With millions upon millions of journal articles being published every year it is impossible to keep up. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.
| Topic | Wrist Examination and Pathology |
| Author | Segn Nedd |
| Duration | 2 hrs |
| Equipment required | Splints, soft bandages, plaster of paris sets |
Expectation is for the learners to have watched or read one of the basic anatomy/pathology links before the session
Anatomy and common injuries:
Examination:
Management:
(From TeachMeAnatomy and LITFL)
The wrist is a common place for injuries in children often occurring following a Fall Onto an OutStretched Hand (FOOSH). The wrist joint connects the hand to the forearm. It is made up of the radius and 8 carpal bones. Although commonly included, the ulna is not technically part of the wrist joint. The ulna articulates with the radius just proximal to the wrist at the radio-ulnar joint. It is separated from the carpal bones by a fibrocartilaginous ligament (articular disk). The wrist joint is a synovial joint. It therefore has a capsule. Its internal membrane secretes synovial fluid to lubricate the joint.
When describing injuries of the wrist (and hand) for documentation or referral purposes it is important to know the terminology widely in use in order to convey an accurate description to others. Injuries present on the palmar surface would be described as Palmar or Volar. Injuries on the back of the hand are dorsal. The proximal part of the wrist is more towards the forearm, whereas the distal end is towards the fingers. The thumb lies on the radial side and the little is the ulnar side.
Anatomy: (from Radiopedia, NYSORA & teachme anatomy)
In order to understand what you are examining and the associated pathologies that need to be considered it is important to have knowledge of the underlying structures that form the wrist. The wrist and hand have a complex anatomy with bony structures surrounded by a matrix of soft tissues including, muscles, tendons and ligaments. It additionally has an intricate blood and nerve supply. We will focus on the structures most important when assessing paediatric wrists in the emergency department.
Bones:
The radius is on the side of the thumb, the ulna on the side of the little finger. A good mnemonic to remember the position of the carpal bones is to describe them starting from the base layer thumb to little finger, followed by the top layer little finger to thumb.
So Long To Pinky, Here Comes The Thumb
Scaphoid, Lunate, Triquestrum, Pisiform, Hamate, Capitate, Trapezoid, Trapezium
Ligaments: (from Radiopedia)
There are multiple ligaments of the wrist. These play a vital role in the stability of the wrist joint. They are specifically important in holding the carpal bones together. Those most clinically important in wrist joint stability are labelled as above. Ligaments of the wrist are not visible on X-ray and to be fully examined are best assessed with a dedicated wrist MRI. However, increases in the spacing between bones on plain X-rays can indicate a ligament injury with clinical correlation.
The Nervous System: (from NYSORA)
The ulnar, median, and radial nerves innervate the hand. The course of these nerves traverse the wrist. They therefore have the potential to be damaged following wrist injuries. The median, anterior interosseous nerve (a branch of the median) and the ulnar nerve specifically although rare can be compromised following wrist fractures. The nerves of the wrist and hand also have an important role in functionality of the wrist (and hand). The radial nerve facilitates extension of the wrist and metacarpophalangeal joints. The ulnar nerve facilitates movement of the small muscles of the hand. The median nerve supports finger extension and anterior interosseous branch enables thumb flexion at the interphalangeal joint and flexion of the index finger at the distal interphalangeal joint.
The corresponding dermatomal innervation of the wrist and hand is illustrated below.
Vasculature: (from teachmeanatomy)
Arising from bifurcations of the brachial artery in the cubital fossa are the radial and ulnar arteries (and their branches) to supply blood to the forearm, wrist and hand. These two arteries merge in the hand forming the superficial palmar and the deep palmar arch. The radial artery supplies the posterolateral aspect of the forearm and is important in contributing to the blood supply of the carpal bones. The ulnar artery supplies the anteromedial aspect of the forearm. It mostly supplies blood to the elbow joint, but its branches do however help supply some of the deeper structures in the forearm.
Examination: From Geeky Medics
The look, feel, move & function approach is generally used to examine the hand and wrist. Always offer analgesia prior to your examination of a child with an injury.
As functions involve both areas they are often examined together
| Look | |
| 1 | Perform general inspection |
| 2 | Inspect the dorsum of the hands |
| 3 | Inspect the palms of the hands and elbow |
Careful note should be taken to ensure that full inspection is undertaken. This may identify any bruising, overlying skin changes, swelling or deformity. Remember also to always examine the joint above and the joint below.
| Feel | |
| 1 | Asses and compare temperature of wrist and small joints of hand |
| 2 | Palpate radial and ulnar pulse & check capillary refill |
| 3 | Palpate thenar and hypothenar eminence |
| 4 | Asses median nerve sensation |
| 5 | Asses ulnar nerve sensation |
| 6 | Asses radial nerve sensation |
| 7 | Perform MCP squeeze |
| 8 | Bimanually palpate hand and finger joints |
| 9 | Palpate anatomical snuff box |
| 10 | Bimanually palpate the wrist joints |
It is important not to miss any neurovascular compromise when examining the wrist and hand. Findings to suggest compromise may include colour change, coolness to touch, prolonged capillary refill time and altered sensation.
| Move | |
| 1 | Assess finger extension |
| 2 | Assess finger flexion |
| 3 | Assess active wrist extension |
| 4 | Assess active wrist flexion |
| 5 | Assess wrist/finger extension against resistance (radial nerve) |
| 6 | Assess index finger ABduction against resistance (ulnar nerve) |
| 7 | Assess thumb ABduction against resistance median nerve) |
Where possible movements should be actively undertaken by the patient. Take notice of any movements that are undertaken with difficulty or cause pain in undertaking.
| Function | |
| 1 | Assess power grip |
| 2 | Assess pincer grip |
| 3 | Assess picking up small objects |
| 4 | Supination and pronation- twisting key movement or ‘turning the key’ |
An 8 year old boy is brought to ED with his father. He had been outside roller-skating but fell over onto the concrete patio within the last hour. He is complaining of pain in his wrist and has difficulty moving it. An x-ray was done following triage: and it’s a buckle fracture
What would be your approach to examining his injury?
What type of fracture do you suspect and how would you differentiate on x-ray?
What type of immobilisation would you use?
What would be your approach to examining this injury?
Historic studies have shown that radial tenderness, focal swelling, or an abnormal supination/pronation were the clinical signs most often associated with correctly identifying children who had wrist fractures. In 2016, in a multicenter study by Slaar et al. a clinical decision tool known as the Amsterdam paediatric wrist rules was created for use in children presenting with wrist trauma to determine clinically whether a radiograph was required or not.
The prediction model had high sensitivity and moderate specificity of 95.9% and 37.3%, respectively. It was calculated that through using this model there would be a 22% absolute reduction of radiographic examinations. Although not perfect, the use of the paediatric Amsterdam wrist rules may therefore be a useful aide memoir in facilitating clinicians to rationalise which children who present with wrist trauma to x-ray.
The clinical prediction model used eight variables to analyse those at risk of any wrist fracture. These were increasing age; sex (if male), swelling of the wrist; swelling of the anatomical snuffbox; visible deformation; distal radius tenderness on palpation; pain on radial deviation and painful axial compression of the thumb. The more of these factors that were present resulted in the increased probability of a fracture. Painful axial compression of the thumb however decreased the probability of a fracture.
This study also further analysed those with distal radius fractures. Children with increasing age, swelling of the wrist, visible deformation, distal radius tender to palpation, pain on palmar flexion, pain on supination and or painful radioulnar ballottement test were more likely to have distal radius fractures. However, pain on ulnar deviation was found to decrease the likelihood of a distal radial fracture.
Always ensure adequate analgesia is given when first assessing an injury. Ensure that the examination is systematic. It is best to use the look, feel, move, function process when examining the wrist. As with any orthopaedic examination however it is always important to also assess and assess the join above and below the affected area.
Look – for any deformity, swelling, bruising, colour change or overlying lacerations
Feel – assess for radial tenderness, remember to assess for any signs of neurovascular compromise and check sensation in the forearm and hand. Neurovascular compromise is rare in distal radius fractures but can occur in greenstick fractures.
Move – making tasks quick and easy to reproduce will assist in making identification of pathologies easier when assessing children. A combination of movements described by Dawson can be used to assess motor and neurological function in the hand and wrist. This can be done by starting a game of rock, paper, scissors. The addition of the O.K sign and also encouraging pronation and supination by “turning the key”, turning the door handle” or “turning the lightbulb” will allow easy testing of wrist and hand movement and functionality
What type of fracture do you suspect?
Types of distal radius and ulna fractures
(from DFTB and Radiopaedia)
Buckle fractures are common in children especially in the 5-10 year old age range. Following a fall (often onto an outstretched hand) the force is transmitted from the carpus to the distal radius and as this is the point of least resistance fractures occur. Fractures are also often around the dorsal cortex of distal radius.
Greenstick fractures are incomplete fractures of the long bones in children. They are usually only seen in those under 10 years of age. The integrity of the bone cortex is breached on the convex side. The concave surface remains intact. It resembles the break that occurs when a young green branch of a tree is bent and breaks incompletely. One side snaps whilst the other side is still intact.
Buckle/torus and greenstick fractures are often discussed together as they have similarities; they are unique to children due to their softer compressible bones. However they also have clear differences.
Buckle/torus fractures:
Greenstick fractures:
More difficult to recognise distal radius fracture features on lateral wrist x-rays include:
What is the normal volar tilt of the radial articular surface?
In a lateral view of the distal forearm
The distal radius, the lunate and the capitate articulate with each other and lie in a straight line, like an apple in a cup sitting on a saucer.
The radius holds the lunate (cup) and the cup contains the capitate (apple)
The articular surface of the radius has a palmar tilt and is usually about 10 degrees with a normal range of 10-25 degrees
What type of immobilisation would you use?
Controversies in management:
Rest, support and analgesia are the mainstay of treatment for buckle fractures. Buckle fractures often heal well without complication. There is however much variance in how these are treated in different departments. Removable splints are widely used for up to 3 weeks in children old enough to keep them on (hard casts may be required in younger children). There is however uncertainty as to whether immobilisation is actually really needed or if early mobilisation to reduce stiffness is preferable. The FOrearm fracture Recovery in Children Evaluation (FORCE) Study is currently in its final stages. It will evaluate outcomes (pain, functional improvement and complications) between encouragement of use of the wrist, an optional bandage, and a point of contact for any ongoing concern versus hard splints use and local hospital outpatient fracture follow up (https://force.octru.ox.ac.uk/).
Buckle fractures often heal well with minimal complication. There is however a risk of refracture. General advice includes avoidance of sports for three to six weeks and contact sports for 6 weeks post injury. You should also refer to your local guideline on the management of buckle fractures.
A 12 year old girl is brought to ED with her mother. She was jumping on her trampoline but fell out. She had immediate pain and has not been able to use her left hand since. Her mum gave her some paracetamol and ibuprofen prior to arrival. An x-ray was then done and is as follows:
What does this fracture show?
How would you further classify this type of fracture?
How would you manage these fractures?
Mum asks you if she should let her 6 year old daughter use the trampoline. What is your advice?
What does this fracture show?
(from Royal Children’s Hospital Melbourne)
In contrast to adult bones, children’s bones are still developing. They have cartilaginous discs which separate the epiphysis from the metaphysis of long bone. This area is called the growth plate (physis). Physeal injuries are very common in children and can account for up to 15-30% of all bony injuries. Physeal injuries occur most commonly in the pre-adolescent growth spurt age.
Physeal fractures are classified by the Salter-Harris classification. A Type II fracture is the most common type. Distal radial physeal fractures are uncommon in children younger than five years. The most common mechanism of injury is a fall on an outstretched hand. Extension of the wrist at the time of injury causes the distal fragment to be displaced dorsally (posteriorly). Commonly this also causes an associated ulna fracture (greenstick, physeal or styloid).
Always give appropriate analgesia prior to assessment and x-ray. Ensure both AP and lateral views are undertaken of the wrist AND distal forearm.
How would you classify it?
See the Salter-Harris Classification below;
How would you manage this?
(from Royal Children’s Hospital Melbourne & First10EM)
Type II is the commonest type of Salter-harris fracture and accounts for around 75% of physeal fractures. Reduction is required for distal radial physeal fractures that are angulated >20 degrees. Salter-Harris type I and II injuries rarely cause growth problems. The risk of growth arrest is higher in type III-V injuries. The risk of physeal arrest is rare in young children but the risk is higher if the child is near the end of growth. It is therefore increasingly important to correct any angulation in adolescents especially where there is less than two years of growth remaining.
For type I and II injuries, closed reduction may be required. A fracture clinic review is required within five days with x-ray. RICE advice and instruction to monitor for any swelling should be given. This as there is a risk of early compartment syndrome due to restriction by the cast.
Urgent orthopaedic review is required when there is an open fracture, a fracture is associated with neurovascular compromise (most notably in the median nerve distribution), any Salter-Harris type III and IV (lower or through) fracture is seen. Additionally referral should be made when there is an associated fracture in the same upper limb or if there is any difficulty achieving acceptable reduction. This should only be attempted with adequate supervision or clinical competence. However, for children presenting with distal radial physeal fractures after 5 days since the injury closed reduction should not be attempted and specialist input from the appropriate orthopaedic team must be arranged.
After any reduction or immobilisation of a fracture, repeat x-rays should be undertaken.
Are trampolines ok?
(from RSPA and GPPaedsTips)
Trampolines are thoroughly enjoyed by children of all ages. Especially in current times many families have invested in trampolines for their gardens. However injuries sustained whilst playing on trampolines contribute greatly to injury presentations in the children’s emergency departments. There are however steps that can be taken to try and minimise the chances of injuries occurring. The first advice would be that children should take turns to bounce. 60% of injuries have been found to have occurred when more than one person is on the trampoline. Often it is the smallest (lightest) person who is (five times) more likely to be injured. If they are not alone they should be of similar age and size.
The Royal Society for the Prevention of Accidents suggests that Trampolining is only suitable for children over six years of age when they can are sufficiently developed to control their bouncing. Adult supervision cannot prevent all injuries but may prevent children engaging in dangerous practices. Additionally having some formal training such as joining a local trampolining club to learn new skills will help children who are keen to learn how to attempt advanced trampolining skills and tricks safely.
A 14 year old boy was skateboarding and dismounted, landing on his outstretched hand. He had significant pain in his wrist around the distal radius. Following analgesia in the emergency department an x-ray was undertaken. No fracture was identified and he was reassured that he had sustained a soft tissue injury. He was discharged with RICE advice.
Four weeks later he is still in pain – the original x-ray is re-reviewed – a scaphoid fracture is seen.
What are thoughts surrounding soft tissue injuries in children and how should they be defined and managed ?
Are there any other pathologies you should consider when x-rays appear normal
How do we decide between a soft tissue injury and suspicion of a scaphoid injury?
Many times when there are no overt fractures on an x-ray we conclude that the patient has a “soft tissue” injury or sprain. A scaphoid series (not wrist views) should be requested when there is ‘snuffbox tenderness’. Even when bony pathology cannot be identified on X-rays it is important to consider that the muscles, ligaments and tendons of the wrist, if damaged, can have a significant impact on a child’s ability to undertake daily activities, especially if the injury is to their dominant hand. As with any injury presenting to the emergency department pain should always be assessed and managed. Fractures through the waist (middle) of the scaphoid jeopardise the blood supply of the proximal fragment. If the patient is managed incorrectly then non-union, delayed union or avascular necrosis of the proximal fragment may result.
Elvey et al. conducted a single centre study of MRI studies of children who had presented in the two weeks prior with wrist injuries. X-rays undertaken at the time had not identified any fracture. Although a small study of 57 cases, over 75% of cases had a positive finding on MRI. There were no cases at all of isolated soft-tissue injury. Occult fractures and bony contusions (focal oedema and haemorrhages which occur following microfracture) accounted collectively for almost 70% of the pathologies seen on MRIs in these children. Following MRI almost ⅓ of cases required additional further management changes. This study raised questions about the best modality and timing of imaging in children presenting with wrist pain following an injury. Fracture lines may not be apparent in children on initial X-rays and may only become visible weeks later following callus formation. Alternative imaging options considered have included ultrasound, CT and nuclear medicine scintigraphy. The cost-effectiveness, time constraints, risk-benefit analysis of radiation exposure and operator feasibility in the emergency setting is however difficult to justify. Additionally, some of these modalities have excellent sensitivity, but low specificity and operator-dependency.
It is important to remember that even when no injury is seen on X-ray wrist injuries often classified as sprains can have clinical sequelae. At 5–6 weeks in the Elvey et al. study children who had had occult cortical fractures typically had resolution of their pain. However, those who had bone contusions typically had continued pain on palpation.
What other pathology should we consider with a normal x-ray?
Carpal instability injuries: (From LITFL)
Some non-fracture pathologies are visible on x-ray but sometimes missed. Scapholunate injuries include scapholunate dissociation which is caused by damage of the ligament between the scaphoid and lunate bones. It is very uncommon in children but may occur in adolescent age groups. These will often be very painful.
The carpal bones on a normal plain X-ray are evenly spaced. Where there is a scapholunate dissociation there will be a large gap (>3mm) between scaphoid and lunate bones. This is also known as the Terry Thomas sign (named after a famed comedian who had a large gap between his two front teeth).
Other ligament bands may tear between carpal bones causing carpal instability. These can lead to the following 4 stages of pathology; perilunate dislocation, perilunate dislocation with triquetrum dislocation and lunate dislocation. Injuries of these ligaments can cause long term damage including chronic pain and arthritis. PA views with help with Terry Thomas sign. Lateral views are most useful in helping to identify any misalignment and potential dislocation of the other carpal bones (mostly lunate and perilunate dislocations).
A lunate dislocation can be a devastating injury. There is loss of articulation between the lunate and radial head and lunate and capitate. This injury would be excruciatingly painful. However most importantly there is also a high risk of median nerve damage as the dislocated lunate bone causes pressure on the median nerve which would usually run freely through the carpal tunnel. This can cause an acute carpal tunnel syndrome. Due to pain it should be hard to miss but needs urgent management.
How to manage scaphoid injuries
Scaphoid fractures (from LITFL and pedemmorsels)
A scaphoid fracture is uncommon in 4-11 year olds as ossification centres appear to be protective against scaphoid fractures. However, the scaphoid bone is the most easily broken carpal bone and is easily broken in the adolescent age group. The fracture occurs via transference of force onto the scaphoid following FOOSH where the wrist deviates radially during impact. It is a more common injury following extreme sports. Where a scaphoid fracture has occured X-ray a lucency will be apparent running through the scaphoid bone.
The scaphoid is positioned beneath the anatomical snuff box. On examination it is important to check for pain here.Tenderness of the Scaphoid Tubercle (on the volar aspect), pain with radial deviation, pain on axial loading to the thumb and pain with active wrist range of motion may also point to this diagnosis. It is important not to miss scaphoid fractures. The reason being is that the scaphoid bone is at high risk of non union and avascular necrosis if fractured and left untreated.
Although simplistic to attribute all blood supply to the scaphoid from the radial artery a fracture especially at the distal end of the scaphoid has been associated with compromise in the blood supply to the rest of the scaphoid. Complications of missed scaphoid fractures can be bone growth arrest and chronic pain.
Controversy is however present as to whether surgical treatment is preferential to conservative management. A recent systematic review of randomised controlled trials surrounding this question in 2018 by Al-Ajmi et al suggested that surgical management of minimally or non-displaced scaphoid fractures resulted in better functional outcomes than conservative management. However, the findings were not significantly strong enough to make concrete conclusions. It is however generally accepted that scaphoid fractures which are unstable due to being at the proximal pole, having displacement > 1 mm, those with associated carpal bone dislocation and those with significant angulation or clinical deformity will need referral to orthopaedics and surgical intervention.
Scaphoid fractures in children are generally believed to heal well. Casting of non-displaced, acute fractures leads to high rates of scaphoid union. Where there is clinical suspicion of a scaphoid fracture but uncertain or negative x-ray findings generally early immobilisation is initiated by application of a thumb spica splint or cast with follow-up imaging 2 weeks later. Casting may however need to be applied for 3 months or more. The videos on thumb splints and hard cast spica’s from Don’t Forget the Bubbles and Orthofilms can be used for demonstration and to assist in practical sessions. (Please see the simulation section for full details).
Conversely Porter et al suggested that symptomatic treatment is sufficient with those who have normal x-rays. This paper advocated using a removable splint with follow-up only arranged if symptoms do not improve. This was however a single centre study and advocated for a larger multicentered prospective clinical trial on this matter.
If in doubt and there is high clinical suspicion of a scaphoid fracture it is not unreasonable to consider application of a thumb spica cast with a plan to bring back the child for review in 2 weeks.
A 13 year old girl is brought to ED following a fall from a tree she has significant pain, swelling and deformity of the distal shaft of the radius. Analgesia is given and she is taken to x-ray:
Case courtesy of Radswiki, Radiopaedia.org. From the case rID: 12221
What type of fracture has occurred?
How would you manage this fracture?
What type of fracture is this?
(from the Royal Children’s Hospital Melbourne)
Distal radius fractures can be classified according to:
How should this be managed?
From RCH Clinical Guidelines: distal radius fractures
With complete fractures generally if there is clear deformity on examination, reduction is likely to be indicated. Acceptable angulations of the distal radius fracture are dependent on the age of the child. Coronal plane angulation (seen on AP view) has a poorer prognosis as it does not remodel as well as angulation in the sagittal plane (seen on lateral views).
As a rule of thumb, if the deformity is clinically visible, reduction (non-operative or operative) may be indicated. Acceptable angulations are dependent on the age of the child.
In the 0 – 5 year age group, an acceptable angulation for a distal radius metaphyseal fracture is < 20 degrees.
Acceptable angulations in the 5 – 10 year old group is < 15 degrees.
Acceptable angulations in the 10 – 15 year old group is < 10 degrees.
Where no reduction is required for a complete distal radius fracture a below elbow plaster of paris back slab should be applied, fracture clinic follow-up arranged within a week and a cast may be required for up to 6 weeks.
Those needing closed reduction may be able to be undertaken in the emergency department using local anesthetic or procedural sedation. However this should only be attempted with adequate supervision or clinical competence. These children will also need a hard cast applied but with extra moulding in the opposite direction to any angulation.
Following any reduction of a fracture X-rays should be taken. Angles of the fracture should be within the same parameters for acceptable angulation. An orthopaedics referral should be made for any child presenting with an open fracture, signs of neurovascular compromise or if there is over 10 degrees of angulation of the fractured segments. In children where there has been difficulty in reduction (be that due to ED team inexperience or difficulty in procedure) and those with an associated fracture in the same or opposite limb an orthopaedics referral must also be made.
What is a Galeazzi fracture-dislocation?
A Galeazzi fracture-dislocation is one such instance where an urgent orthopaedic team referral should be made. Galeazzi fracture-dislocations are often missed and may be difficult to recognise. It is however really important that a Galeazzi fracture is identified as it must be repositioned prior to casting. If there is an isolated radius fracture, always examine the distal radioulnar joint (also known as DRUJ) on x-ray.
A Galeazzi fracture-dislocation is a fracture of the distal third of the shaft of the radius with a disruption to the DRUJ. This by ulnar displacement which can occur in the volar or dorsal direction. True Galeazzi fractures are very uncommon in children but can occur after a FOOSH with forearm rotation. However, the Galeazzi equivalent is more common and is when there is a distal radius fracture with an associated distal ulna physeal fracture. There is however no disruption of the DRUJ.
Most Galeazzi-equivalent fractures can often be managed with closed reduction in children. However, in some adolescents especially where there is a true Galeazzi fracture-dislocation then open or percutaneous fixation to stabilise the distal radioulnar joint after reduction may be required. Children with Galeazzi-type fractures should be placed in an above elbow cast following any manipulation.
The majority of these fractures will do well. However outcomes can be poor if there is a delay in diagnosis and or the fracture of radius has been immobilised without correct alignment of the ulnar dislocation or inadequate support such as a below-elbow cast. Nerve injury is uncommon but there have been some case reports of ulnar nerve injury. Neurovascular status must therefore be carefully examined and assessed. This however does usually resolve with observation.
Depending on the experience of the learners in your group please choose and adapt the following practical elements
Question 1
Which of the following is false?
A: A buckle fracture occurs due to longitudinal force along long bone
B: Greenstick fractures do not have any breach in the bone cortex
C: A buckle fracture will have an intact cortex
D: A torus fracture is always circumferential
Answer 1
B: Greenstick
Greenstick, torus and buckle fractures occur due to longitudinal forces exerted along a long bone. Whilst generally used interchangeably with a buckle fractur, a torus fracture actually involves both sides of the bone whereas a buckle fracture generally involves on side. What differentiates a torus or buckle fracture from a greenstick fracture is that there is a breech in the cortex of the bone in greenstick fractures. The cortex itself remains intact in buckle and torus fractures.
Question 2
Which nerve is most likely to be affected by a lunate dislocation?
A: Radial nerve
B: Ulnar nerve
C: Median nerve
D: All of the above
Answer 2
Answer C
The ulnar, median, and radial nerves innervate the hand. The course of these nerves all traverse the wrist. They therefore have the potential to be damaged following wrist injuries. It is important to assess neurovascular status in wrist and hand injuries. However, the median nerve runs through the middle of the palmar side of the hand through the carpal tunnel. This can cause an acute carpal tunnel syndrome. Radial nerve damage may be associated with supracondylar and humeral shaft fractures, whilst Ulnar nerve damage although rare may be seen supracondylar and Galeazzi-type fractures.
Question 3
Which statement is true?
A: A Galeazzi fracture-dislocation is one in which the radius is fractured and also dislocated from the radioulnar joint.
B: Scaphoid fractures always require surgical intervention
C: The ulnar nerve may be affected following a Galeazzi fracture-dislocation
D: Bayonet apposition is when the two portions of a fracture are aligned end to end with some angulation
Answer 3
Answer C
A Galeazzi fracture-dislocation is where the distal third of the shaft of the radius is fractured. There is also a disruption to the distal radioulnar joint. The ulna (not radius) bone is displaced. This can occur in the volar or dorsal direction. The Galeazzi equivalent fracture-dislocation is more common and is when there is a distal radius fracture with an associated distal ulna physeal fracture. The ulnar nerve may be affected in a Galeazzi fracture dislocation as it is entrapped by the ulna displacement. Bayonet apposition is a terminology used to describe fractured bone portions which are aligned side by side and not end to end. Depending on the patient’s age and degree of angulation it may be acceptable to leave a fracture in the Bayonet position to heal. Scaphoid fractures may be managed conservatively, however unstable fractures (due to being at the proximal pole, those having displacement >1mm, those with associated carpal bone dislocation and those with significant angulation or clinical deformity will need referral to orthopaedics and are more likely to need surgical intervention.
| Topic | Cervical spine injury |
| Author | Ronán Murphy |
| Duration | Up to 2 hours |
| Equipment required | Computer with projector for imaging |
Blog posts:
Expectation is for the learners to have read some of these links before the session.
pedemmorsels.com/pediatric-cervical-spine-injury/
pedemmorsels.com/airbag-injury-and-children/https://pedemmorsels.com/airbag-injury-and-children/
EMS – Emergency Medical Services
CSI – Cervical Spine Injury
SCIWORA – Spinal cord injury without radiological abnormality
XR – X-radiography
ED – Emergency Department
NEXUS – National Emergency X-radiography utilization study
PECARN – Paediatric Emergency Care Applied Research Network
GCS – Glasgow Coma Scale
MILS – Manual in line stabilization
MVC – Motor Vehicle Collision
ATV – All terrain vehicles
NPV – Negative Predictive Value
PEM – Paediatric Emergency Medicine
TBI – Traumatic Brain Injury
NICE – National Institute for Health and Care Excellence, United Kingdom
MRI- Magnetic Resonance Imaging
The incidence of cervical spine injury is low and represents only 1-2% of all paediatric major trauma (1).
The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column (2-4). Other features also make it susceptible to injury: ligamentous laxity, incompletely ossified vertebrae and more horizontally orientated facet joints (5).
The incidence of ligamentous injury is thought to be higher in younger, non-communicative children under 3 years of age (6).
The precise location of injury in the cervical spine can be variable across the age range (7-9).
Four injury patterns are common in children with cervical spine trauma:
Dislocations or subluxations are more common in upper cervical spine injuries and associated with greater morbidity (9). To compare with adults, children are over twice as likely to suffer atlanto-axial injury (8).
Weaker musculature and underdeveloped interlocking bony processes contribute to the subluxation/dislocation and SCIWORA (spinal cord injury without radiological abnormality) type injury patterns we see in children (10). SCIWORA refers to CT and plain film. A lesion may be detected on MRI.
SCIWORA is the presence of myelopathy as a result of trauma with no evidence of fracture or ligamentous instability on imaging. The mechanism relates to the flexibility of the paediatric spine being greater than that of the spinal cord which becomes damaged as it is stretched beyond its limits. Neurological signs or symptoms even if transient must be elicited in the history to make this diagnosis (2).
Manage the cases below as you would in your own setting using local guidelines and procedures to make this whole exercise as realistic as possible and also to stimulate further analysis and discussion.
A 13 year old boy arrives in your ED. He came off his bicycle at speed whilst engaged in a downhill mountain racing contest. He was wearing a helmet and protective clothing but hit his head against a tree as he landed. He did not lose consciousness. He describes immediate onset neck pain which now persists. Volunteer ambulance services were supervising the event and treated his pain with paracetamol and ibuprofen whilst preparing him for transfer in full spinal precautions. He is brought into your ED strapped to a spinal stretcher with a hard cervical collar in place as well as head blocks and tape. On handover it is noted that he felt a weird sensation in his right arm at the time of the event which lasted perhaps 3-5 mins and has not returned. The crew found his neck to be diffusely tender on examination.
What features in history and on examination are we concerned about regarding the potential for cervical spine injury?
How do we take handover of these patients and protect them whilst we work up their injury?
Predisposing vulnerability to bony or ligamentous failure: Down Syndrome(T21), Rheumatoid Arthritis, Rickets, Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Marfans Syndrome, Renal osteodystrophy, Klippel Feil disease, Morquio Syndrome, Grisel syndrome.
A high risk MVC is one of the following: Head on collision, rollover, patient ejected from the vehicle, death of another passenger occurred, speed of collision over 88kph (55mph).
Distracting injury is vaguely defined by NEXUS to include burns and long bone fractures etc. It can be refined to mean any substantial injury of the upper torso due to proximity to the cervical spine (14).
As described above (11), the Viccelilo study (2001) looked at the performance of NEXUS in the paediatric subgroup. In 2017 however, Cochrane (2017) found there was conflicting evidence to support use of NEXUS in children and called for additional well designed studies with larger sample sizes to better evaluate this population (15).
Some points to consider regarding immobilization:
Where a cervical spine injury is suspected, appropriate immobilization must be achieved.
Ask the co-operative child to lie still. Apply gentle manual in line stabilisation (MILS) and give lots of encouragement (age appropriate) to minimise movement. The neck should reside neutrally or in a position of comfort for the child. Bear in mind that babies may require a pad or similar thoracic elevation device laid onto the trauma mattress to elevate the torso and preserve neutral alignment of spine due to their relatively larger heads. This will prevent any forced flexion occurring.
While providing MILS and reassurance, we must address pain as a matter of urgency. Immobilisation may increase leverage on the neck in a sore and struggling child. Once deemed safe to do so (and rapport has been established where applicable), radiolucent blocks and straps can be applied to free up that team member from the task of MILS. As well as helping limit movement, blocks also serve as a communication tool / visual reminder to the team that we are worried about this spine and to handle with care.
Transfer: If coming in by EMS, transfer using scoop from ambulance mattress to radiolucent ED trauma mattress. During transferring manoeuvres, the team leader should ensure that the minimal number of movements and gentle max 30 degree tilts are all that’s needed to get them on and off a scoop stretcher. The leader should also ensure that all team members understand their role and are given adequate prompts prior to any movements being performed “ready, steady, move”. Use the opportunity allowed by tilting to complete your standard assessment of the spine (and the patients back for other injuries or relevant findings). Document appropriately. Sometimes children 6 years old and above (not possible to put on below this age) may come in via EMS wearing cervical collars. These are removed to assess the cervical spine in ED while MILS is being applied and hard collars should not be placed back on as they can have a number of negative effects, particularly with prolonged use (16).Two piece collars are different and are often recommended by spinal specialists as a treatment modality for stable fractures or as a bridge to definitive management.
A 10 month old girl who was a back seat occupant in a rearward facing baby seat is involved in a head on RTC at 30kph (18mph). The incident occurred in a housing estate. She presents with her Mother who was the restrained driver for review at a mixed Adult and Paediatric ED. You have already assessed and cleared Mum from any serious injury. You now examine her baby who is crawling away from you on the bed saying “mama”.
Discuss how we need to adapt our assessment to suit younger children.
Are we worried about this baby and do we want imaging?
Outside of the factors looked at in the large studies, are there any other items which we should consider important in history and on physical examination for all children?
The studies we have looked at so far don’t have many children under the age of three years old. We will now explore some which do:
Expert Consensus on factors which are suspicious for CSI (18-21):
Suspicions of CSI in the history:
Suspcions of CSI in the examination
Where the child does not have any concerning features on history or examination, we can look at some low risk factors which offer us some reassurance:
Low risk factors identified by NICE (ref 20)
In the awake and alert patient with no neurological signs or symptoms who has neck pain or unspecified neck tenderness, NICE Clinical Guideline 176 permits the search for any one low risk factor from the above list.
If one is found, further clinical assessment of the neck, beyond the initial assessment and palpation is performed.
This comprises asking the patient to perform 45 degree bilateral active neck rotations. If this is tolerated the cervical spine can be cleared clinically. If not, the patient gets imaged.
Further learning points
Persistent neck pain/tenderness in the posterior midline with normal clinical examination otherwise and normal conventional radiographs requires further evaluation. The same applies even if the patient presents sub acutely (18). This will vary between institutions but may take the form of a referral to the orthopaedic or spinal service followed by MRI or CT.
Beware the “trivial” injury, especially in younger children. Correlate history with clinical examination. Remember these patients can be more difficult to assess and there exists limited evidence to guide their management. There are cases in children 9 months to 6 years of falls less than 5ft, out of bed, down steps, running, somersaulting which have led to C1-2 subluxations, rotatory subluxation, C2 pedicle fractures, odontoid fractures and neural arch C2 fractures. Examination findings were torticollis, neck pain, limited range of motion neck, refusal to move neck any one or combination of the above on exam but never just neck pain (22).
Beware also of markings on the child’s body from seatbelts or other age appropriate restraint systems. These may indicate extreme flexion of the cervical spine has occurred especially in head on collision (23).
As always, consider the potential for non-accidental injury in your differential.
Involve a senior early in the assessment and management of all suspected cervical spine injury children.
Interpretation of imaging (where it is necessary) and patient reassessment:
As we have discussed above, plain films are the main imaging tool used to assess the cervical spine in the ED. These must be interpreted by a senior physician due to the inherent challenges involved.
If imaging is adequate and shows no abnormality in an alert and cooperative patient (or if imaging was not required in the absence of concerning features), reassess for resolution of neck pain post analgesia. Check 45 degrees of neck rotation either side of the midline. If normal, ask if you are satisfied that there isn’t any persisting clinical concern. If they examine well and there is no residual concern, many institutions and the NICE guidelines declare that the spine is now clear. This final clearance step should always be performed with a senior present.
An 11 year old boy is involved in a single vehicle RTA as a front seat passenger restrained in a booster seat. The vehicle slid at 120kph (75mph) and spun out of control demolishing a fence at the side of the dual carriageway and impacting a treeline before being propelled back onto the road. There is extensive damage to the four door saloon and all airbags deployed. The boy’s father was driving at the time and they self extricated by kicking out a front door which was slightly wedged by the distorted frame. They stood by the side of the road awaiting help to arrive. The father states he is fine apart from a few scrapes from broken glass and declines further assessment by Paramedics. The son complains that he now notices neck pain on moving his head backward and forward. EMS reviewed and decided to treat him with full spinal precautions. He arrives in your ED and is assessed as having no evidence of bruising or deformity of the neck and no midline bony tenderness. He has a normal neurological examination. His neck pain is persistent despite ibuprofen and paracetamol given by EMS en route. He is reluctant to move it much.
Do you want to image this child and if so, what imaging do you want to perform?
X-rays
The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous (24).
To obtain the optimal sensitivity from plain film we need two or more views. The odontoid view is technically difficult to obtain in children less than 5 years old and may not yield much diagnostic information which can’t be obtained on antero-posterior and lateral.
Many paediatric radiologists do not routinely obtain odontoid views in children younger than 5 years and many more stop after the first attempt is unsuccessful. The fracture that can only be assessed on the odontoid view is the Jefferson fracture (an eponym for a burst fracture of C1) and this occurs with axial loading mechanisms (uncommon below this age). Usually there is an associated head injury which would require neuroimaging (including upper cervical spine in CT) (25).
In infants and young children, fractures of the dens tend to involve the subdental synchondrosis (naturally weak area of C2), from flexion mechanisms. The resulting anterior tilt of the dens is normally visible on lateral views.
Adopting a pragmatic approach based on the child’s age and clinical status allowing them to obey commands and open their mouth is the best course of action (26). Safety is paramount and this view can be dangerous as some movement is required of the patient (10).
It is common practice now to minimize the exposure of children, parents and staff to radiation. The neck is a radiosensitive anatomical area and the thyroid gland receives a 100-200 fold higher radiation dose with CT than with the standard three view plain film series. This extrapolates to a 2x higher mean excess risk of thyroid cancer for patients 0-4years (27).
To help put that into perspective, in the Republic of Ireland the incidence of thyroid cancer is 3.61/100,000 at baseline (28).
Ionizing radiation imparts a small but real risk of malignancy at the population level. This impact is greater on paediatric patients (29).
CT
It takes time and a greater degree of patient cooperation to obtain plain films. As explored above, plain films can have lower sensitivity than CT so require a reliable history and physical examination to back them up as a diagnostic tool. CT has a superior ability to detect critical paediatric cervical spine injury in higher risk trauma patients because it provides more anatomical detail (30, 31).
Indications for CT imaging (1, 13, 18, 20):
MRI
The use of MRI will vary between institutions.
In patients who have neurological signs on examination, MRI should be the primary modality wherever possible (26). It is often used as a follow on investigation from CT in the intubated sick trauma patient who is unconscious and difficult to assess from a neurological perspective clinically. They are now stabilized enough either via Intensive Care or Surgical input to undergo an MRI.
Younger children with isolated neck injury who are difficult to assess and in whom we are concerned due history and physical examination may also be suitable candidates for MRI (32) post normal plain XR instead of going to CT. Bear in mind that many children will require a general anaesthetic to tolerate this imaging modality as it takes longer than CT or XR to perform.
A 2 year old girl presents with her father after landing awkwardly post a fall down the last two steps of stairs in her home yesterday evening. She has been starting to walk up and down the stairs and is always supervised. Last night, she complained of some pain which responded to the paracetamol syrup given to her by Dad. She slept well but since this morning, she has been holding her neck strangely and prefers to lie down.
You are the senior registrar on duty and one of your colleagues asks for your review. She is lying in a position of comfort on her left side. When you go to examine her she sits up and clings to her father crying and making it clear that she does not want to be examined, saying bye-bye. She has a torticollis to the left and is moving all limbs. Analgesia was given and plain films were obtained. These looked normal to you and the patient was reviewed and looks more comfortable now, although the torticollis persists.
Should we be concerned? Outline your steps in this patient’s management.
Torticollis in the setting of trauma, even in the absence of neurological signs or symptoms is concerning.
There is an association between torticollis and cervical spine injury, particularly rotatory subluxation of C1 on C2 (Atlanto axial rotatory subluxation or fixation as it is sometimes termed), however it can also be seen in other patterns of cervical spine injury too (34-38).
Typically, in trauma, the ipsilateral sternocleidomastoid muscle is in spasm. This differs from torticollis from other causes (benign paroxysmal torticollis, cervical lymphadenitis, cervical spine/cord tumours, posterior fossa tumours) where the contralateral sternocleidomastoid is in spasm (37).
Despite the fact this little girl’s neurological assessment remained normal, it was decided to proceed to MRI under general anaesthesia. This demonstrated atlanto-axial rotatory subluxation.
This case emphasises the concerning nature of traumatic torticollis, even in the absence of neurological signs or symptoms.
Injuries sustained by mechanism (33):
| Hyper-flexion | Hyper-extension | Axial Load |
| Flexion teardrop | Hyperextension dislocation | Burst fracture (If occurs to C1 the eponym of Jefferson applies) |
| Bilateral facet dislocation | Extension teardrop | |
| Unilateral facet dislocation | Hangman’s fracture (C2 Pedicles) | |
| Anterior subluxation | ||
| Wedge fracture | ||
| Spinous process fracture |
Falls from elevation, MVCs, being struck by motor vehicles while walking or riding and blunt blows to head and neck are more likely to result in axial (C2 and above) CSIs.
Sports related cervical spine injuries are more likely to result in injuries to the sub-axial (below C2) region or SCIWORA. Children involved in diving and motor sports (All-terrain-vehicles and motorcycles) are more likely to sustain sub-axial cervical spine injuries (8).
Question 1
What percentage of paediatric spinal injuries are located in the cervical region?
A: 12%
B: 40%
C: 50% or more
D: 2%
Answer 1
C: 50% or more
The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column.
Question 2
Which of the following mechanisms in history are concerning for a cervical spine injury?
A: Motor Vehicle Collision at a speed of above 30kph (18mph)
B: Diving into a pool
C: Fall from greater than body height
D: Transient neurological symptoms
E: All of the above
Answer 2
E: All of the above
Expert consensus on factors which are suspicious for a CSI include: persistent neck pain, child or parent feeds like the child has an abnormal head position, difficulty with neck movement, fall >1m or 6 steps of stairs or fall from greater than body height, hyperextension injury, acceleration-deceleration injury involving the head or clothes-lining (blunt trauma to the head/neck by a stationary object while the patient is in motion), bicycle collision, pedestrian versus bicycle, accidents involving motorized recreational vehicles, horse riding accidents, current or transient neurological symptoms (motor or sensory): weakness, paraesthesia, lightning or burning sensation down the spine or radiating to an extremity, neurological symptoms related to neck movement.
Question 3
Plain films are not sensitive enough in children to be our first choice in most circumstances where imaging of the cervical spine is deemed necessary.
A: True
B: False
Answer 3
B: False
The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous.
1. Luehmann NC, Pastewski JM, Cirino JA, Al-Hadidi A, DeMare AM, Riggs TW, et al. Implementation of a pediatric trauma cervical spine clearance pathway. Pediatr Surg Int. 2020;36(1):93-101.
2. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg. 2011;19(10):600-11.
3. Adib O, Berthier E, Loisel D, Aube C. Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol. 2016;45(12):1607-17.
4. Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol. 2016;71(9):844-53.
5. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics and Trauma. 2018;32(5):288-92.
6. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-6.
7. Polk-Williams A, Carr BG, Blinman TA, Masiakos PT, Wiebe DJ, Nance ML. Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg. 2008;43(9):1718-21.
8. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC. Cervical spine injury patterns in children. Pediatrics. 2014;133(5):e1179-88.
9. Patel JC, Tepas JJ, 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-6.
10. Egloff AM, Kadom N, Vezina G, Bulas D. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol. 2009;39(5):447-56.
11. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20.
12. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841–8.
13. Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, et al. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019;144(1).
14. Michelle L. Paucis Verbis: Distracting injuries in c-spine injuries California2011 [Available from: https://www.aliem.com/paucis-verbis-distracting-injuries-in-c-spine-injuries/.
15. Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, et al. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database of Systematic Reviews. 2017(12).
16. Chan M, Al-Buali W, Charyk Stewart T, Singh RN, Kornecki A, Seabrook JA, et al. Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord. 2013;51(5):360-4.
17. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA, Jr., Wales PW, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009;67(3):543-9; discussion 9-50.
18. Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019;101(1):e1.
19. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3):358-62; discussion -62.
20. National Institute for Health and Care Excellence UK. Head injury: assessment and early management, Clinical Guideline 176 2014 [updated September 2019. Available from: https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893.
21. Council P-hEC. Pre-hospital spinal injury management– PHECC position paper: Pre-Hospital Emergency Care Council (PHECC), Republic of Ireland; 2016 [updated June 2016. Available from: https://www.phecit.ie/Custom/BSIDocumentSelector/Pages/DocumentViewer.aspx?id=oGsVrspmiT0dOhDFFXZvIz0q5GYO7igwzB6buxHEgeDKIJ1qe4KMTbg0PR6g5rsqv0UG7SxVNTJNy77oXQjs2j1HSTJmgAW%252fSZveFhrJdevzBefQ%252b6h%252bH%252fxwJoeP22ouJte%252begki%252bcrlDSFj6a%252b%252bRVIqMv2PmiT2JVsY5T2RjJpHZlKxsjlq4%252foSxAKwZlBC%252fbAutc5W5Mhuoptkdh9A4Q%253d%253d.
22. Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.
23. Maxwell MJ, Jardine AD. Paediatric cervical spine injury but NEXUS negative. Emerg Med J. 2007;24(9):676-.
24. Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, et al. ACR Appropriateness Criteria((R)) Suspected Spine Trauma-Child. J Am Coll Radiol. 2019;16(5s):S286-s99.
25. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000;30(3):186-9.
26. The Royal College of Radiologists UK. Paediatric Trauma Protocols 2014 [updated 2017. Available from: https://www.rcr.ac.uk/publication/paediatric-trauma-protocols.
27. Jimenez RR, Deguzman MA, Shiran S, Karrellas A, Lorenzo RL. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol. 2008;38(6):635-44.
28. Lennon P, editor Thyroid cancer in Ireland, a 10 year review of the national cancer registry. 17th European Congress of Endocrinology; 2015; Dublin, Ireland: European Society of Endocrinology.
29. Puchalski AL, Magill C. Imaging Gently. Emerg Med Clin North Am. 2018;36(2):349-68.
30. Brockmeyer DL, Ragel BT, Kestle JR. The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst. 2012;28(5):699-705.
31. Tat ST, Mejia MJ, Freishtat RJ. Imaging, clearance, and controversies in pediatric cervical spine trauma. Pediatr Emerg Care. 2014;30(12):911-5; quiz 6-8.
32. Booth TN. Cervical spine evaluation in pediatric trauma. AJR Am J Roentgenol. 2012;198(5):W417-25.
33. Easter JS, Barkin R, Rosen CL, Ban K. Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging. Journal of Emergency Medicine. 2011;41(2):142-50.
34. Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.
35. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics & Trauma. 2018;32(5):288-92.
36. Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of emergency medicine. 2011;58(2):145-55.
37. Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2019;45(5):777-89.
38. Klimo P, Jr., Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurgery Clinics of North America. 2007;18(4):599-620.
| Topic | Non-traumatic MSK injuries |
| Author | Stephen Gilmartin |
| Duration | Up to 2 hours |
| Equipment required | AV to project x-ray images |
Expectation is for the learners to have understood the basics before the session.
Anatomy video: https://www.youtube.com/watch?v=kkHRRu6q2_o
Assessment tips: http://pmm-int.boxmodelstaging.co.uk/file.aspx?id=865
If possible or for further resource
Apophysitis, avulsions, Spondolysis: http://pemplaybook.org/podcast/pediatric-sports-injuries/
Rheumatology: https://dontforgetthebubbles.com/podcast/paediatric-rheumatology-jane-munro-dftb19/
Non traumatic pain is a common presentation in children and one which has a wide differential. Lower limbs are most commonly involved. The potential diagnoses range from benign and self-limiting to life and limb threatening.
There is often a history of an innocuous traumatic event which has prompted the attendance for assessment, but this often has little to do with the underlying diagnosis.
Clinicians should have a standardised approach to history and examination of non-traumatic MSK pain to ensure no diagnoses are missed
The underlying cause varies between age groups as children become susceptible to specific conditions as they progress through childhood.
Common causes
| Diagnosis | Location | Age | History | Exam | X-ray changes |
| Apophysitis | Any apophysis | F 10-14/M12-16 | Gradual onset Pain worse on activity Eases after rest | Point tenderness over apophysis With or without swelling | Sclerosis and fragmentation |
| Osteochondrosis | Joints: Commonly elbow/hip/foot | 4-18 dependent on site | Gradual onset Pain worse on activity Eases after rest | Mild swelling Stiff and painful joint | Irregular growth of epiphysis Sclerosis Fragmentation |
| Osteochondritis dissecans | Commonly knee and ankle | >10 | Gradual/sudden onset Pain worse on activity Associated intermittent swelling | Swollen joint in acute phase Tender joint line | Lucency about the cortical surface May be occult |
| Osteomyelitis | Commonly in areas of high bone turnover such as metaphysis/epiphysis | Any age | Gradual onset Pyrexia | Point tenderness Pyrexia Limp | Soft tissue swelling Local osteopenia Bony lysis or cortical loss Periosteal reaction |
| Spondylolysis | Lumbar spine | Adolescents | Gradual onset History of repetitive activity involving back extension | Pain on extensions and rotation of lumbar spine | Limited compared to CT Scotty dog sign: oblique view, break in pars interarticularis can have appearance of collar on dog |
| Avulsion fractures | Any tendon/ligament attachment | Adolescents | Sudden onset History of pain following sudden muscle contraction | Swelling and bruising if superficial Pain and weakness with resisted movement | Widening of open apophysis With or without displacement and angulation |
| Patellofemoral pain | Anterior knee | Adolescents | Gradual onset Worse on running/jumping and ascending stairs Commonly in young girls | Weak quadriceps Altered tracking of patella Pain on flexion of knee | Normal |
| Slipper upper femoral epiphysis | Hip/Knee | 10-16 | Gradual/sudden limp May be non-weight bearing | Limp Reduced ROM of hip Out toeing Forced external rotation on hip flexion | Displacement of epiphysis from physis. |
| Inflammatory arthritis | Any joint | Any age | Gradual onset May have multiple joints involved Associated systemic symptoms | Swelling of one or more joints Stiffness Systemic features | Soft tissue swelling Osteopenia Loss of joint space Joint subluxation Irregular growth |
| Malignancy | Commonly in areas of high bone turnover such as metaphysis/epiphysis | Any age | Gradual onset Systemic symptoms May have pyrexia | May have swelling and tenderness Lethargy Pallor | Bone destruction Irregular borders Wide zone of transition |
| Septic arthritis | Any joint | Any age | Gradual onset Red hot swollen joint Pyrexia Non weight bearing | Swollen, erythematous painful joint Pyrexia | Normal in early stages |
Assessment
One of the main priorities in patients presenting with atraumatic MSK pain is to seek out red flag symptoms and signs in order to rule out sinister diagnosis.
Red flag symptoms and signs include:
A standardised assessment should be performed depending on the body area/areas involved. Look for any swelling, bruising, erythema or cellulitis. Determine if there is any point tenderness which may give indicate a possible fracture. Assess joint function for range of motion (passive / active / resisted), weight bearing status, additional stiffness and stability.
Always ask yourself, is the story really atraumatic? Has there been any possibility of non-accidental injury?
Investigations
Some level of investigation is required for each of the potential diagnoses. You may make the diagnosis of apophysitis based on an accurate history and exam alone but even then, one study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease (apophysitis of the calcaneus).
A low threshold for a baseline x-ray is sensible in all paediatric patients presenting to secondary care with atraumatic MSK pain. They can be helpful to identify bony lesions, signs of osteomyelitis and unexpected fractures.
Inflammatory markers are useful when the patient’s presentation is concerning an infective or inflammatory process.
Other conditions that may be covered
Apophysitis: https://dontforgetthebubbles.com/apophysitis/
JIA http://www.pmmonline.org/doctor/child-with-a-swollen-joint/diagnosis-of-jia
Osteochondrosis: https://dontforgetthebubbles.com/osteochondrosis/
Avulsion fractures: https://dontforgetthebubbles.com/pelvic-avulsion-injuries/
Osteomyelitis and septic arthritis: https://www.rch.org.au/clinicalguide/guideline_index/Osteomyelitis_and_septic_arthritis/
Patellofemoral pain: https://pedemmorsels.com/patellofemoral-pain-syndrome-anterior-knee-pain/
Marie is a 12-year-old girl who presents to you complaining of anterior knee pain. She is an active volleyball player and is trying hard to make her school team. The pain is getting worse over the past month and is now affecting her ability to train. She denies any trauma.
What are your differential diagnoses?
What factors in the history and exam would you like to elicit in order to narrow the diagnosis?
You feel she has apophysitis of her tibial tuberosity.
What is the pathophysiology of apophysitis?
Can you name any other common sites affected by apophysitis?
What investigations would you like to perform?
What is your treatment plan?
What are your differentials?
What factors in the history and exam will help your diagnosis?
Apophysitis has a typical history of gradual onset localised pain in a child from 10-16 years of age. Pain is exacerbated by activity and initially improves with rest. The typical patient is highly active and may be overtraining. Examination will typically reveal point tenderness over the area involved with possibly some mild swelling.
Important factors to exclude are pyrexia, trauma, weight loss and systemic symptoms.
What is the pathophysiology of apophysitis?
An apophysis is an area of bony growth in children separate to ossification centres. It is the site of tendon or ligament attachment and fuses with the bone as the body matures. Rapid growth and repetitive movements combined with relative bone weakness, cause increased traction forces at the point of tendon attachment. This leads to micro-separation and bone fragmentation which is known as apophysitis. This clinically presents as an insidious onset focal pain, worsened by activity and eased by rest. There may be point tenderness and swelling on exam.
What other sites are affected by apophysitis?
Apophysitis commonly affects:
What investigations would you like to perform?
Apophysitis is described as a clinical diagnosis and as such patients do not require any investigations.
Despite this, it is reasonable with the above differentials in mind to perform a baseline x-ray in all patients presenting with possible apophysitis. This is especially important if the patient presentation or clinical course is atypical.
One study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease.
Knee x-ray of a 12-year-old female volleyball player. She is presenting with progressive pain over her tibial tuberosity. Her pain is exacerbated by jumping. The x-ray shows fragmentation of apophysis with overlying soft tissue swelling. Some isolated fragmentation can be normal at the tibial tuberosity.
Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 9740
https://radiopaedia.org/articles/osgood-schlatter-disease?lang=gb
Plain ankle radiograph of an 11-year-old male basketball player complaining of heel pain. There is increased density of the calcaneal apophysis, typical for ages between 7 and 14 years. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation. This may be seen in the context of the clinical diagnosis of Sever’s disease.
https://radiopaedia.org/cases/sever-disease-5
Case courtesy of Dr Dinesh Brand, Radiopaedia.org, rID: 60324
What is your treatment plan?
Exercise programmes https://bjsm.bmj.com/pages/wp-content/uploads/sites/17/2019/06/OSD-table.pdf
Good podcast for extended learning https://soundcloud.com/bmjpodcasts/osgood-schlatter-not-the-self-limiting-condition-we-once-thought-episode-384
Katie is a 9-year-old complaining of left 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. She denies any trauma and is systemically well.
What are some of the differential diagnosis?
What changes do you see on the x-ray?
What is the diagnosis?
What is the pathophysiology?
What other sites can be affected?
What is your treatment plan for this patient?
What is on your list of differentials?
What changes do see on the x-ray?
Flattening and sclerosis of the navicular bone. Mild soft tissue swelling. No fracture seen.
What is your diagnosis?
Kohler disease: osteochondrosis of the navicular bone.
Typical x-ray Findings of osteochondrosis:
Early: Potentially normal
Initial radiological findings
Radiological findings as disease progresses
What is the pathophysiology?
What other sites can be affected?
| Common Location | Eponymous name | Age of onset |
| Femoral head | Legg-Calve-Perthes (Perthes) | 4-8 |
| Capitellum | Panner | 10-16 |
| Capitellum | Kohler | 4-10 |
| Head of metatarsals (2nd most commonly) | Freiberg | 13-18 |
What is your treatment plan?
Treatment in this case will involve activity modification. This will entail reduced overall activity but and specifically avoiding activity which stresses the foot. Immobilisation in a walking boot may be beneficial if there is significant pain or inability to weight bear comfortably.
Three broad treatment strategies exist for osteochondrosis
Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physio 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.
A 15-year-old girl attends with intermittent pain and swelling to her left knee for the past two months. She is a keen soccer player but pain on the medial aspect of her knee is affecting her ability to run. She complains that after every game her knee swells and is now taking increasingly longer to subside. On exam she is walking with a limp, her knee is swollen and she has pain to the medial joint line. Her knee feels stable with all ligaments intact on testing.
You decide to do an x-ray:
Describe the x-ray findings.
Are you aware of any grading system used for Osteochondritis dissecans?
What investigations should you consider?
What are the x-ray findings?
Largely normal knee x-ray. Subtle lucency to chondral surface of medial femoral condyle. Findings consistent with osteochondritis dissecans.
Presentation depends on the stage of lesion. Initially nonspecific pain with or without swelling. As the process progresses, patients can develop mechanical symptoms such as reduced range of movement (ROM) and locking of joints.
What is the grading system?
Osteochondritis dessicans grading system:
Clanton Classification of Osteochondritis (Clanton and DeLee)
| Type I | Depressed osteochondral fracture |
| Type II | Fragment attached by osseous bridge |
| Type III | Detached non-displaced fragment |
| Type IV | Displaced fragment |
What investigations should you consider?
What is the treatment?
There is a lack of consensus on appropriate type and length of treatment.
The latest American Academy of Orthopaedic surgeons’ guidelines were unable to recommend any conservative treatment regime.
Masquijo and Kothari (2019) illustrate their preferred treatment algorithm in a flowchart
Modern protocols recommend patients should have a three to 6 months trial of conservative management.
Conservative management involves
Favourable prognostic factors are:
Poor prognostic factors include
Approximately 50-75% of lesions will heal in 6-12 months following conservative management.
Conservative management is not suitable for displaced or loose fragments.
Surgical treatment
Surgical treatment is preserved for large or unstable lesions, displaced fragments and those not responding to conservative therapy
Three broad surgical options
Drilling and fixation are usually successful surgical options with minimal complications. Up to 90% of patients can expect radiographic resolution of lesions. Unfortunately, grafts are usually seen as salvaging surgeries and outcomes can be variable.
Judith is a 10-year-old girl who is attending with pain and stiffness to bilateral wrists with intermittent swelling to fingers. She has no history of trauma. You think she may have arthritis.
What will you want to decipher during your history and exam?
Our patient has bilateral wrist, metacarpophalangeal and proximal inter phalangeal joints involvement. She complains of some morning stiffness but denies any previous medical problems. She cannot remember any trauma and has not had any temperatures or rashes.
What are your differentials?
You think this patient has Juvenile Idiopathic Arthritis. What is JIA?
What investigations will help with this diagnosis?
What is your chosen treatment for JIA?
Apart from rheumatology who else should see this patient with JIA?
What do you need to know in the history?
Length of symptoms: This is important as JIA can only be diagnosed once the patient has had symptoms for over 6 weeks without any other cause found.
Effect on activities: Has the patient stopped playing a sport they previously enjoyed. Is the patient regressing at physical activity or schoolwork such as handwriting?
Pattern of symptoms: Important to elicit if any stiffness or worsening of symptoms in the morning. Ask about symptoms associated with malignancy such as leukaemia.
Illicit any associated symptoms which may help discover a cause such as multisystem condition (Lupus/Vasculitis/psoriasis) or a reactive arthritis from a satellite infection (UTI/STI)
You should also enquire about symptoms which may indicate complications such as eye pain caused by uveitis or tendon pain caused by enthesitis.
Pattern of joint involvement.
Monoarthropathy: Single joint. Can still be JIA but infection, trauma and malignancy would be higher on your list and need to be consciously out ruled.
Oligoarthritis: Four or fewer joints involved
Polyarthritis: Over four joints involved.
Typical patterns include:
Examination:
What are your differentials?
The most likely diagnosis is JIA but there are also some other reasonable differentials.
What is JIA?
JIA comprises a group of inflammatory disorders that begins before the 18th birthday and persists for at least 6 weeks and other known conditions are excluded.
There are six main disorders of JIA with their own individual diagnostic criteria
For further background on the individual criteria. http://www.jrheum.org/content/46/2/190
What investigations will help?
No blood or radiological test can definitively make a diagnosis of JIA. The diagnosis is based on careful clinical assessment, exclusion of other possible causes and aided by blood and radiology.
pGALS screen has the benefit of quickly assessing all joints. pGALS is a standardised musculoskeletal (MSK) basic examination. Free educational resources to demonstrate pGALS are available online. (www.pmmonline.org).
What is your chosen treatment?
Refer early. Treatment should be initiated by a specialist. If you have concerns about JIA, you should discuss with rheumatology. The dawn of biologic treatment has ensured reduced symptoms, chronic complications and minimised need for systemic steroids.
Who else should see this patient?
Ophthalmology. JIA patients are at risk of losing their eyesight from chronic uveitis and may be asymptomatic despite having eye changes.
Question 1
Which of these conditions and age of onset do not match?
A: Apophysitis 10-14 F 12-16 M
B: Osteochondrosis 12-18
C: SUFE 10-16
D: Osteochondritis dissecans >10
E: Septic arthritis Any age
Answer 1
B: Osteochondrosis, the usual age of onset is anywhere between 4 and 18. There have even been some Kohler diseases documented as young as 3.
Question 2
Which of these anatomical areas do you not commonly see apophysitis?
A: Capitellum
B: Inferior pole of patella
C: Tibial tuberosity
D: Medial condyle of elbow
E: Calcaneal tuberosity
Answer 2
A: Capitellum. Apophysitis only occurs at sight of apophysis formation.
Question 3
Which of these statements about osteochondritis dissecans is not true?
A: Osteochondritis is a focal disruption of articular cartilage and subchondral bone
B: Most commonly seen on the medial femoral condyle
C: The aetiology is largely unknown
D: Recovery can take 6-12 months
E: A closed physis is a good prognostic factor
Answer 3
E: An open physis is seen as a good prognostic factor
Question 4
Which of these is not a radiological finding of osteochondrosis?
A: Sclerosis
B: Fragmentation
C: Flattening of epiphysis
D: Lytic lesion
E: Irregular epiphyseal growth
Answer 4
D: Lytic lesions. There may be no radiographic changes in the initial stages of osteochondrosis. You will then begin to see epiphyseal changes, soft tissue swelling, fragmentation and sclerosis.
Lytic lesions would help point you towards another possible differential diagnosis depending on its location and characteristics. Lesions can be caused by infections, malignancy or simple cysts.
Apophysitis:
Brenner, J. S. (2007). Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics, 119(6), 1242 LP – 1245
Rathleff, M. S., Winiarski, L., Krommes, K., Graven-Nielsen, T., Hölmich, P., Olesen, J. L., … Thorborg, K. (2020). Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine.
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.
Osteochondrosis
Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common
Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–
618.
Chan, J. Y., & Young, J. L. (2019). Köhler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.
Osteochondritis dissecans
Masquijo, J., & Kothari, A. (2019). Juvenile osteochondritis dissecans (JOCD) of the knee: current
concepts review. EFORT Open Reviews, 4(5), 201–212.
American Academy of Orthopedic Surgeons. Clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont, IL: American Academy of Orthopedic Surgeons, 2010.
JIA
Alberto Martini et al, for the Pediatric Rheumatology International Trials Organization (PRINTO) Toward New Classification Criteria for Juvenile Idiopathic Arthritis: First Steps, Pediatric Rheumatology International Trials Organization International Consensus, The Journal of Rheumatology Feb 2019, 46 (2) 190-197
Jason Palman, Stephanie Shoop-Worrall, Kimme Hyrich, Janet E. McDonagh, Update on the epidemiology, risk factors and disease outcomes of Juvenile idiopathic arthritis, Best Practice & Research Clinical Rheumatology, Volume 32, Issue 2, 2018, Pages 206-222,
| Topic | RSI and the difficult airway |
| Author | Robyn Goodier |
| Duration | Up to 2 hrs |
| Equipment required | Can be done without equipment, however for interactivity it would be useful to have different laryngoscopes/ETT/bougie/stylet etc for demonstration purposes. |
Adventures in RSI – PEM Playbook
Paediatric Formulae – LITFL
Paediatric airway compromise requiring emergency management by rapid sequence induction (RSI) is a rare event in the Emergency Department. However, despite it being rare, it is associated with high mortality and morbidity with an overall death rate of 3.8%, the highest for a critically unwell child.
Airway securement is a procedure that every critical care physician should be competent in performing.
So what do we mean when we say RSI?
RSI is an airway management technique that produces unconsciousness and muscular relaxation for the purposes of intubating and taking control of the emergency airway. The airway is usually intubated and controlled within 3 minutes of paralysis.
What are the indications for an RSI?
Don’t forget ABC…
A – Airway protection, this can be due to numerous reasons such as burns, penetrating neck injury
B – Respiratory failure – hypoventilation, severe asthma, hypercarbia
C- Circulatory collapse – severe sepsis
D – Neurological problems – termination of seizures, need for neuroprotection, GCS <8, C Spine trauma, diaphragmatic paralysis
E- Everything else! Transportation or facilitation of procedure, for patient safety (e.g. combative patient)
Once you have decided that you need to intubate the child, you should prepare to intubate the child using a local cognitive aid. The Twelve P’s of RSI are a useful way to intubate the child safely and successfully, however please refer to your local guidance.
The 12 Ps of RSI
1. Preparation
To ensure you are correctly prepared, we would advocate the use of an airway checklist. This is a checklist to ensure that all aspects of the RSI have been thought about to mitigate any omissions during the procedure. This is an example airway checklist from Liverpool Hospital, Sydney (Airway Checklist) recommended by the Emergency Care Institute in Australia.
Please check your hospital for your airway checklist – if you don’t have one, then check the ECI website for a blank version to create your own! They are a great aide memoire for a safe intubation.
Preparation includes:
Roles allocated
Team Leader
Airway Doctor
Airway Nurse
Procedure Nurse x2 for drug checking
Procedure doctor – usually the drug giver
Scribe
This is the minimum set up – you may have more but ensure your roles are clearly allocated
Labels on the front of scrubs can help the team know who is responsible for each role.
Have you considered calling for help? The definition of help will depend on your setting but could include Emergency Consultant, Anaesthetics or ICU.
Equipment required – remember the mnemonic SOAP ME
Suction – large bore suction (x2 if soiled airway) under the pillow and turned on
Oxygen (mask and BVM ventilation)
Airway equipment:
Pharmacy:
Patent IV line with fluids available – from bag or flushes drawn up
Specific RSI medications: Correct doses drawn up, labelled correctly as per local guidelines, order of medications to be given decided before administration
Monitoring Equipment:
ECG
NIBP on 2 minutely cycles (or arterial line if already inserted)
SpO2 probe with good trace
ETCO2 – attached to the circuit, if ETCO2 is unavailable alternative capnography such as colour capnography should be used.
How do I size my equipment?
ETT
ETT = age / 4 + 4 (for uncuffed tube)
Age / 4 + 3.5 (for cuffed tube)
Depth of insertion
<1 year insert to 10cm
>1 year age/2 + 12cm
Laryngoscope
Miller blades are straight blades which are designed to directly lift the epiglottis
MAC blades are curved to sit in the vallecula to lift the epiglottis indirectly but putting pressure on the glossoepiglottic ligament.
Miller blades are better for neonates and young infants – up to 1 year then MAC blades are better. Miller are used in this age group due to their large floppy epiglottis and laxity of the ligament.
< 1 year Miller 00, 0 and 1
>1 year MAC size 2 and 3 (size 3 usually 5 years upwards)
Please see your local policy for what is available in the area in which you work.
Royal Children’s Hospital Melbourne Airway Recommendations
Remember – you can intubate with a larger blade, but not a smaller one! If in doubt go for the bigger one!
2. Position
Anatomical differences in paediatric vs adult airways
Positioning in an RSI
What are the differences in physiology in intubating children?
The two most important things to consider are:
3. Pre-oxygentation
Pre-oxygenation should be done for all patients requiring an RSI. The aim is to wash out all of the nitrogen from the lungs and replace it with oxygen, thereby creating a reservoir of oxygen within the lungs. This is especially critical in children due to their propensity to desaturate quickly.
Pre-oxygenation can be done in a number of ways and will largely depend on the patient’s physiology. All patients (except trauma with suspected base of skull fracture) should have nasal prong oxygen delivering 15L min on in addition to preoxygenation aids.
4. Perform airway assessment
Use a LEMON!
L – Look Externally
E – Evaluate
M – Mallampati
NB This should be done ideally in an upright patient without vocalisation.
O- Obstruction
N – Neck mobility
5. Predict physiological difficulties
Respiratory
Cardiovascular
Disability
6. Plan (Airway plan ABCD)
So, you have everything ready and the team leader asks you for your airway plan, “what is an airway plan?” you ask….
As the airway doctor you should have an airway plan which is verbalised to the entire team so everyone is aware of the expected sequence of events.
This is an example of an airway plan from Life In the Fast Lane.
At each plan everyone is aware of the expected outcome and the triggers for moving on to each section. Although this is written for adults, the same is true of paediatrics.
IF YOU PREDICT A DIFFICULT AIRWAY, VERBALISE THAT TO THE TEAM AND HAVE THE DIFFICULT AIRWAY TROLLEY WITH YOU AND THE AIRWAY NURSE TO BE CLEAR ABOUT WHAT YOU WILL NEED!
Difficult airways will be covered in more detail later – however signposting the Vortex website to learners now is helpful. Vortex approach is an approach where there are set triggers meaning you move further down the vortex mental model to prepare for front of neck access. The website has invaluable information regarding CICO packs and an instructional video of paediatric front of neck access.
7. Pre-treatment
Consider atropine – this will be discussed in detail later.
8. Paralysis and induction
Induction agent of choice – i.e. ketamine, propofol, thiopentone
This will differ with institutions, clinical picture, availability and personal preference
The majority of emergency environments will now prefer ketamine as the induction agent of choice, except for status epilepticus where thiopentone is preferred, however this is site specific.
In a neonate an induction agent is often not required and it is an opiate based induction using either fentanyl or morphine, remembering that morphine has a longer time of onset.
Muscle relaxant
Depolarising – e.g. suxamethonium
Non- depolarising e.g Rocuronium, Atracurium etc
Other medications indicated by presentation e.g. mannitol, adrenaline, midazolam etc
Post intubation sedation – usually morphine and midazolam, check with the team leader
9. Perform laryngoscopy
Perform laryngoscopy
Insert ETT past the vocal cords
Inflate cuff
10. Placement with proof
11. Post intubation care
Post intubation care is a large topic on its own and beyond the scope of this session.
The main considerations post RSI are:
Package and transfer
Again, transportation of the critically unwell child is beyond the scope of this teaching session. There are numerous specialist retrieval services that facilitate interhospital transfers. For any staff member doing transfers within the hospital they should have specialist training.
Robert is a 7 year old boy seen in ED with a cough for 5 days, increasing shortness of breath and fevers. Mum brought him to ED as he was lethargic and breathing quickly. On examination he is lethargic with dry mucous membranes, in respiratory distress with a rate of 45, saturations of 92% on 15L oxygen. He is persistently hypotensive despite 40ml/kg fluids. He is becoming bradycardic and his GCS is now 9. You are worried he is in septic shock with impending respiratory failure and circulatory collapse. You decide to proceed to an emergent RSI.
How can he be optimized physiologically before RSI?
Would you start inotropes?
What is your induction agent of choice for RSI in these haemodynamically compromised children?
How can he be optimised physiologically?
First thing’s first here, this is a very, very sick child – have you called for help? Depending on your setting you will require help from ICU, senior Emergency and Paediatric staff and if not in a tertiary centre from specialist paediatric retrieval services.
In this setting this child has a high risk of mortality associated with the RSI. Ensure you have optimised and resuscitated as much as possible before the RSI.
Hypotension before intubation is associated with a higher mortality. This child has been fluid resuscitated, therefore you will need pressors to maintain the blood pressure prior to intubation.
In this situation you need to optimize the blood pressure prior to intubation, therefore an adrenaline infusion is the treatment of choice to support the blood pressure during the induction process.
What would be your induction agent of choice here?
Ketamine is the drug of choice. It exhibits a stimulatory effect on the cardiovascular system and is the least cardiac depressive induction drug available, therefore has the least chance of inducing hypotension. That being said, it is not only the drug that is important but the dose. Smaller amounts of induction agent will be required than a “typical” RSI.
Dosing is usually 1-2 mg/kg, doses of 0.5mg – 1mg/kg would be more appropriate in this setting.
Intubation, Hypotension and Shock • LITFL • CCC Airway
Additional reading – please look at the powerpoint from Dr Chris Nickson
Jeremy is a 10 year old boy brought in by ambulance after falling off his BMX at a skate park doing a jump without a helmet on. He had a fall from approximately 2 metres onto his head. He had an initial LOC for 2 minutes then was ok, but since then he has had multiple vomits and become drowsy. The ambulance have issued a pre arrival phone call as they are concerned he has a reduced GCS of 8 but no evidence of raised ICP at this stage. The ambulance crew have immobilised his C Spine.
You decide to prepare for an RSI before the child arrives as it seems he will need a secure airway.
How do you do an RSI with a C spine collar on?
His friend tells you they went to McDonalds 2 hours prior to this happening. Would you alter your approach knowing this information? Would you ask for cricoid pressure?
What is your choice of induction agent and why?
How do you do an RSI with a c spine collar on?
The reason the C Spine collar is on is because of suspected cervical spine trauma, therefore the cervical spine must be protected and avoid hyperextension of the neck during laryngoscopy and intubation. The C Spine collar in children has been contested, with the latest APLS update stating that C spine manual in line stabilisation (MILS) is the preferred option in the conscious patient and that C spine collars can potentially be very distressing for children, fit poorly and therefore a risk/benefit discussion should take place before routinely applying them in children.
In this case the child has a reduced GCS and a properly fitted, well tolerated collar. Prior to intubation the C spine collar should be removed, however immobilisation should remain in place at all times via MILS.
The current recommendations of when MILS should be used in general (when C Spine should be thought of) are:
This is aimed to keep the head in a neutral alignment whilst laryngoscopy occurs, to avoid hyperextending the neck. MILS involves a secondary person being tasked with holding the head in neutral alignment, this can either be done facing the intubator and having the hands placed over the side of the head from below, or can be done by crouching beside and underneath the intubator and holding still from above.
Once the airway is intubated the C Spine should be protected with a Philadelphia Collar and sandbags/rolls to ensure ongoing stability is maintained.
He ate a McDonald’s two hours ago. How would that change your approach? Would you use cricoid pressure?
He is likely to have a full stomach or at least food in his stomach which would make him more likely to aspirate, however in an Emergency Situation, not protecting the airway is a larger risk than aspiration. RSI is designed to be a quick induction and reduce the chance of emesis.
Cricoid pressure was initially thought to help reduce aspiration by blocking the oesophagus, however in children it has been widely contested and not thought to be of benefit. The force required to do cricoid pressure in children is a lot less than in adults; a less trained assistant may cause damage by improperly applied cricoid pressure. It can worsen the view at laryngoscopy and studies have shown that it may only displace the oesophagus laterally and not help with passive aspiration. It can also cause full occlusion of the trachea making intubation impossible.
The short answer is no, you would not change your approach and you would not have routine cricoid pressure.
What would your choice of induction agent be?
Ketamine was previously contraindicated for use in isolated head injury due to the concerns that it raises ICP, however now it is the drug of choice for the head injured child (with the exception of globe injury as ketamine can raise intraocular pressure).
Evidence that it raises ICP was weak. It is advocated for this use now due to its maintenance of haemodynamic stability.
Haemodynamic stability is very important in traumatic brain injury as hypotension is a major predictor of poor outcomes in TBI, even a single hypotensive event can have deleterious consequences in terms of secondary brain injury. This is a situation where an opiate adjunct would be helpful in ensuring that haemodynamic stability is maintained but so that laryngoscopy does not provoke a hypertensive response. Ketamine activates the sympathetic nervous system, therefore it can result in maintaining cerebral perfusion pressure. Doses should be titrated according to the haemodynamic parameters of the child in front of you; the dosing range is 1 – 2 mg/kg.
Ashleigh is a 2 year old female brought in to you on New Year’s Eve after her sister accidentally let off a firework that exploded in her face.
Ashleigh has obvious burns to her face/neck/chest/upper limbs. When you perform an airway assessment you can hear soft stridor and see burns inside her mouth.
You decide that she has a threatened airway and decide to intubate her.
Your consultant decides to use suxamethonium as the muscle relaxant of choice. You ask why because you heard it was contraindicated in burns. What is the evidence surrounding use of suxamethonium in burns?
You find yourself in a CICO situation after failed intubation and LMA placement. What is your difficult airway plan for this 2 year old?
Why is expectant airway management in burns so important?
What is the evidence around suxamethonium in burns?
This is an area that is easy to get confused about. The evidence regarding suxamethonium and burns is that it is safe within the first 24 hours of injury (some evidence states 48 hours) but not for use after 24 hours of injury. After this time it is contraindicated, due to hyperkalaemia (thought to be due to release of potassium from extrajunctional acetylcholine receptors). This potassium release can cause severe hyperkalaemia and lead to cardiac arrest. The important thing to remember is it is contraindicated for 1 year after a burn injury.
What is your difficult airway plan for this patient?
NB The ideal situation for this child is that they are intubated in theatre by an experienced anaesthetist with ENT on standby where there is an option of fibreoptic intubation. This is not available in all institutions.
Can’t intubate, can’t oxygenate is the worst thing an airway team can hear – but they MUST hear it. The first thing to do is ensure you have said loudly to the team that they are in can’t intubate, can’t oxygenate situation.
DAS UK guidelines suggest that children over 8 should have a “scalpel, finger, bougie” technique. Under 8 the cricothyroid membrane is so small that needle jet insufflation should be utilised. Early involvement of ENT and anaesthetics is a must.
The technique for this as described by DFTB:
Front of neck access is rarely done, however it is a lifesaving skill that all critical care physicians looking after both adults and children should be able to do. Practice on mannequins and watch videos so that you are able to call upon your knowledge should you ever have to use it!
Why is expectant management ofr burns so important?
Airway swelling rapidly increases after the burn and is at risk of airway closure and difficulty intubating the airway later.
Signs of airway burns:
If any of those are present the airway is at risk and consider intubation of the airway earlier rather than later.
Lily is a 2 month old infant being brought into ED by her mum as she is not feeding well and she has noticed her breathing is abnormal. She has an unremarkable birth history, born at term via NVD, GBS negative, Apgars 9 +9.
She has an older brother Isaac who attends daycare and has a runny nose recently.
Lily is in respiratory distress with grunting, nasal flaring, recession and head bobbing. You have tried HFNP and CPAP to little avail over the past 3 hours. She is now tiring and is becoming bradypnoeic and bradycardic. To prevent cardiac arrest you decide to intubate this child so proceed to an RSI.
Does this child need atropine preloading? Do all children need atropine?
Would you use a cuffed or uncuffed ETT?
Would you use a bougie?
Would you give atropine preloading?
There is much debate regarding premedication with atropine prior to RSI. The idea behind atropine as a pre RSI agent is that it increases the heart rate prior to induction to reduce the chance of bradycardia on induction.
There have been multiple studies which have suggested that atropine is not routinely required for premedication for an RSI and that uncontrolled hypoxia is the largest determinant in bradycardia when compared to the use or not of atropine.
In this case you could consider atropine given that the patient already has a bradycardia secondary to her respiratory failure, however you could also argue that adrenaline would be a better choice to reverse her bradycardia and improved general perfusion prior to induction.
This decision would be made with senior decision makers as an RSI in this situation would be high risk due to her already deranged physiological parameters.
Atropine is not a drug to be given “just in case”, careful consideration needs to be given as it is not without important side effects such as increased temperature with a risk of malignant hyperthermia: at too high a dose it can induce ventricular arrhythmias, at too low a dose it can cause bradycardia. It lowers seizure threshold and increases risk of aspiration by relaxing the lower oesophageal sphincter.
The general rule is no, it is not needed for every RSI, however it should be drawn up and available in the event of a bradycardia. However if you start out bradycardic prior to induction then this needs treatment otherwise there is significant risk of clinical deterioration or cardiac arrest during induction.
Would you use a cuffed or uncuffed tube?
First of all why are we asking this question? In an adult circumstance the answer is always a cuffed ETT, so why is there a choice in paediatrics?
The issue comes from neonates. Cuffed ETTs are thought to cause cuff-related trauma and subglottic stenosis, despite the benefits of a cuffed ETT (better aspiration protection, more accurate ETCO2 detection and lung recruitment). These rates however are much lower than previously thought and the evidence suggests that cuffed tubes are more advantageous. The current APLS guidance is that cuffed ET tubes are advantageous however it requires meticulous attention to size, cuff pressure, and to exact placement to ensure it is in the correct position.
This will be determined by what is available in the correct size in your department, the correct size is more important than cuffed vs uncuffed. Remember, if you are not in a tertiary centre the tube can always be exchanged if there is an issue. Please check in your department what is the accepted practice and be aware of the availability of these tubes.
Would you use a bougie?
A bougie is a plastic stick which is used to help instrument the airway; it acts as a rigid placeholder for the ETT to be railroaded over the top. In many emergency airways the bougie is the first thing to be called for, however, be aware that it is not small enough for paediatric airways especially neonatal ones. Check and see what your department has – most may have an adult and paediatric bougie with the paediatric bougie being compatible until approximately a size 5 ETT. You do not want to intubate the airway with a bougie and then realise your ETT does not fit!
With the smaller airway especially the neonatal airway then you use a stylet which is small enough for the ETT to fit over the top.
Difficult airway leading to cricothyroidotomy Paediatric Difficult Airway Simulation
More airway learning material Optimus Bonus
Question 1
The airway assessment mnemonic is named after which fruit?
A: MANGO – Mallampati/Airway Diameter/Neck/Gnashers/Obstruction
B: APPLE – Airway diameter/Positioning/Palate/Look/Evaluate
C: LEMON – Look/Evaluate/Mallampati/Obstruction/Neck
D: LIME – Look/Incisor distance/Mallampati/Evaluate
Answer 1
C: LEMON
Don’t forget it is a LEMON! Look first, then evaluate, check the mallampati, check for obstructions and lastly look at the neck!
Question 2
What can you use to help optimise airway anatomy when intubating a small child?
A: Philly collar
B: Neck/shoulder roll
C: Head of the bed sloping downwards
D: Put the child in the recovery position
Answer 2
B: Neck/shoulder roll
Neck/shoulder roll should be used to due to the large occiput in a child to ensure appropriate position for laryngoscopy.
Question 3
Which of these is an indication for an RSI in the Emergency Department?
A: Elective surgery for inguinal hernia repair
B: Suspected airway burns
C: Child with GCS 14
D: Trauma – isolated leg injury but going to theatre in a few hours
Answer 3
B: Suspected airway burns
Airway burns need to be managed promptly. If possible this should be done in theatre by anaesthetics, but not all centres have this availability therefore it may have to be done in an Emergency Department setting.
Top Tips for Oncology
Ana Waddington. Top Tips for Oncology, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29036
Next up in our DFTB Top Tips series is a set of helpful tips for caring for oncology patients.
Top Tips for Managing Febrile Neutropaenia
3 other things to think about…
What are some of your top tips when caring for oncology patients? Feel free to share them in the comments below!
For your convenience or as a handy reminder for your workplace, the top tips are highlighted in an A4 poster below (infographic design by Kat Priddis @kls_kat):