leave some behind with this method.

Tools for removing foreign bodies from ears and noses

Crocodile forceps – helpful with small or softer objects or those with an uneven surface where there’s something to grab.  

TOP TIP: magnetize the shaft to make it easier to pick up metal FBs

Magnets – can be used by rubbing them down the side of the nostril to work a foreign body down and out.

TOP TIP: the magnets on name badges are often useful for this if you don’t have a store of magnets specifically for the purpose.

Cotton bud and glue – can be used to remove foreign bodies from the ear canal if they’re difficult to get behind or to grab.  Apply a drop of whatever tissue adhesive you use to the end of a cotton bud and hold it on the offending item for 30 seconds or so then pull out.  This requires a steady hand and a reasonably still child. Be aware that this method can lead to adherence of the offending item to the ear canal.

Foley catheter – pass it behind a foreign body in either the nose or ear, inflate the balloon and then pull out, bringing the piece of corn with it.

If at first, you don’t succeed… stop

Complications can arise from failed attempts at removal, especially those involving the ear canal. These can range from pain, bleeding, distress, and the loss of trust to rare, but severe, complications including middle ear damage, hearing loss, vertigo, facial nerve paralysis and meningitis (Dance et al., 2009). If an attempt isn’t going well, stop, re-group, and consider the options. It may be that referral or a different approach is required.

Or maybe, don’t even start

If there is minimal chance of success, either because the FB is deep, impacted, or ungrabbable, or the child is unable to co-operate for whatever reason, think twice before starting. It may be better to bring them back when you have play specialist support or to refer to ENT for specialist assistance.

You involve the play specialist and prepare George for removal of the foreign body in his ear.  Wearing your headtorch, you gently pull on his pinna and gently insert a pair of crocodile forceps into his ear canal and pull out… a teeny tiny toy phone!  Vindicated, George squares up to his mum: “I told you!”.

*This is a true story (anonymized) from a long time ago, and one of my favourite ED presentations ever!

Selected references

Chan, T. C., Ufberg, J., Harrigan, R. A., & Vilke, G. M. (2004). Nasal foreign body removal. Journal of Emergency Medicine, 26(4), 441–445. https://doi.org/10.1016/j.jemermed.2003.12.024

Dance, D., Riley, M., & Ludemann, J. P. (2009). Removal of ear canal foreign bodies in children: What can go wrong and when to refer. British Columbia Medical Journal, 51(1), 20–24. https://www.bcmj.org/articles/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer

Mandible Injuries

Cite this article as:
Helen Nightingale. Mandible Injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21585

A fifteen year old named Jason limps into A&E at midnight with a black eye, a split lip, and pain in his jaw, worst around the left angle of the mandible. He is guarded about what has happened to him. He is reluctant to give his full name or for his parents to be called. You smell cigarettes on his clothing and you wonder if he might be intoxicated. He says it is numb when he touches his chin but it was really painful when he tried to eat some crisps in the waiting room.

Triplane ankle fractures

Cite this article as:
Anna O'Leary. Triplane ankle fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23578

Sean is 13 years old. He was playing basketball but when he jumped to score a basket he landed awkwardly on his ankle, twisting and externally rotating it. He immediately fell to the floor on the court and couldn’t weight bear on it. The swelling and bruising increased and he attended his local emergency department where he was told that he had a triplane ankle fracture.

 

Epidemiology

Although triplane ankle fractures account for only 5-15% of overall paediatric ankle fractures, along with Tillaux fractures, they are the most common ankle fractures in adolescents. This type of fracture represents a unique spectrum of injury that does not fit neatly into the Salter-Harris classification of physeal injury. They occur before complete closure of the distal tibial physis (hence why they occur in adolescents whose epiphyseal plates are closing) and are classically seen in 10-17 year olds. They are slightly more common in males.

 

History

Adolescents with triplane fractures will usually present to the emergency department with a very painful and swollen ankle after a twisting force to the leg during athletic or recreational activities. They are usually very reluctant or unable to weightbear.

 

Examination

There will often be swelling and bruising with focal or referred pain at the affected ankle. There may be deformity of the ankle. It is important also to examine skin integrity and the presence of neurologic defects or vascular injuries. Don’t forget to palpate the full length of the fibula to evaluate for a proximal fracture as well as along the foot to evaluate for injuries such as a fracture to the base of the 5th metatarsal.

 

Investigations

AP and lateral ankle xrays will help evaluated the fracture type. Addition of a mortise view, performed with the leg internally rotated approximately 15 degrees to allow better assessment of the articular space, should be included to assess the amount of displacement if this can’t be fully appreciated on the AP view (although in some countries the AP view is a mortise view).

The triplane fracture on x-ray looks like a Salter-Harris II or III depending on whether this is a medial or lateral triplane fracture. The fracture is in all three planes, classically looking like a Mercedes sign on CT.

 

Triplane Mercedes sign. From Orthobullets

 

It may be classified as in 2, 3 or 4 parts.

 

It is important not to miss fibular fractures which are seen in 50% of triplane fractures. Typically this is a spiral fracture pattern located proximal to the physis in children nearing skeletal maturity.

CT scans are not routinely performed in the emergency department but may be organized by the orthopaedic team. Small dislocations and the vertical component of the fracture are not infrequently overlooked. CT is therefore often organized to fully delineate fracture pattern and to assess the degree of intra-articular congruity.

 

Management

In the ED, as with any injury, ensure you prescribe adequate analgesia and provide assistance with non-weight bearing status, such as a wheelchair or crutches depending on the ability of the child. Placement in a boot or cast for comfort prior to definitive treatment by the orthopaedic team is appropriate.

Once the diagnosis is made, ongoing care depends on the degree of displacement. Orthopaedic review for consideration of conservative management versus operative management is important as these fractures will often need CT imaging to ensure adequate delineation of fracture pattern.

 

Conservative management

Fractures with minimal displacement (<2mm), particularly if they are 2 part triplane fractures, can often be managed with closed reduction and casting. If the fracture is in 3 or 4 parts, closed reduction is difficult to achieve.

Post reduction, place in a long leg/above knee cast for 3-4 weeks to control the rotational component of the injury, followed by a further 2-4 weeks in a short leg cast or walking boot to initiate ankle range of movement.

 

Operative Management

Any triplane fracture with >2mm displacement or that is in 3 or 4 parts is likely to require ORIF (Open Reduction, Internal Fixation). Intra-articular reduction to within 2 mm is required for optimal treatment of these unique paediatric ankle fractures.

A CT showing triplane fracture requiring ORIF with >2mm of displacement. You can clearly see why the fracture is called triplane, as it extends in 3 planes: coronal, sagittal and axial. Image from Orthobullets

 

Complications and Risks

  • Growth Arrest:

The main concern in an adolescent with a triplane fracture is growth arrest. This occurs in between 7-21% of triplane injuries. This is often insignificant but does mean that patients with more than 2 years of growth remaining must be closely followed up.

  • Ankle Pain and Degeneration:

Rare but increased risk with articular step greater than >2mm.

 

Controversies

As with all things orthopaedic, the debate continues: should these fractures be managed operatively or conservatively? Though still in preliminary research stages, recent evidence suggests that non-operative treatment of triplane fractures may have comparable clinical and radiographic results to operative treatment. Discussion with the orthopaedic team is advised prior to discharge given the different management options.

 

Things not to miss!

Don’t forget to examine the rest of the child’s lower limb when they present with a painful swollen ankle as there may be an associated accompanying fracture. Ensure that you examine and especially palpate both the foot and the entire length of the fibula. With rotational forces, proximal spiral fibula fractures and base of 5th metatarsal fractures are relatively common with triplane fractures. Carefully check and document neurovascular status as nerve injury can occasionally be associated with spiral fibular fractures.

Triple fracture with accompanying spiral fibula fracture. From Orthobullets

 

Sean was found to have a 2 part nondisplaced Triplane Fracture and was placed in an above-knee cast and followed up at his local orthopaedic outpatient clinic. He had interval x-rays which showed good healing and no evidence of displacement. After 4 weeks he was switched to a walking boot to encourage early ankle mobilization for another 2 weeks. He is looking forward to next year’s basketball season already!

 

References

Schnetzler, Kent A et al 2008 ‘The Pediatric Triplane Ankle Fracture’ The Journal of the American Academy of Orthopaedic Surgeons 15(12):738-47

Hyman et al, MSK Key https://musculoskeletalkey.com/transitional-ankle-fractures-juvenile-tillaux-and-triplane-fractures/ Accessed at 09/02/20

Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006:1105

https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-in-children/

Min Ryu, Seung et al 2017 ‘Is an operation always needed for pediatric triplane fractures?’ Journal of Pediatric Orthopaedics B 27(5):1 · November 2017

https://www.orthobullets.com/pediatrics/4029/triplane-fractures

https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-in-children/

Paediatric analgesia and pain assessment

Cite this article as:
Ciara Murphy. Paediatric analgesia and pain assessment, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23666

Jamie is a 3-year-old boy who presents to the emergency department. He was playing with his 5-year-old brother on the trampoline and fell off. He is very distressed and crying in triage but his mum doesn’t know where he hurt himself. She had rushed to the department with him and so hadn’t given him any prehospital analgesia. Mum herself also appears very anxious and worried.

 

Pain assessment and management in the paediatric population is a challenging area, and it is something that we often get wrong.   Children’s pain is historically poorly measured and often undertreated because children may not exhibit the common signs and symptoms of pain that we come to expect from adults.

Pain is multifactorial. In children, it is important to not just focus on the injury but the age and developmental stage of the child, the circumstances of the presentation to ED, the behavior of the parent/caregiver and the child’s interaction with them.

In the case of James, his mum appears very anxious about his injury. Children tend to feed off of their parent’s anxiety and become more distressed. Moving them to a quiet area for assessment and reassuring mum that they are in the right place and that you’re going to take great care of James is an ideal starting point. Hopefully, reassuring and calming his mum will go some way to diffusing the situation, and calming James also.

 

Pain assessment

Assessment of a child in pain varies greatly with their age and developmental stage. This is one of the most important things to take into account during your encounter. If the wrong tool is used, the pain may be underestimated and the child under-treated. The longer the time to proper pain relief, the more distress there is for both child and parent, and so the spiral continues.

 

Neonates and infants (0 – 2 years)

For the youngest, the FLACC (Faces, Legs, Arms, Cry, Consolability) scale can be useful. This scale comprises of five components. The child needs to be observed for at least a minute. A child of this age isn’t going to be able to tell you much about their pain, so you need to rely heavily on your observational skills. Involving the parent in the assessment is  key.

Context is very important in this group also, particularly for the one-year-old who seems very distressed in triage or when being examined by the strange doctor but is more settled in mum’s lap. Frequent reassessments are therefore extremely important and beneficial.

 

Toddlers and preschoolers (2 – 4 years)

In this group, developing a rapport is a must in order to be able to accurately assess the level of pain. Get on the child’s level, use a soothing friendly voice, employ some ice-breaking chat.

Ask open-ended questions, don’t just palpate areas and say “Does this hurt?” – as you may well get a yes in every area – e.g. “Can you show me where is sore? Can you point to what is hurting you?

For these slightly older children, the Wong-Baker faces scale is great. These can be produced in bright colours to make them fun  and to aid with their participation in the assessment.

 

 

This scale has been validated in children aged 3 and up, but in practice it is often used in those over 2. The child is shown the faces and asked to point to the one that best represents how they are feeling.

Again, reassessment after initial analgesia using the same scale/method of assessment is important.

 

School-aged children (4 – 16 years)

As the child develops verbally, the assessment of their pain should become easier. For children aged 4-8  years of age, the Wong-Baker faces scale is probably still the most appropriate tool to use. In the older child, you can use the numerical pain ladder.

This can be either a visual representation where you ask them to draw a line or indicate where their pain falls on a physical scale, or you can simply ask them to give their pain a score out of 10 without showing them the scale.

 

 

You move James and his mum to the minors area to complete his assessment. Mum is now calmer, and this seems to have settled James somewhat. He is no longer crying, but he is still grimacing and he appears to be holding his left elbow fixed in flexion. You ask him point to where it is sore and he indicates his left arm. He refuses to move it. A survey of the rest of his body doesn’t reveal anything else concerning, he is fully weight-bearing and is moving his neck and right arm without issue. On palpation and careful examination of the left arm he is very distressed when his elbow is touched, and it appears to be swollen. You show him the Wong-Baker scale and he points to the orange sad face, which indicates a pain score of 8.

 

Pain management

To achieve the best pain management for our patients, we first have to have a basic grasp of pain physiology.

Nocioceptive pain follows a sequence where 4 events take place:

Pain transduction – a painful stimulus eg trauma causes tissue damage – this leads to the release of chemical mediators in the tissue, e.g. prostaglandins/substance P etc. These trigger an action potential.

Transmission – the action potential moves along the nerve fibres, travelling from the peripheral site of injury to the spinal cord.

Perception – the action potential travels along the spinothalamic tract to the brain, where it is relayed to the areas involved in pain perception (limbic system, somatosensory cortex, parietal and frontal lobes)

Modulation – the midbrain releases endorphins/serotonin etc to mitigate pain

We can target each part of the sequence in our treatment of pain, as long as we remember that analgesia is multi-modal, and does not just revolve around drugs.

 

 

Transduction

We can intervene at this stage by employing basic first aid measures – for example

  • If the child has a burn – run it under cool/room temperature water. This will provide pain relief as well as arresting further tissue damage
  • If a limb is obviously deformed or clinically has a fracture – splint or backslab the limb during your initial assessment and before sending the child for x-rays
  • If there is a suspicion of a clavicular or shoulder injury give the child a sling
  • If they have a swollen area ?soft tissue injury e.g. ankle – place an ice pack and get them to elevate the ankle.

These things may seem like common sense, but all too often they are forgotten in favour of pharmacological interventions which will not have as immediate an effect.

 

Perception

A child can be distracted much more easily than an adult, and we need to use this to our advantage in the context of pain management. Employing distraction techniques can affect and reduce a child’s perception of pain.

There are many options available and you can get the parents involved also. Distraction techniques obviously vary in their effectiveness depending on the age of the child, but they include: story-telling; singing a song (I can’t be the only one that hears Baby Shark as they fall asleep at this point!); balloons; stickers; bubbles; playing a video on a smartphone.

For older children, guided imagination can be used to great effect, particularly before procedural sedation with nitrous oxide or ketamine. Letting them listen to their own music on their phone via earphones is also a good idea. Some departments are now looking at the role of virtual reality headsets for older children undergoing painful procedures which appears to be a very successful method of distraction.

 

Transmission

Pharmacological agents act to interrupt the transmission of the painful stimulus. There are many agents available, depending on the child’s age and the level of pain described.

Topical anesthetics

Ametop (4% w/w Tetracaine) and EMLA 5% (lidocaine/prilocaine) are anaesthetic creams that can be applied to intact skin, usually pre-cannulation. They numb the skin and make the procedure less painful. They are ideal in situations where a slight delay to cannulation is safe, as they need to be in situ for a while to work (Ametop 30 mins, EMLA for an hour).

LAT gel – Lignocaine 4% / Tetracaine 0.5% / Adrenaline 0.1% is an anaesthetic gel. It comes in a single-use bottle. It is designed for use on broken skin, and so it should be ideally applied to wounds/lacerations in triage and left in situ for 30. It numbs the area and allows for thorough cleaning, proper assessment, and closure of wounds while reducing the need for injectable local anaesthetic in a lot of cases.

Contraindications

  • ANY previous reaction to local/ general anaesthetic or known cholinesterase deficiency
  • Wound on or near mucus membrane including eye, nose or mouth.
  • Wound > 5 cm in length
  • Concern about tissue viability i.e. crush or flap wounds
  • Wounds over 8 hours old
  • Obvious injury to associated structures i.e. bone, tendon, blood vessels, joint or nerve
  • Wounds to the ear, nose, genitalia or digits should be discussed with a registrar before using LAT gel. This is due to concerns about perfusion and also due to evidence showing less effect on extremity wounds.

 

Paracetamol

This is perhaps best known to parents as Calpol (UK and Ireland), Panadol or Crocin (Australia) or Tylenol (in the States), however, there are other brand names. There are two different preparations of Calpol depending on age (120mg/ 5mls or 250mg/5mls) so make sure to clarify what the parent has at home.

Paracetamol can be given PO/PR/IV but is most commonly given orally. The dose is 15mg/kg to a maximum dose of 1 g.

It can be given 4-6 hourly, but to a maximum of 4 doses in 24 hours. It takes approximately 30 minutes to work

Overdose is 75mg/kg (although toxicity usually doesn’t occur until >150mg/kg in an acute ingestion or repeated supra therapeutic doses>100mg/kg). If this happens it can cause hepatic necrosis – so bloods will need to be checked and if the paracetamol level is beyond a certain threshold the child will need to be started on n-acetyl cysteine.

 

Ibuprofen

Ibuprofen is a non-steroidal anti-inflammatory (NSAID) that is available over the counter. NSAIDs work to stop the inflammatory cascade of chemical mediators and thus reduce inflammation and pain. It is also an anti-pyretic.

It is commonly sold as Nurofen (in the UK, Ireland and Australia) and Advil (in America) but again has other brand names as well as being sold by generic name. Nurofen also comes in two preparations (100mg/5mls or 200mg/5mls) – always clarify with the parents as to what they have at home to ensure appropriate dosing.

Ibuprofen can be given at a dose of 10mg/kg to a max of 400mg 8 hourly. An overdose obviously isn’t desirable but does not carry the same dangers as paracetamol.

It can be given PO or PR, however the suppositories only come in 60mg so are not as useful in bigger children.

Always, always double-check which medicine a parent may have given at home. For example, Calpol contains paracetamol but Calprofen contains ibuprofen – you can see how double doses can accidentally be given in the emergency department soon after a child presents.

 

Diclofenac

Diclofenac also a member of the NSAID family. It can be used in place of ibuprofen in the older child in its oral form.

In my own practice PR diclofenac suppositories have been invaluable in the pain management of infants with stomatitis or bad tonsillitis causing distress and poor oral intake, while also controlling their pyrexia.

The dose is 1mg/kg 8 hourly (max 50mg per dose) and can be given PO/PR.

Max dose is 3mg/kg in 24 hours.

 

Morphine

Morphine is a strong natural opioid. It is used for severe pain, or pain that is not responding to first-line analgesics. It can be given by a variety of routes, but most commonly PO or IV.

Oramorph is an oral form of morphine, available in liquid preparation and is dosed by age band:

  • <1 year: 80 -200mcg/kg
  • 1-2 years:200-400mcg/kg
  • 2-12 years:200-500mcg/kg
  • 12-18 years: 10-15mg

Its IV dose is 0.1mg/kg. It can be given prn usually every 4-6 hours

Potentially serious side effects include decreased respiratory effort and low blood pressure. Overdose treatment includes the administration of naloxone (0.1mg/kg IM or IV).

 

Fentanyl

Fentanyl is a strong synthetic opioid with a faster onset / offset than morphine, starts to work within 7 minutes. It’s great for initial analgesia for fractures/dislocations, burns, major lacerations.

The loading dose is 1.5mcg/kg and can be repeated after 20-30 minutes

Side effects are uncommon, but may include respiratory depression/hypotension/nausea and vomiting. It is given intranasally (IN) with an atomizer device and has great mucosal uptake without having the need for IV access.

 

Diamorphine

Diamorphine is also an opioid that can be given intranasally as an alternative to fentanyl, using an atomizer device.

The dose is 0.1mg/kg IN

It carries the same potential side effects as morphine and fentanyl, but has been shown to be very safe at this dose in the paediatric population.

 

Methoxyflurane

Methyoxyflurane is also known as Penthrox / the green whistleIt is an inhaled medication primarily used to improve pain following trauma. Each dose lasts approximately 30 minutes.

Pain relief begins after 6–8 breaths and continues for several minutes after stopping inhalation

It is self-administered to children and adults using a hand-held inhaler device

 

The STOP trial looked at its safety and efficacy in adults and children >12 and found that it was safe and worked well. It is currently being investigated in those aged 6-18 in the MAGPIE trial, which is still undergoing data collection.

 

Procedural sedation

Sometimes, analgesia alone isn’t enough. If a child has a deformed fracture for example that needs to be manipulated, they will need procedural sedation. This is usually achieved with wither nitrous oxide or ketamine, depending on the child’s age and the procedure required.

 

You suspect that Jamie has a fractured arm, perhaps a supracondylar fracture. His weight is 18kg. Given his level of distress and pain score of 8, you give him both IN fentanyl 27mcg and paracetamol 270mg. Mum plays a video on her phone for him while you apply an above elbow backslab to splint and immobilize his arm before he goes to x-ray.

You reassess him after these interventions and he looks much happier, you even get a smile. He indicates the second green face on the Wong-Baker scale, equating with a pain score of 2. He goes for an x-ray which confirms a supracondylar fracture – Gartland 2. 
You refer him to the orthopaedic team for admission and management. You ensure that he has regular analgesics as well as PRN extras written up in his drug Kardex before he leaves the department to go to the ward.

 

References

Srouji R, Ratnapalan S, Schneeweiss. Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics. 2010. doi:10.1155/2010/474838

https://pemplaybook.org/podcast/pediatric-pain/

Manwarren R and Hynan L. Clinical Validation of FLACC: Preverbal patient pain scale. Pediatric Nursing. 2003; 29(2):140-6

Keck JF et al. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996;11(6):368-741996

Tomlinson D et al. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010;126(5):e1168-98. doi: 10.1542/peds.2010-1609

Horeczko T. “Acute Pain in Children”. In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  

Knight K, McClenaghan CE, Singh B: Virtual reality distraction from painful procedures in the paediatric emergency departmentArchives of Disease in Childhood 2019;104:204-205.

Leicester Children’s Hospital clinical guideline. Use of Topical Wound Anaesthetic- LAT gel in the PED. Rowlands. Feb 2014.  https://static1.squarespace.com/static/546e1217e4b093626abfbae7/t/59cba0aa12abd9d55c449106/1506517164347/Topical+Wound+Anaesthetic+-+LAT+Gel+UHL+Paediatric+Emergency+Guideline.pdf

Royal Children’s Hospital Melbourne clinical guideline. Management of paediatric paracetamol overdose. https://www.rch.org.au/clinicalguide/guideline_index/Paracetamol_poisoning/

Sharif MR et al. Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children. Iran Red Crescent Med J. 2016;18(1): e27932

Kendall J, Maconochie I, Wong ICK, et al; A novel multipatient intranasal diamorphine spray for use in acute pain in children: pharmacovigilance data from an observational study. Emerg Med J 2015;32:269-273.

Coffey F, Wright J, Hartshorn S, et al: STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. Emerg Med J 2014;31:613-618.

Nerve blocks

Cite this article as:
Nicola Mulrooney. Nerve blocks, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23517

Nerve blocks provide a fast and efficient method of providing adequate analgesia to facilitate treatment or repair of injuries such as fractures, dislocations, lacerations or removal of foreign bodies.

Caution must be taken in choosing patients suitable for regional anaesthetic; a cooperative patient is absolutely essential and therefore, it may be more appropriate to use procedural sedation in very young children. As well as a struggling child, there are other contraindications to regional techniques. These include:

  • Local anaesthetic sensitivity/allergy
  • Circulatory compromise
  • Overlying skin infection

Choosing an appropriate local anaesthetic agent

The choice of agent depends on the type of injury and the desired onset and duration of pain relief. Commonly, short-acting agents alone are used for digital and auricular blocks, while a combination of short and long-acting agents are useful for femoral nerve blocks.

Short-acting agents

Lignocaine 1% or Procaine: onset 5-10 mins, duration 30-40mins

Max dose 3mg/kg

Long acting agents

Bupivacaine (Marcaine): 0.25%, onset 5-10mins, duration 2 hrs

Max dose 2.5mg/kg

*It is thought that the combined use of lignocaine and adrenalin (1:100,000) can increase the risk of digital ischaemia and is best avoided. Actually the evidence isn’t that clear cut. Adrenaline is added to a local anaesthetic to prolong its effect. The concern it will constrict end arteries, leading to localized ischaemia, has led to the recommendation to avoid adrenaline in fingers and toes. Cochrane published a review  in 2015  which concluded, “from the limited data available, the evidence is insufficient to recommend use or avoidance of adrenaline in digital nerve blocks.” So there we are, still on the fence.

There’s a bit of a Catch-22 when it comes to injecting local anaesthetic. It hurts, because it’s an acid, and causing pain can lose the trust and rapport you just spent the last 15 minutes building with a child. Even worse, adding adrenaline makes it even more acidic and therefore even more painful to inject. There are two things we can do to make lignocaine less painful to inject:

  • Buffer it to bring the pH up to a more physiological pH. Mix 10ml of 1% lignocaine (or 1% with 1:100,000 adrenaline) with 1ml of 8.4% bicarbonate (using a ratio of 8.4% bicarbonate : 1% lignocaine of 1:10)
  • Warm it to room temperature. An EMJ review in 2007 suggested that warming local anaesthetic solution can significantly reduce the pain of infiltration.

Preventing infection

The preparation for regional nerve blocks is the same at any site; clean the area with iodine or chlorhexidine solution to reduce the risk of infection. Soaking a digit in a bath of the antiseptic solution may be easier.

So, let’s look at some specific blocks.

Digital nerve block

Harry is a 14-year old who injured his right hand while playing football. He explains that, as he fell, he caught his little finger on the ground, bending it awkwardly. On presentation, there is an obvious deformity of the little finger. He has had paracetamol and ibuprofen prior to arriving in the emergency department and is comfortable.

On assessment, Harry has a closed injury of his 5th finger, with no neurovascular compromise. There is an obvious deformity of the proximal phalanx, with reduced movement at the joint. An x-ray reveals a dorsal dislocation of the proximal interphalangeal joint, with no evidence of an associated fracture. Harry needs that finger relocating but you think to yourself, you’d better put in a ring block.

Indications

Repair or treatment of injuries such as dislocations, lacerations, foreign bodies to the digits of the upper or lower extremities

Anatomy

  • Two dorsal digital nerves at the 10 and 2 o’clock positions of the phalanx.
  • Two palmar digital nerves at the 4 and 8 o’clock positions.
  • Each palmar digital nerve is closely associated with a digital artery and vein.

Technique

  • Place the hand or foot flat on a sterile surface.
  • Clean the skin
  • Hold a syringe containing a short-acting anaesthetic, such as 1% lignocaine, perpendicular to the digit and insert the needle into the subcutaneous tissue of the digital webspace.
  • After aspirating to ensure you’re not in a vessel, slowly inject 2 ml of anaesthetic into the subcutaneous tissue and infiltrate, surrounding the nerve, as you withdraw
  • Withdraw needle and repeat procedure on the opposite side of the digit.
  • Allow 5 to 10 minutes for the local anaesthetic to work before performing the procedure.

You perform a digital ring block on Harry using 1% lignocaine. You successfully relocate the proximal phalanx and confirm placement on repeat x-ray. You buddy strap Harry’s finger and refer him to for orthopaedic follow-up. As Harry waves you goodbye, your registrar says, “Next time you should try an ulnar nerve block, it works really well for hand injuries.” On your lunch break you log onto DFTB and read up on ulnar nerve blocks for the next hand injury you see.

Ulnar nerve block

Indications

The management of injuries to the ulnar border of the palm, as well as the 5th finger such as lacerations to or manipulation of metacarpal or interphalangeal fractures.

Anatomy

  • The ulnar nerve passes between the ulnar artery and tendon of the flexor carpi ulnaris (FCU). The ulnar nerve is deep to the tendon flexor carpi ulnaris, and medial to the ulnar artery.
  • The palmer and digital branches of the ulnar nerve supply the medial aspect of the palm and ring finger, as well as the entire little finger, respectively.

Technique

  • Insert needle deep to the FCU, proximal to its attachment at the styloid process of the ulna
  • advance the needle 5-10mm further beyond the tendon on the FCU, injecting 3-5ml of local anaesthetic
  • If blood is visible on aspiration, redirect the needle superficially and medially to avoid the ulnar artery

Have a look at this fabulous video from Mike Stone for some in-action ulna nerve blockade.

Auricular nerve block

Ciara, a 7-year-old girl, has been brought to the emergency department because her earring is stuck somewhere in her earlobe. Ciara won’t let anyone look for it as it’s too painful to touch. You sit Ciara on her mom’s lap, and with the help of the magical play specialist, you successfully perform an auricular block. Ciara then allows you to make a small incision on the posterior aspect of her earlobe and you retrieve the missing earring. You dress the earlobe with Steristrips and advise her mum about the signs of infection.

Indications

Treatment of injuries to the external ear such as lacerations, haematomas requiring drainage, and removal of foreign bodies, such as embedded earrings, while preserving anatomy.

Anatomy

  • The outer portion of the auricle receives its innervation from the greater and lesser auricular nerves and auriculotemporal nerve
  • The medial portion receives innervation from the auriculotemporal nerve and auricular branch of the vagus nerve

Technique

To anaesthetise the greater auricular nerve (for all things earlobe related):

  • Clean the skin
  • Insert a 25 gauge needle containing a short-acting local anaesthetic such as 1% lignocaine subcutaneously below the earlobe in line with the external auditory meatus.
  • Direct the needle behind the ear towards the mastoid process, advance it parallel to the skin, aspirate to ensure you’re not in a vessel, then inject 2-3ml as you withdraw the needle
  • Withdraw the needle back to the first position.

If the procedure also involves the upper half of the ear, rather than just the earlobe, continue with the following steps:

  • Direct the needle anterior to external ear towards the area just anterior to the tragus, aspirate, then inject as you withdraw the needle completely.
  • Insert the needle subcutaneously directly above the ear again in line with the external auditory canal
  • Repeat the above steps with the needle facing caudally towards the mastoid process and anterior to the tragus

Posterior tibial nerve block

Freddie, an active 9-year-old, was running barefoot in the garden when he stood on something sharp, sustaining a large cut to the sole of his foot. He hops into the emergency room, supported by this dad. He’s taken Calpol prior to arrival in the department. On examination, there is a 5cm wound on the sole of his foot and you are concerned that there may be glass in the wound. You give further analgesia and arrange an x-ray. You think to yourself, ‘Posterior tibial blocks are great for foreign bodies or wounds in the sole of the foot. I’ll get things ready while he’s in x-ray.’

Indications

Provides sensory paraesthesia to the anterior 2/3 of the sole of the foot, allowing for the management of lacerations and wound in this area. It is not suitable for injuries on the extreme medial or lateral aspect of the sole.

Anatomy

Posterior tibial nerve is located at the medial aspect of the ankle, between the medial malleolus and the Achille’s tendon.

Technique

  • Position the patient lying supine with the foot partially dorsiflexed.
  • Locate the posterior tibial artery, the nerve lies posterior to this.
  • Inject 2 -4 ml local anaesthetic at the level of the upper edge of the medial malleolus, aspirating prior to injection
  • If the artery cannot be felt, the point of injection is the midpoint between the medial malleolus and the achilles tendon.

Freddie’s x-ray confirms a shard of glass in the sole of his foot. With a posterior tibial block in place, you successfully remove the glass and are able to washout and close the wound without him even noticing. Freddie’s dad confirms he’s had all his vaccinations, including tetanus. Freddie is discharged home with wound care advised and promises to always wear his shoes in the garden.

Once again, Mike Stone shows us how it’s done.

Femoral nerve block

Sam is a 15-year-old brought to the emergency department by ambulance following a fall from a tree. The ambulance crew have given paracetamol and ibuprofen en route but Sam is very distressed, complaining of severe pain in his right leg, as he is moved from the trolley to the bed. Following a primary survey, you are satisfied Sam is stable with no airway, c-spine, breathing or circulatory compromise. His right thigh is grossly swollen and tense. You place it in a traction splint, give Sam intranasal fentanyl and organise an urgent x-ray of his right femur, which confirms a proximal femur fracture.

 

Indications

Femur fractures
Anterior thigh wounds requiring exploration and washout

Equipment

  • Ultrasound machine with a linear probe. Ultrasound-guided is the gold standard.
  • Sterile drape, probe cover and gloves
  • Needle for injection
    • Specific nerve block needle or a spinal needle with trocar removed
  • Monitoring; continuous ECG and pulse oximetry
  • Consider adjunct analgesic eg: intranasal fentanyl

Anatomy

  • The femoral nerve is located at the midpoint of the inguinal ligament; half way between ASIS and pubic tubercle.
  • Moving lateral to medial: Femoral nerve > artery > vein
  • Clean the skin and palpate the artery.
  • In an adolescent, the site of local anaesthetic injection if 5cm lateral to the artery towards ASIS. This distance is smaller in children. Using ultrasound will help find the femoral nerve accurately.

Technique

  • Prepare the ultrasound machine: Choose the correct probe, position yourself on the opposite side of the bed, apply gel to the probe and apply a probe cover.
  • Prepare a dressing pack with 1-2% lignocaine, appropriate  needle, sterile dressing and low-pressure tubing
  • Clean the area and drape appropriately.
  • Use the ‘in-plane’ ultrasound probe orientation with the marker pointing to ASIS
  • Observe landmarks (lateral > medial)
  • Infiltrate 1-2ml of 1-2% lignocaine superficially lateral to the artery
  • Pierce the skin the with block needle through anaesthetised skin
  • Advance the needle slowly ensuring tip of the needle is always visible
  • When lateral to the nerve and between layers of fascia iliaca, aspirate the needle to ensure it is not within a vessel, and then infiltrate local anaesthetic slowly, aiming to fully encircle the nerve (total 10-20ml in an adolescent)
  • Apply a sterile dressing over injection site; label the block time and date.

You have completed the nerve block and are tidying up your equipment when Sam complains of a funny sensation around his lips and says he feels sick. As you turn towards Sam you notice he is heart is racing and he looks really unwell…

Local Anaesthetic Systemic Toxicity (LAST)

LAST is a severe and life-threatening condition which can occur when local anaesthetic reaches significantly high levels in the circulation. The causes are often iatrogenic; accidental injection into a vein or artery or excessive doses of anaesthetic used.

Signs and symptoms of LAST are:

STOP the infusion of local anaesthetic, MOVE the patients to the resus area if not already there and CALL for HELP.

Management

A: Maintain airway, if necessary prepare for intubation

B: Ventilate with 100% oxygen

C: Confirm or establish IV access

D: Treat seizures with benzodiazepines. Check glucose.

E: Perform ECG, looking for treatable arrhythmias

Give lipid emulsion therapy, as per your local hospital guideline. Lonnqvist (2012) designed a user-friendly guideline for management of paediatric local anaesthetic toxicity.

From Lönnqvist P-A (2011)

You ask a colleague to repeat Sam’s observations and perform an ECG, as you call your ED consultant for help. You call the anaesthetics registrar asking for an urgent review and you search for the local anaesthesia toxicity guidelines. Lipid emulsion therapy is initiated and Sam is transferred to PICU for close observation. Thankfully it all ends well. A few days later Sam is well enough to undergo surgery for his femoral fracture, and recovers without complication. You complete an incident report and develop a teaching session on femoral nerve blocks and LAST.

With thanks to Aarani Somaskanthan for her excellent teaching on auricular nerve blocks.

Selected references

Prabhakar H, Rath S, Kalaivani M, Bhanderi N. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010645.

Clinical Practice Procedures: Drug administration/Regional anaethetic: digital block. Queensland Government 2018. https://ambulance.qld.gov.au/clinical.html

Murtagh J. John Murtagh’s Practice Tips, 7e.

Girolami A, Russon K, Kocheta A. Wrist block – landmark technique anaesthesia tutorial of the week 275. https://www.wfsahq.org/components/com_virtual_library/media/bfa40b8c7129208c53f1c3fdc22b03c0-9b9355ee59555d0f6139e7ecceb60ad2-275-Wrist-Block—Landmark-Technique.pdf

Nerve blocks of the face. https://www.nysora.com

Martinez NJ, Friedman MJ. External ear procedures. https://obgynkey.com

Clinical practice guidelines; femoral nerve block. The Royal Children’s Hospital Melbourne 2017. https://www.rch.org.au/clinicalguide/guideline_index/Femoral_Nerve_Block/

Fox S. Local Anesthetic Systemic Toxicity and Lipid Emulsion Therapy, 2018. https://pedemmorsels.com/local-anesthetic-systemic-toxicity-and-lipid-emulsion-therapy/

Posterior tibial nerve block.Government of Western Australia Child and Adolescent Health Service. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Posterior-tibial-nerve-block

Ultrasound guided nerve blocks for hip fractures & femoral fractures; Barts Health. National Health Service 2014.https://www.rcem.ac.uk/docs/Local%20Guidelines_Audit%20Guidelines%20Protocols/12u.%20Ultrasound%20guided%20nerve%20block%20for%20hip%20and%20femoral%20fractures%20(Barts%20Health,%202014).pdf

Martin N, Darcey M. Local Anaesthetic systemic toxicity (LAST) in children. The Royal Children’s Hospital Melbourne 2012. https://www.rch.org.au/uploadedFiles/Main/Content/anaes/LAST_submission_draft6-2.pdf

Lonnqvist PA. Toxicity of local anaethetic drugs: a paediatric perspective. Paediatric Anesthesia, 22 (2012), 39-43.

Frank SG, Lalonde DH. how acidic is the lidocaine we are injecting, and how much bicarbonate should we add? Can J Plast surg 2012;20(2):71-74.

Sultan J, Curran AJ. The effect of warming local anaesthetics on pain of infiltration. Emergency Medicine Journal 2007;24:791-793.

Managing wounds

Cite this article as:
Orla Kelly. Managing wounds, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23609

Wounds are a common presenting complaint to a Paediatric Emergency Department. Children will be children, and slips, trips and falls resulting in minor injuries are all part of growing up. Most wounds are small and can be easily (a relative term!) dealt with in the ED. This prevents the need for referral to speciality care, reduces the time spent in hospital for patients and parents, and provides the satisfaction of a job well done for the ED doc!

Managing expectations

As with any presentation to a healthcare professional, it is important to explore and address patients’ and parents’ concerns and expectations. With wounds, scarring is often a major concern. There are some important points to consider when managing these expectations:

All wounds scar

Scarring is part of the natural healing process of the skin. All full-thickness injuries to the skin will result in scar tissue formation. Multiple factors contribute to the scar that will eventually form – the nature of the injury, the location of the wound, the direction of the wound, some patient-specific factors, the degree tension on closure and lastly, closure technique chosen.

Everyone scars differently

There is no way to tell how each wound will heal. Hypertrophic scars and keloid scarring are patient-specific and often not foreseeable. These can be managed at a later stage by specialist teams. Other patients are at risk of poor healing – smokers (hopefully not too common in a paeds ED), diabetics, long term steroid users and those with other chronic diseases.

The most important part of wound management isn’t the closure but the cleaning

Infected wounds will heal badly (if at all) and can affect the underlying structures. Patients and parents need to aware to look carefully for any redness or exudate that might indicate infection and to seek medical attention appropriately.

Different wounds require different closures

Some parents will be set on the idea that stitches are superior – this is not always the case as we’ll discuss later.

Wounds take longer than a few days to heal

Wounds heal in three phases – inflammatory (day 1-3), proliferative (day 4-21) and remodelling (day 21 – 1 year). Scars can, therefore, take up to 12 months before they reach their final appearance. Because of this patients and parents need to know that the initial appearance is not the final outcome.

That said, measures can be implemented to reduce scarring

For instance, I recommend Steristrip support for a week, and then pinpoint massage with petroleum jelly or other oil-based products for a month to six weeks to provide a moist wound bed and reduce visible scarring. Sun protection is also important – the wound should not be exposed to the sun for at least three weeks, and sun cream used for more than a year on that area.

Scar revision is possible at a later stage

If after initial closure and sufficient healing time has passed, and a scar still remains that is distressing to the patient, referral for scar revision is possible.

Managing clinicians

It can be often tempting to be distracted by a nasty wound. No doubt the patient will be. But it is important to see the bigger picture and not to miss any important steps in management. Having a structure to work through is always something I find helpful, and the following questions will make sure your patient is treated safely and comprehensively.

  1. Is there any other associated injury?

Always think of the ABCs and make sure any haemorrhage has been controlled. Has the patient received a head injury, or has another body part been injured?

  1. How has it been caused?

The history of the injury will lead you to suspect any further damage or special considerations for management. For instance, was the wound caused by a sharp instrument or blunt trauma? Did it happen in a particularly contaminated area (e.g. a farmyard accident) that would prompt the need for surgical washout and antibiotic coverage. If describing wounds in medical notes be careful of nomenclature – if in doubt use ‘wound’. An abrasion is a wound caused by friction (a graze, or road rash for instance). These can be tricky to clean, but it’s important to remove any debris, otherwise a tattoo type scar can remain. A laceration is caused by a shearing force; these are more difficult to repair as there has been surrounding tissue damage. An incisional wound is caused by a sharp object, often more straightforward to repair. A puncture wound is one where the skin has been breached and is deeper than it is wide. Beware of these wounds – they are the icebergs of the wound world – who knows what is going on beneath the surface?

  1. Is there a foreign body present?

Puncture wounds, in particular, carry a high risk of foreign bodies, and therefore of infection and wound breakdown. If a foreign body is suspected, an x-ray is reasonable as it will pick up metal and most glass, although it won’t demonstrate wood, plastic and clothing. For cases where suspicion is high, ultrasound can be used to pinpoint the material. Often, in this case, speciality services need to be contacted.

  1. How deep is the wound and might other structures be involved?

The location of the wound and a good knowledge of anatomy is particularly important when it comes to this question. Wounds on the hands and arms, for instance, carry a high risk of underlying tendon and nerve damage. Always make sure to test and document a neurovascular examination distal to the wound.

  1. Is it safe to close the wound immediately?

If the wound isn’t too old (opinions differ on this, but usually >8hrs) or contaminated then healing by secondary intention is usually preferred in order to avoid sealing in infection.

  1. How should the wound be best closed?

Factors which help in making this decision include the size of the wound, the location and the degree of tension it is under.

  1. What dressing should be used?

Usually, a non-adherent dressing for abrasions will facilitate healing as well as less painful dressing changes. Wounds that have been sutured can be covered with a simple bandage. Other wounds on fingers or places likely to get wet (or drooly!) may require a waterproof dressing.

  1. Does the area need immobilisation?

If the wound is over a joint or subject to movement, it is good practice to immobilise the joint in order to allow healing. Beware wounds overlying joints and ensure that there is no communication with deeper structures.

  1. Are antibiotics indicated?

There is no evidence for ‘prophylactic’ antibiotics in simple wounds. However, those that are heavily contaminated, or involve joints or underlying structures/fractures will often require specific antimicrobial cover (and surgical washout). Consult with local speciality teams for their preferences.

  1. Is the child tetanus immune?

Always important to check the immunisation status of any child presenting to a healthcare professional. Consult national guidelines as to the recommendations for tetanus prone wounds and indications for booster shots and immunoglobulin.

First – let us remind ourselves of the structure of the skin. It is composed of the epidermis and dermis, and underlying subcutaneous layers.

The structure of skin

Wounds to the epidermis are very superficial; the dermis and epidermis are tightly adherent to each other. Wounds to epidermis need nothing more than a wash and a non-adhesive dressing (a sticking plaster or Band-Aid). Do not be tempted to glue or suture these as they will worsen outcomes.

Wounds that extend through to dermis or subcutaneous layers must be treated with more care. Of course, the age of the patient will determine the approach, but the management remains the same. The following are some techniques to allow us to manage our patients, before the wounds.

Managing patients

If your department is lucky enough to have a play specialist – use them. They can magically turn a difficult situation into a calm and even fun event. Using distraction techniques (I personally turn to the name of the blog for my distraction of choice) a child can be calmed and the wound can either be managed immediately, or anaesthetised.

LAT gel (lidocaine adrenaline and tetracaine) is magical stuff. A mixture of local anaesthetic and adrenaline, it takes about 20-30 minutes to be effective, and it helpfully blanches affected skin (due to the adrenaline) to show you it’s ready. Generally not suitable for under 1s (an infant presenting with a wound that requires suturing should prompt immediate senior review), the doses are 0.5ml/1cm of wound, with a max dose of 2ml in 1-3 year olds and max 3ml in >3 years. It shouldn’t be used on mucous membranes or eyes due to absorption or on extremes of digits, nose, genitalia or ears due to the vasoconstriction effect of the adrenaline, or wounds greater than 8 hours old (as these are likely to need formal washout). LAT gel can also be used to sufficiently numb an area enough for local anaesthetic injection if further anaesthesia is required. Remember the full dose of lidocaine shouldn’t exceed 5mg/kg. Inject local anaesthetic SLOWLY using an orange needle – local anaesthetic is painful when injected, so infiltrate slowly to negate this, and use a small gauge needle.

The other option is procedural sedation. This is department-specific and dependent on the availability of senior clinicians and departmental equipment/space. It can allow for a more thorough washout and definitive closure of wounds without another trip to the hospital.

If there is an obvious underlying fracture or structural (ie nerve or tendon) defect, then the patient requires a referral for speciality treatment, and is not suitable for ED closure, so I don’t see any benefit in further possibly distressing a child by poking and prodding – one such session is enough!

Managing wounds

Once the patient is suitably distracted/analgesed/sedated, it’s time for the easy part. Wounds must be cleaned thoroughly, and underlying structures assessed. If there is any risk of underlying fracture, an x-ray is mandatory – a missed open fracture is unacceptable. Normal saline is perfectly fine for wound washout. All large/visible debris should be removed, and then the wound thoroughly irrigated. I find an 18G cannula (with the sharp bit removed) attached to the end of a 20ml syringe for small wounds works well as it gives good pressure effect. For larger wounds, a 50ml syringe on its own can be used. There is no consensus around the amount of fluid needed for a washout. It is often clinician and wound dependent. If in doubt, keep washing it out!

Now for the closure. Depth, length, tension and location are the predominant features that guide the decision for closure materials and techniques. It is important to remember that the goals of wound closure are to eliminate dead space, avoid dehiscence by using appropriate materials and technique, and approximate wound edges without tension.

Paper stitches

Paper stitches, butterfly stitches, or Steristrips©, are fantastic when used for wounds with low tension (i.e. the wound edges are easily apposable). They come in a range of sizes to fit different wounds and locations. Make sure to cut them to size; if they are too long the edges can peel away and little fingers can be tempted to peel them off. Place them perpendicular to the wound, sticking down one side first, then gently pinch the wound edges together, and secure the other side down. Ensure the wound edges are everted (the pinching helps). Leave approximately 3mm in between each strip. A parallel strip can be added to the ends of the strips at either side of the wound (not directly over it) to help prevent them peeling away. Cover with a regular dressing. I advise using tincture of Benzoin as an adjunct – it increases the adherence of the Steristrips© (and smells nice). If the area is likely to get wet (i.e. chin), a personal trick is covering the closed wound with a DuoDERM©, or equivalent dressing, as it will help it stay protected. Give the usual infection safety net advice to parents. I generally advise them to leave the Steristrips© in situ until they themselves fall off naturally (usually that gives plenty of time for the wound to heal). Steristrips© aren’t suitable for wounds that are under tension or likely to be subject to movement such as over joints.

Glue

Tissue adhesive has been covered in a separate blog post which can be found here

Sutures

For most wounds being repaired in the ED, simple interrupted sutures are appropriate.

Simple interrupted dermal sutures can be absorbable (eg Vicryl Rapide©) or non-absorbable (eg nylon, Prolene©, Seralon©).

Absorbable sutures are useful under casts, where it’s not possible to remove them after a required time, or for wounds in young children where suture removal could cause distress and the wound is not in an area of cosmetic concern (e.g. scalp).

For facial wounds, non-absorbable sutures should be used, as absorbable sutures may not disintegrate prior to the epithelisation of the suture, leaving the stereotypical ‘dots’ either side of the wound site. Use the smallest suture possible. Holding the needle 2/3 along the curve with the needle-holder, always position the tip of the needle at a 90-degree angle to the skin, and using a supination movement rather than pushing or dragging the needle through the tissue, make a corresponding incision on the other side of the wound and tie the knot. Tying the knot parallel rather than perpendicular to the wound can result in better eversion and therefore better cosmetic outcome. Remember – approximate, don’t strangulate. The base of the suture should be wider than the top in cross-section – this gives strength to the wound and ensures no deep cavities are left. A useful trick in ensuring this shape to the stitch is to gently evert the second side of the wound as you’re passing the needle from deep to superficial. Sutures should be removed between day 3-5 on the face, and around day 7 on the rest of the body.

Geeky Medics have a lovely video on simple interrupted sutures.

Deep dermal sutures are sometimes required if the wound is under tension. In this case, a reverse suture from inside-out for the initial stitch, with a corresponding outside-in stitch on the far side allows you to bury the knot. An absorbable suture such as Vicryl© or Monocryl© is great for this. As the knot is being buried, only three throws should be used. With deep dermal sutures, the superficial dermal sutures should not be under tension and just provide a means to evert the wound edges. Deep sutures are at more risk of infection as you are leaving foreign material in the wound. For simple facial lacerations in children, they are often not necessary. The Children’s Hospital of Philadelphia has a great video on deep dermal sutures.

Special considerations

Bites: Bite wounds are prone to infection and therefore require antibiotic cover. They usually should be left to heal by secondary intention, as closure of these wounds can result in deep-seated infections. If they are deep to subcutaneous tissues, washout in theatre is likely more suitable than in the ED.

Large area superficial abrasion (eg road rash): These are difficult to treat and clean. The use of a porous sponge and surfactant cleaner is useful here. If it is extensive and the patient uncooperative, often sedation or GA is most appropriate.

Delayed presentation: Wounds that present after 24 hours are unsuitable for primary closure due to the high risk of infection. Thorough cleaning with regular dressings and close follow up with possible grafting or scar revision is often necessary.

Selected references

Grabb and Smith’s Plastic Surgery 7th Edition, Editor in chief Charles H Thorne, Lippincott Williams And Wilkins Philadelphia 2014

Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on Postsurgical Scar Management. Semin Plast Surg. 2016;30(3):122–128. doi:10.1055/s-0036-1584824

Paediatric Emergencies Beattie, Hendry, Duguid, 1997, Mosby-Wolfe Barcelona

Ghafouri HB, Bagheri-Behzad B, Yasinzadeh MR, Modirian E, Divsalar D, Farahmand S. Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment. Bioimpacts. 2012;2(1):33–37. doi:10.5681/bi.2012.004

Kanegaye, J. A Rational Approach To The Outpatient Management of Lacerations In The Pediatric Patient. Current Problems In Paediatrics. 1998: 28(7):205-34.

The child with a limp

Cite this article as:
Andrew Tagg. The child with a limp, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23509

This post is based on the talk Andrew Tagg was invited to give at BadEMFest20 in Capetown. Unfortunately, world events made that a little challenging.

Humans evolved from Homo erectus to Homo sapiens around 500,000 years ago. Fossils dug up from by the Leakeys in Olduvai Gorge, Tanzania, revealed how we moved from shuffling knucklewalkers to the upright hominids we recognize today. Walking on two legs allowed us the freedom to use our hands – to communicate, to use tools, and to keep ourselves safe.

 

How do we walk?

The normal human gait is comprised of three distinct phases:

  • The contact phase – from heel strike to flat foot
  • The stance phase – from flat foot to heel off the ground
  • The swing phase – the propulsion phase as weight transfers from the toes

The swing phase normally comprises 40% of the gait cycle.

 

 

Like Sherlock Holmes or his progenitor, Joseph Bell, if you watch your patient walk you can get a lot of clues as to the potential underlying pathology before you even exchange a word with them or their parents.

Antalgic gait

This hobbling gait has a normal contact phase and normal propulsion with a decreased stance phase. In essence, the patient is trying to decrease the amount of time spent bearing weight through the hip joint itself.

Trendelenburg gait

In this gait disturbance, the hip muscles are too weak and so the unaffected side drops towards the floor. It suggests a biomechanical issue such as ass avascular necrosis, or a slipped capital femoral epiphysis.

Circumduction gait

The patient swings their leg out and around to clear the floor. This is often due to a leg-length discrepancy in the delayed diagnosis of developmental dysplasia of the hip (DDH).

Equinus gait

Toe walking, though normal up to the age of three may suggest that the child is unwilling or uncomfortable engaging their gastrocnemius muscles in walking. This can occur in many conditions.

 

The rate of presentation to the emergency department with an atraumatic limp is approximately 1.4 per 1000 in children under the age of 14. It occurs more often in boys than in girls (1.7:1) and the median age is 4.4 years. When we consider the potential causes the list is massive. In this post, we are going to concentrate on both the more common conditions and those diagnoses that we really shouldn’t miss. Whilst any part of the limb might be the cause (from the toes to the hip) this post is going to focus on causes centred around the hip joint. They account for about 60% of cases of limp. That doesn’t mean you shouldn’t look in their shoes for pebbles or look at their toes though!

Let’s break it down to some age-specific diagnoses and those that can occur at any age


Late presentation of developmental dysplasia of the hip (DDH)

It is just possible that routine screening with Ortolani’s and Barlows test might have missed a case of hip dysplasia. The limb resultant limb shortening can be hard to detect if it is bilateral but this is one time to get out the tape measure and look for a leg length discrepancy as you measure from anterior superior iliac spine (ASIS) to medial malleolus.

If you don’t have a tape measure to hand then look for a positive Galeazzi sign, suggesting a shorter hip segment on the affected side.

Original by Walt Shumway

 

Transient synovitis

This diagnosis accounts for the majority of cases of atraumatic limp and may follow an upper respiratory tract infection though the evidence for causation is poor. It is most common in young boys, aged 4 to 8 years of age and is self-limiting in nature. It’s a diagnosis of exclusion rather than anything else made easier by the well-appearing, afebrile child. It should respond to simple NSAIDs though is recurrent in 20% of cases.

Dr. Sathya Subramaniam, Pediatric EM Fellow – Kings County/SUNY Downstate and The POCUS Atlas

According to Viera and Levy, bedside sonography has a sensitivity of 90% and specificity of 100% to detect an effusion. Unfortunately, it doesn’t help with determining the cause.

Occult trauma

It’s beyond the scope of this post to talk about NAI and long bone injuries in children (especially as Nikki Abela did such a great job at DFTB18) so instead, it’s worth thinking about toddlers’ fractures. These occur due to torsional force on the tibia, accompanied by a fall, and may only be picked up as tenderness over the distal third of the tibia. That first set of x-rays performed in the emergency room may not show any obvious pathology with signs only becoming obvious after a couple of weeks. This is one of those occasions where ultrasound may be much more helpful though if clinical suspicion remains it should be treated with immobilization and close follow-up. Repeat imaging may then show the beginnings of some callus formation or a radionuclide bone scan may be needed. If they are not toddling and waddling it is not going to be a toddler’s fracture.

 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 9317

Neuromuscular

Although unlikely to present as an isolated limp, cerebrovascular events may present as hemiparesis; It’s beyond the scope of this post to go into them in more detail. Watch this space.

 

Perthes disease

This is idiopathic avascular necrosis of the growing femoral head and typically presents in boys at the younger end of the scale (4 to 8 years old). Because of this, these children are often shorter than their peers and there is a possible association with hyperactivity. The classical findings on a plain AP x-ray of the pelvis include sclerosis leading to destruction and the eventual collapse and flattening of the femoral head.  As this is a biomechanical problem, they might present with a slow onset antalgic gait with pain on internal rotation and ABduction. Around 20% of cases are bilateral.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 7980

 

Both MRI and bone scan are equally sensitive if the plain films are equivocal. Treatment may be surgical or conservative depending on the degree of bone destruction and the age of the child. Left unchecked neovascularization occurs with the destruction of the femoral head.

Though first described in 1897, it was not until 1910 that it was found to be unrelated to tuberculosis. Arthur Legg, Jacques Calvé and Georg Perthes are guilty of its eponymous name.

Transient synovitis

I think we’ve said enough about transient synovitis already.

Neuromuscular

As well as a stroke a limp might be the initial feature of an ascending paralysis in Guillain-Barré. We’ll talk about that and ADEM another time.

 

Slipped Capital Femoral Epiphysis

A slipped capital femoral epiphysis or slipped upper femoral epiphysis is more common on older, overweight boys, over the age of 10 years of age. There is often a structural weakness of the physis itself so it is more common in cases of endocrine dysregulation (such as hypothyroidism) and metabolic conditions (such as renal osteodystrophy). The proximal epiphysis displaces anteriorly and laterally relative the metaphysis. Involvement of the medial obturator nerve may mean that they present as knee pain rather than hip pain. Early fixation and we mean in less than 24 hours in unstable cases, can ward off the threat of life-long pain and deformity. Plain AP films may not be enough in the case of subtle slippage. So if you are suspicious then you should go ahead and order a lateral film as well.  A lot of other hip pathology is made easier to spot in a frog-leg lateral. Don’t do this if you are suspicious of a SCFE, you might make things much, much worse.

Look for Klein’s line. A line along the superior aspect of the femoral neck should intercept with the epiphysis. Imagine it as an ice cream slipping off the cone on a hot summer day.

Adapted from case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 2715

Case courtesy of Dr. Hani Salam, Radiopaedia.org. From the case rID: 9298

 

 

Some things need to be in our differential no matter the age of the child.

Septic arthritis

The hip is the most commonly infected joint with the haemategenous spread of organisms grown dependent on the local flora. Young children (under the age of 2), those who are immunosuppressed or asplenic are at higher risk. In Australia, for instance, the commonest organisms grown are Staphylococcus aureus and Group B Streptococcus (especially now that Haemophilus influenzae b infections have been almost wiped out by immunization). In the youngest, patients consider the weirder organisms like Kingella kingae and Salmonella (in patients with sickle cell disease).

The juvenile physis does not prevent the spread from a remote source from entering the epiphysis and so haematogenous spread (rather than direct local invasion) is often the culprit. The hip is classically held in a position of external rotation, ABduction and, flexion, perhaps in an effort to maximize the joint space and minimize the pain.

It would be great if there was a way we could differentiate the serious diagnosis of septic arthritis from something less serious, such as transient synovitis. Step forward Meninder Kocher et al. and their seminal paper.

Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. JBJS. 1999 Dec 1;81(12):1662-70.

They looked at 17 years of data for patients that presented to a single tertiary hospital with an acutely irritable hip. This amounted to 282 cases in all of which only 168 had their hip joint aspirated.  Of this 168,  only 26 had true septic arthritis as confirmed by a positive culture of joint aspirate or 50,000 WCC in the aspirate with a positive culture, 9 had a positive joint culture and negative blood cultures and 3 had only positive blood cultures.  By performing a multivariate analysis they then looked for key indicators that differentiated cases of septic arthritis from the more benign irritable hip. Four key factors cropped up. They were a history of fever, inability to bear weight, a WBC greater than 12 x 109/l and an ESR ≥ 40mm/hr. If you had none of these then the probability of having septic arthritis is 0.1%. But if you have all four it jumps to 99.8%.

Of course, this is all the primary literature that most people read but when Kocher tried to validate the study having all four markers gave the chance of having septic arthritis as 93% and when Luhmann et al. tried to externally validate the criteria it dropped to 59%. Caird et al. must have realized that not many of us use ESR any more and so appended the more common C-reactive protein (CRP). Having all 5 gave a 97.5% positive predictive value though there were only 14 cases of transient synovitis, and 5 of septic arthritis.

 


 

Osteomyelitis

An indolent course and a non-specific physical examination make this a difficult diagnosis to pick up at first glance. Around 1.5-2% of all children presenting with an atraumatic limp will have osteomyelitis.  Plain films may be unremarkable early in the course of the illness and only show periosteal changes after a week to 10 days. An MRI scan is more sensitive and if the diagnosis is still a challenge then radionuclide scanning might pinpoint the infection. The hip is one of the more common joints affected (25%) followed by the tibia/fibula (25%) then the humerus (13%). Osteomyelitis and septic arthritis can coexist as infection from the bone spreads to the joint capsule.

 

One case series suggests that 40% of cases are due to transient synovitis, chronic muscle sprain or trauma accounted for 16% and no diagnosis was made in 30%. All those diagnoses we have to learn for exams are much less common (Perthes’ disease 2%, osteomyelitis 1.5%, toddlers’ fractures 1%, and SCFE 1%). What has not been mentioned, as the incidence is incredibly low is the thing that many parents worry about – cancer.

 

Malignancy

Whilst parents may not have heard of a slipped capital femoral epiphysis or Kocher’s criteria but they have heard of cancer and so we need to address it. Primary benign tumours (unicameral bone cysts, for example, as well as malignant ones can present as bony hip pain.  Hip pain can also be a presenting feature in haematological malignancies such as acute lymphoblastic leukaemia. The most common malignant bone tumours in infants are osteogenic sarcoma and Ewing’s sarcoma. Both of these are most common in the second decade of life.

Persistent pain, coupled with constitutional symptoms such as night sweats, weight loss and night pain are highly suspicious and should prompt imaging and blood tests.

 

 

 

Selected references

Please, Just STOP LIMPING from Tim Horeczko and the PEM Playbook

Septic arthritis from PEM Morsels

 

Adamson J, Waterfield T. Fifteen-minute consultation: The limping child. Archives of Disease in Childhood-Education and Practice. 2019 Jun 29:edpract-2018.

Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. JBJS. 2006 Jun 1;88(6):1251-7.

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. The Journal of bone and joint surgery. British volume. 1999 Nov;81(6):1029-34.

Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2001 Mar 1;9(2):89-98.

Herman MJ, Martinek M. The limping child. Pediatrics in review. 2015 May;36(5):184-95.

Hill D, Whiteside J. Limp in children: Differentiating benign from dire causes. Journal of Family Practice. 2011 Apr 1;60(4):193.

Hussain M, Gholipour B, Owen N. A pictorial review of the radiological presentations of the child presenting with an acute limp in the emergency department. Clinical Radiology. 2019 Oct 1;74:e14.

Kocher MS et al. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.

Leet AI, Skaggs DL. Evaluation of the acutely limping child. American Family Physician. 2000 Feb 15;61(4):1011-8.

Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. Journal of Clinical Ultrasound. 2006 May;34(4):190-4.

Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. Western Journal of Emergency Medicine. 2019 Mar;20(2):331.

McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009;9(Special issue A):S115.

Mooney III JF, Murphy RF. Septic arthritis of the pediatric hip: update on diagnosis and treatment. Current opinion in pediatrics. 2019 Feb 1;31(1):79-85.

Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ. 2010 Aug 20;341:c4250.

Ryan DD. Differentiating Transient Synovitis of the Hip from More Urgent Conditions. Pediatric annals. 2016 Jun 15;45(6):e209-13.

Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. American family physician. 2009 Feb 1;79(3):215.

Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. The Journal of bone and joint surgery. British volume. 2011 Nov;93(11):1556-61.

Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55(3) :284-9

Wainwright, AM; Catterall, A (2010). “Chapter 27: Legg–Calvé–Perthes disease: Its name”. In Benson, M; Fixsen, J; MacNicol, M; Parsch, K (eds.). Children’s orthopaedics and fractures (3rd ed.). London: Springer. p. 465