Don’t Forget The Christmas: the bubble wrap treasure hunt

Cite this article as:
Team DFTB. Don’t Forget The Christmas: the bubble wrap treasure hunt, Don't Forget the Bubbles, 2020. Available at:

The bubble wrap treasure hunt is back! Use the clues in the questions to find the original paper to help you choose the correct answer. Good luck!

Question 1

In Nijman et al.’s 2020 single centre prospective evaluation of sepsis screening tools how many febrile children, aged 1 month−16 years, with greater than one warning sign of sepsis across 1,551 disease episodes had an invasive bacterial infection?

  • a) 2 (0.1%) children
  • b) 6 (0.4%) children
  • c) 20 (1.3%) children
  • d) 68 (4.4%) children
  • e) 158 (10.1%) children

Question 2

In Waterfield et al.’s 2020 multi-centre Petechiae in Children (PIC) study, of the 1334 included children (fever and petechial rash) how many had confirmed meningococcal disease? 

  • a) 19 (1.4%)
  • b) 52 (3.9%)
  • c) 63 (4.7%)
  • d) 78 (5.8%)
  • e) 99 (7.4%)

Question 3

In a retrospective evaluation by Reeves et al. how many children presented with a suspected magnet ingestion in the United States between 2009 and 2019?

  • a) 5486
  • b) 11472
  • c) 23756
  • d) 59621
  • e) 112456

Question 4

In a single centre study Watkins et al. undertook Bayley Scales of Infant-Toddler Development (BSID-III) and neurologic examination at 18-22 months of corrected age for survivors of birth before 26  weeks. In the surviving infants, no or mild neurodevelopmental impairment in surviving infants was 3 of 4 infants at 24-25 weeks. What was the proportion in the 22-23 week group? 

  • a) 1 of 5
  • b) 1 of 3 
  • c) 3 of 5
  • d) 2 of 3 
  • e) 4 of 5 

Question 5 

Trivić et al. undertook a systematic review and meta-analysis evaluating strain-specific probiotic interventions for paediatric functional abdominal pain (FAP) including 9randomised controlled trials published up to April 2020. How many studies reported the authors’ primary outcome which was the number of children with the cessation of pain symptoms after intervention?

  • a) 0
  • b) 1
  • c) 3
  • d) 6
  • e) 9

Question 6

Park et al sought to find evidence to support the claim that Santa Claus “knows if you’ve been bad or good, so be good for goodness sake” in their retrospective observational study of 186 members of staff who worked on paediatric wards in the UK over Christmas. But which one of the following did they find?

  • a) Santa Claus visited a greater proportion of children’s wards in Scotland than in Northern Ireland.
  • b) Santa was more likely to visit children in hospitals in areas of higher socioeconomic deprivation 
  • c) Santa was less likely to visit children in areas with high primary school absenteeism. 
  • d) After Santa, the most popular non-clinical visitor to bring festive cheer to paediatric wards on Christmas Day was Disney’s Elsa. 
  • e) Distance to the North Pole in kilometres did not have a statistically significant effect on whether Santa Claus would or would not visit a paediatric ward.

Stay tuned for the answers tomorrow!

Don’t Forget The Christmas Quiz: the crossword answers

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the crossword answers, Don't Forget the Bubbles, 2020. Available at:

How did your teams fare in our Christmas crossword? Here are the answers and the hidden word.


1. Signs of abnormal breathing and hypoxaemia are valuable clinical findings when diagnosing pneumonia – hypoxaemia

Children with pneumonia may present with fever, tachypnoea, difficulty in breathing, cough, wheeze or chest pain. Tachypnoea is a non-specific sign in children; iIt may be present with fever, with pain or distress and in many non-respiratory cases. Cough and fever are non-specific symptoms and are not grounds for diagnosing lower respiratory tract infections on their own. The Rational Clinical Examination Systematic Review concludes that more important than tachypnoea and auscultatory findings are hypoxia (saturations ≤ 96%) and increased work of breathing/abnormal breathing. Read more on pneumonia in the DFTB Pneumonia Module.

2. An alternative to Levetiracetam for the management of status epilepticus – phenytoin.

The ConSEPT and EcLiPSE trials were published concurrently in May 2019. ConSEPT concluded that Levetiracetam is not superior to phenytoin as a second line agent for convulsive status epilepticus and EcLiPSE concluded that there is no significant difference between phenytoin and levetiracetam in the second-line treatment of paediatric convulsive status epilepticus for any outcome, including time to seizure cessation. Read more about these studies in the Seizing the Truth post and learn more about seizures with the DFTB Seizure module

3. Constipation can lead to this, and as such the two can, and often do, co-exist – UTI (Urinary tract infection)

In a child with abdominal pain, the diagnosis of UTI makes constipation more likely. Constipation can lead to urinary retention and UTI, and as such the two can, and often do, co-exist.  A positive urine dip or culture doesn’t rule out constipation as a cause of abdominal pain. Don’t forget to think about constipation in the child with a history of recurrent UTI. Check out our DFTB Constipation module for more information.

4. A test which detects tuberculosis exposure. Mantoux

Tuberculin skin test (TST), or Mantoux test, and new immunological assays such as IGRAs detect Tuberculosis exposure. A Mantoux is performed by injecting 0.1ml of tuberculin purified protein derivative (PPD) intradermally into the inner surface of the forearm. The skin reaction produced by the PPD should be read between 48 and 72 hours and the reaction is measured in millimetres of induration, not redness. Read more about Tuberculosis and causes for prolonged fever by visiting the DFTB PUO module

5. Characteristic feature of the scarlet fever rash – sandpaper

The symptoms of scarlet fever start with fever (over 38.3°C), sore throat and general fatigue, headache and nausea. 12-48 hours later a rash appears on the abdomen and spreads to the neck and extremities. Characteristic features of the rash are a rough texture (like sandpaper) and worse in the skin folds e.g. groin, axilla, neck folds (Pastia’s lines). Read more about common childhood exanthems in the DFTB Common Rashes Module

6. An uncommon pathogen causing pneumonia – mycoplasma

Atypical pneumonia refers predominantly to an uncommon pathogen causing pneumonia, of which Mycoplasmas are one example. There is also fungal pneumonia which in addition to common bacterial and viral pathogens are considered uncommon and opportunistic microorganisms in a ‘poly-microbial mix’ seen mainly in immunocompromised children such as in HIV-exposed or infected children. While lower respiratory infection decreases with age, the prevalence of atypical infections increases, with a median age of about 7. Read more about Mycoplasma pneumonia in our DFTB Pneumonia Module

7. This rash in this viral exanthem classically presents after a fever and mild upper respiratory symptoms – Roseola

Roseola results in an acute febrile illness lasting between 3 and 7 days, which is then followed by the characteristic rash in around 20% of infected children. The prodrome to the rash is a high fever (39-40 °C), palpebral oedema, cervical lymphadenopathy and mild upper respiratory symptoms. The child appears well and as the fever subsides the exanthem appears. Read more about roseola at the DFTB Common Rashes Module

8. The organism most often associated with the viral exanthem in question 7 – HHV6 (Human Herpes Virus 6)

Roseola is caused most commonly by human herpesvirus 6 (HHV-6) and less commonly by human herpesvirus 7 (HHV-7). Human herpesvirus 7 (HHV-7) was discovered in 1989 as a new member of the beta-herpesvirus subfamily. Primary infection occurs early in life and manifests as exanthema subitum, or other febrile illnesses mimicking measles and rubella. Thus, HHV-7 has to be considered as a causative agent in a variety of macular-papular rashes in children. In addition, HHV-7 was found in some cases of other inflammatory skin disorders, such as psoriasis. Learn more about rashes at our Skin Deep website

DAS UK guidelines suggest that children over 8 should have a “scalpel, finger, bougie” technique used to gain front of neck access. Under 8, the cricothyroid membrane is so small that needle jet insufflation should be utilised. You can read the technique for this as described by DFTB in our RSI and the difficult airway module

10. What do you get if you eat mistletoe? Tinsillitis

A common complaint in Santa’s Grotto.


1. What group of conditions cause focal pain, typically in areas such as the tibial tuberosity and inferior pole of the patella? Apophysitis

Apophysitis of the tibial tuberosity (Osgood Schlatter disease) or inferior pole of patella (Sinding-Larsen-Johansson) have 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. Read more about apophysitis and other non-traumatic musculoskeletal (MSK) injuries at our DFTB non-traumatic MSK injuries module

2. A tropical infection characterised by prolonged fever, splenomegaly and pancytopaenia – Leishmaniasis

Leishmaniasis is a parasitic disease spread by the sand-fly. Main symptoms are fever, enlargement of spleen and liver and pancytopenia. Leishmaniasis is the second-largest parasitic killer in the world after malaria. Diagnosis is made by histological finding of amastigotes on spleen aspiration/bone marrow aspiration and RK39 Antigen detection. Read more about the causes of prolonged fever in the DFTB PUO Module

3. In paediatric migraine, analgesia and an antiemetic together are more effective than either alone.

In the acute setting, evidence points to antiemetics as an effective migraine symptom reliever. Analgesia and antiemetics together are even more beneficial. Read more about combination therapy and the role of Chlorpromazine in the management of Paediatric migraine in the DFTB Headache Module

4. Significant weight loss, vomiting, lethargy, hypoglycaemia, jaundice and hepatomegaly point to which diagnosis in a neonate? Galactosaemia

Galactosaemia is an inherited metabolic disorder characterised by a defect in the enzyme galactose-1-phosphate uridyl transferase (GALT). It presents after the affected neonate receives the sugar galactose, present in milk. Accumulation of galactose-1-phosphate results in damage to the brain, liver, and kidney. The affected neonate presents with vomiting, hypoglycaemia, seizures due to an inability to metabolise glucose, irritability, jaundice, hepatomegaly, liver failure, cataracts, splenomegaly, and Escherichia coli sepsis. Read more about other inherited metabolic disorders and how to identify them in the ED by reading our DFTB Inherited Metabolic Disorders Module

5. This c-spine rule, when validated in children under 16, has a specificity of 19.9%. NEXUS (National Emergency X-radiography Utilization Study)

NEXUS is a validated clinical decision instrument designed to identify patients who are at extremely low risk of cervical spine injury (CSI). The Viccelilo study looked at the performance of NEXUS in the paediatric subgroup under 18 years. All patients with low risk for CSI were correctly identified (100% sensitivity) but a large proportion were also incorrectly identified as having a CSI (19.9% specificity) making this study unreliable in children under 9 years. Read more about c- Spine injuries here.

6. One of the three types of brain tumours associated with tuberous sclerosis – tubers

Tuberous sclerosis (TS) is a rare multisystem genetic disease affecting the kidneys, heart, eyes, liver and skin. A combination of symptoms may include seizures, developmental delay, intellectual disability and skin conditions. The three types of brain tumors associated with TS include giant cell astrocytomas, cortical tubers and subependymal nodules. Want to know more about seizures or developmental delay? Take a look at our DFTB Seizure Module or this fantastic DFTB post on developmental delay.

7. What does Santa suffer from if he gets stuck in the chimney? Claustraphobia

Of course.

And the hidden word? 

Bauble, a type of Christmas bubble.

And now for the next round

Don’t Forget The Christmas Quiz: the crossword round

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the crossword round, Don't Forget the Bubbles, 2020. Available at:

Welcome to Don’t Forget The Christmas Quiz, a Christmas quiz with a difference. Over the next four days and nights, we’ve got something to bring a little festive cheer. Who knows their research? Who’s good with images? And who doesn’t love playing scavenger hunt?

We’re kicking off with a Christmas crossword. Can you complete the clues to find the hidden word? If you need some help with any of the clues, take a peek at the DFTB Modules for some inspiration…


1. Signs of abnormal breathing and what are valuable clinical findings when diagnosing pneumonia?

2. An alternative to Levetiracetam for the management of status epilepticus.

3. Constipation can lead to this, and as such the two can, and often do, co-exist.

4. A test which detects tuberculosis exposure.

5. Characteristic feature of the scarlet fever rash.

6. An uncommon pathogen causing pneumonia.

7. This rash in this viral exanthem classically presents after a fever and mild upper respiratory symptoms.

8. The organism most often associated with the viral exanthem in question 7.

9. “Scalpel, finger, bougie” is the recommended technique for front of neck access in children over 8 years in which national society’s guideline?

10. What do you get if you eat mistletoe?


1. What group of conditions cause focal pain, typically in areas such as the tibial tuberosity and inferior pole of the patella?

2. A tropical infection characterised by prolonged fever, splenomegaly and pancytopaenia.

3. In paediatric migraine, analgesia and what together are more effective than either alone?

4. Significant weight loss, vomiting, lethargy, hypoglycaemia, jaundice and hepatomegaly point to which diagnosis in a neonate?

5. This c-spine rule, when validated in children under 16, has a specificity of 19.9%.

6. One of the three types of brain tumours associated with tuberous sclerosis.

7. What does Santa suffer from if he gets stuck in the chimney?

Answers tomorrow!


Cite this article as:
Miran Pankhania. Epistaxis, Don't Forget the Bubbles, 2020. Available at:

Epistaxis is common and affects >10% of us in our lifetimes. Children present with epistaxis for a number of reasons, many different to adults. Unfortunately, physics underpins most of these causes.

The nose is a very vascular part of the head and neck, owing to its function in humidifying air as it is breathed in. The nasal mucosa becomes engorged in response to dryness and low temperatures to make air more comfortable to breathe in. This response is more noticeable in patients who are ethnically extracted from tropical and equatorial climates.

Sagittal view of nose showing blood supply of inner aspect
Anatomy of the nasal vessels

The arteries contributing to the blood supply of the nose include:

Anterior and Posterior Ethmoid arteries – branches of the Internal Carotid artery

The Superior Labial, Sphenopalatine, and Nasopalatine arteries – branches of the External Carotid artery.

These aren’t necessarily directly relevant to the management of paediatric epistaxis but do become important in some very special circumstances.

These arteries form a plexus in Little’s area called Kiesselbach’s plexus – Conveniently located approximately as far as a person can put their index finger inside their nostril.

Nose picking

The most common cause in children, but surprisingly common in adults too. Look for the tell-tale white keratinised patch inside the nostril, almost invariably on the anterior septum, at Little’s area. Nose picking can directly traumatise a vessel or can cause turbulent flow over an area, drying out the septum and increasing the risk of bleeding.


Common airborne allergens, such as house dust mite faeces, grass and tree pollen, and animal antigens eg cat saliva and dog hair can cause a Type I hypersensitivity reaction in the upper airways. This results in further engorgement of the nasal mucosa and can make already fragile vessels bleed, again by increasing turbulent airflow through the nose.

Idiopathic – Most people have a deviated nasal septum to some extent. Non-laminar flow over a deviated nasal septum can differentially dry out one side compared to the other and result in epistaxis.

Blunt force trauma

To differentiate this from simple nose picking, we need to consider a mode of injury which, although more common in adults through falls or assault, is also seen in children who fall whilst playing, or as a result of non-accidental injury. Blunt force trauma can result in arterial bleeding from the anterior ethmoid vessels and may be associated with other facial injuries. Acute manipulation of the bones can stop significant bleeding but sometimes an inspection of the nose under general anaesthetic is also needed to identify a bleeding point.

Rare causes

Epistaxis can rarely be the first presentation of haematological disease through derangement of clotting, for example, in leukaemia, lymphoma, or haemophilia. Beware the adolescent male who presents with torrential bleeding and unilateral nasal obstruction, who may have a rare vascular tumour centred on the sphenopalatine artery  – a juvenile nasal angiofibroma – which accounts for 0.05% of all head and neck tumours. Whilst benign, they are locally aggressive and in advanced disease, they can involve the internal carotid artery.


Very rarely, children undergoing oncological treatment may develop mucositis which can affect their nose. This, in conjunction with thrombocytopaenia and nasal cannulae, NG tubes, and turbulent airflow can cause a very difficult to treat epistaxis. ENT may use Floseal – a haemostatic semi-solid matrix made of human recombinant thrombin. Do not pack or instrument the nose as this will cause more bleeding.

Clinical Assessment

General inspection

Check for signs of distress, anaemia, pallor, cachexia, and lymphadenopathy.

Nasal examination

Check for signs of bleeding – Is this unilateral or bilateral? If you have a cold metal spatula, hold this under the nose to see if it mists equally assuming the nasal cavities are clear of blood. Evert the tip of the nostril to examine the nasal vestibule. You should be able to see the septum in the midline and the inferior turbinate laterally on either side. The colour of the inferior turbinate can give you an idea as to underlying pathology – a bluish, oedematous turbinate suggests venous congestion and is seen in allergy.

Oral examination

The posterior nares open into the nasopharynx, behind the soft palate and uvula. Before and after any nasal intervention, check the posterior pharyngeal wall with a good headlight and tongue depressor to see if there is blood still trickling down the pharynx or not. In drowsy or obtunded patients, this can pose a risk of aspiration.

No active bleeding?

Good news. The bleeding has probably stopped but might start again. You can inspect the nostrils with an otoscope with a speculum on it. This magnifies and the lens can also be slid aside to allow you to insert a silver nitrate stick through it if you’re able to see a point to cauterise – don’t do this without some form of topical anaesthetic as it causes a chemical burn which…well…burns! Some departments have 1% lidocaine spray but this can also sting as it hits the mucosa so ideally squirt it onto some cotton wool with some 1:10000 adrenaline before applying it to the nose for 5 minutes then remove it prior to cautery. If you don’t know how to cauterise, don’t worry…a Cochrane review found that emollients such as Vaseline or Naseptin ointment were as effective as silver nitrate cautery in stopping paediatric epistaxis. You’re just as likely to succeed by making an outpatient referral to ENT and prescribing some emollient for intranasal use 3-4 times a day until reviewed. Make sure they don’t try to rub it in with their finger or a cotton bud. Simply insert the tip of the nozzle into the nostril, squirt, pinch the nostrils together, and sniff.


So you’ve got an active bleeder?! Worry not…anxiety is contagious so it’s important to stay calm for both your sake and the child and their parents.

Sit the child upright, attach monitoring, and raise the bed so you don’t injure your back. Get PPE on. This means gloves, apron, goggles, and a mask. Meanwhile, ask someone, if not the child, to pinch the soft part of their nose whilst tipping the head forward. Do this without letting go for 10-15 minutes. This prevents aspiration and compresses the septum which is where the bleeding is likely to be coming from. Assess the airway, breathing, and circulation as you would for any other emergency patient.

Get hold of cotton wool balls, 1% lidocaine, and 1:10000 adrenaline. If you happen to have pre-mixed 5% lidocaine with 0.5% phenylephrine, this is even better. Make some pea-sized balls with the cotton wool and soak in the anaesthetic and adrenaline mixture. Gently place inside the offending nostril(s) and wait. This will buy you time and allow you to coordinate the rest of your care.

Use this time to ask yourself some questions.

Do I need to cannulate the child? (Probably not)

Where is the ice kept? Fill a glove with some ice and place over the forehead or pop a cube inside the mouth to aid vasoconstriction and stimulate the diving reflex – this will reduce the cardiac output a little and facilitate haemostasis.

Do we have silver nitrate and do I know how to use it?

Do I need to pack the nose?

Do I need to call ENT?

Reassess ABC

When should I refer to ENT?

  • Heavy bleeding
  • Heavy bleeding in the presence of trauma
  • Recurrent epistaxis
  • An adolescent male with unilateral nasal obstruction and torrential bleeding

Children with JNAs ultimately go to the operating theatre for resection of the tumour endoscopically. They will also have pre-operative embolization. This can be done for the sphenopalatine branch but there is a risk of stroke and blindness if the branches of the internal carotid are inadvertently embolised.

Some common pitfalls:

Not using anaesthetic – this is one of the most common failings and is very unpleasant for an already traumatised child.

Cautery – It’s great when it works, however, silver nitrate dissociates into nitric acid and silver hydroxide on contact with water. The nitric acid burns anything it comes into contact with so after cauterising, place some cotton wool inside the nose to soak up the excess. Similarly, the silver hydroxide can also dribble down the nose and cause an unsightly but temporary black tattoo.

Naseptin – This contains chlorhexidine and arachis oil. Whilst the arachis oil is boiled to sterilise it, caution should be taken in those with severe peanut allergy in case of anaphylaxis. Chlorhexidine is similarly allergenic – 2% of healthcare workers are sensitive to chlorhexidine, and 0.2% of the general population.

Clavicle fractures

Cite this article as:
PJ Whooley. Clavicle fractures, Don't Forget the Bubbles, 2020. Available at:

Darragh is a 7 year old who needed to get his ball back from his neighbour. He decided to jump the tall fence but fell before he got over the top and landed on his right shoulder. Mum brings him in and he is holding right arm to his side and not happy when you try and examine his shoulder. The ED doctor has ordered an x-ray.


Clavicular fractures are the most common shoulder fracture in children (8% to 15% of all paediatric fractures). They are common during delivery too and occur in 0.5% of all normal and 1.6% of breech deliveries, accounting for 90% of obstetric fractures.


80% of clavicular growth occurs at the medial epiphysis. It ossifies between 12-19 years of age and fuses fully by 22-25 years. The clavicle is the first bone in the body to ossify (intrauterine week 5), but the medial clavicular epiphysis is the last to appear and close. There are multiple ligamentous connections that are relevant.

Mechanism of injury

There are two mechanisms of injury: indirect and direct.

Indirect injuries commonly occur after a fall onto an outstretched hand (FOOSH).

Direct fractures are sustained from direct trauma to the clavicle or acromion and are associated with a higher incidence of injury to underlying neurovascular and pulmonary structures.


Children typically present with a painful, palpable and tender mass. There is usually a discrete tender swelling, but tenderness may be diffuse in the cases of a plastic bowing. Bony crepitus and ecchymosis are often present. It is important to ensure there is no overlying skin compromise.

Assess neurovascular status as although brachial plexus and subclavian artery injuries are rare, they can occur and will require urgent orthopaedic intervention.

In the setting of direct trauma, assess the child’s respiratory status. Rarely medial clavicular fractures may be associated with tracheal compression in the setting of significant posterior displacement.


Clavicle plain films are often sufficient rather than full shoulder x-rays. Often a single view might be all that is obtained. The diagnosis may be made as an incidental finding on other x-rays such as a chest x-ray. In the trauma setting, 2 views are ideally better than one: a frontal view and a cephalic tilt (15-45 degree).

In most cases, clavicle fractures are easily identified on plain x-ray. There is commonly displacement of the fracture; the medial fragment is pulled upwards by the sternocleidomastoid while the distal fragment is pulled downwards by the weight of the arm. Occult fractures may also be present. When describing a clavicle fractures note the location of the fracture along the shaft. The Allman Classification of clavicle fractures separates the segments into thirds.

Look for angulation and/or displacement of the fracture. Is it comminuted?  If there is shortening, measure, and document the degree of overlap (> or < 2cm), sometimes best seen on a PA chest x-ray.

Note any relevant negatives and associated findings. Comment on any variation in sternoclavicular (SC) joint, acromioclavicular (AC) and coracoclavicular (CC) alignment and distances.

Normal acromio-clavicular alignment

Midshaft clavicular fractures

Midshaft clavicular fractures are the most common paediatric shoulder fractures, accounting for 10-15% of all fractures. Half of these are in children <10 years. They almost always heal but if they don’t, the malunion is usually not of clinical significance. There is excellent remodeling within one year and complications are very uncommon. Thankfully, like many other children’s fractures, they commonly fracture in a greenstick pattern.

Operative management is reserved for adults and children over the age of 10 years, particularly if the clavicle is significantly shortened or displaced.

Case courtesy of Dr Ian Bickle, From the case rID: 53795

Neer classification of midshaft fractures

  • Non-displaced: If there is less than 100% displacement, these are managed conservatively
  • Displaced: If there is greater than 100% displacement, the non-union rate is 4.5%. These are managed operatively.

Medial Clavicular Injuries

Medial clavicular injuries are much less common in children. Most medial clavicular injuries are Salter-Harris type I or II.

True sternoclavicular (SC) joint dislocations, though rare, may occur and in the case of posterior dislocations, 30% are associated with life-threatening mediastinal injuries.

I’ll take a minute to describe this as it’s an important point. In SC joint dislocations, the clavicle typically displaces anteriorly in up to 90% of cases.

If concerned, then x-raying both sides (called a serendipity view) would help make a diagnosis.  If there remains concern, then a CT scan of the SC joint can be helpful, and is generally favoured as the imaging modality of choice.

Clinical image showing a protrusion over the right SCJ. Corresponding AP plain film demonstrating widening of the SCJ. From

Most children with an anterior SC joint dislocation can be managed with a sling or collar and cuff.

Much less often the clavicle moves posteriorly in relation to the sternum, especially in the setting of tremendous force applied to the shoulder or the medial clavicle. If there is no evidence of medial epiphyseal fracture but pain and swelling is present you must consider a dislocation. Posterior dislocations can present with pain over the anterior chest, increased on shoulder movement. A dislocation may impact the structures behind including the trachea and blood vessels in that region. Hoarseness could indicate a recurrent laryngeal nerve injury or airway compromise.

SC joint dislocations are classified as Grades I-V, with Grade V being a posterior dislocation. Any child with a suspected posterior SC joint dislocations should be referred to the on-call orthopaedic team – these are orthopaedic emergencies, with CT angiograms favoured to characterise the extent of vascular injury and operative reduction performed, often in consultation with vascular surgeons.

Lateral third clavicle fractures

These can be easily confused with acromioclavicular (AC) joint injuries. Both present clinically with pain and tenderness around the AC joint plus swelling and bruising. The ‘cross-arm test’ (ABDuction across the chest) results in increased pain in both conditions. Little or no deformity may be seen on x-ray unless a Salter-Harris II fracture is present.


Nonoperative management involves sling immobilisation with gentle range of motion exercise at 2-4 weeks and strengthening at 6-10 weeks. This is indicated in fractures of the middle 1/3, if there is shortening and displacement that is under 2cm with no neurology.

Operative management, open reduction and internal fixation (ORIF), is indicated in open fractures, displaced fractures with skin compromise and/or subclavian artery or vein injury and in major trauma with a floating shoulder where the clavicle and scapular neck are both fractured.


Non-union can occur in up to 5% of all types of clavicular fractures. Clavicular injuries that are most at risk of non-union include comminuted fractures and 100% displaced fractures with shortening that is over 2cm, resulting in decreased shoulder strength and endurance. Children over the age of 10 with displaced clavicular fractures will often have a face to face consultation in fracture clinic to discuss operative options to optimize outcome.

Who doesn’t need follow-up?

Children under 10 with an undisplaced fracture don’t need follow-up (although some places offer virtual follow-up), with simple management with a broad arm sling for 2 weeks and no contact sports for another 6 weeks after the sling is removed. It’s important to tell the child’s parents that a lump will form at the fracture site and will last for about a year. Give safety netting advice to return if they develop any sensory changes.

Thankfully Darragh only suffered a midclavicular greenstick fracture with minimal angulation. His arm was placed in a broad arm sling and his parents were told to keep it on for 2 weeks and no fence vaulting for a couple of months! As Darragh’s only 7 years old and his fracture was not significantly displaced, his parents were reassured that it would heal nicely. Most importantly he eventually got his ball back. Phew!


JS. Zember, ZS Rosenberg, S. Kwong, SP. Kothary, MA. Bedoya. Normal Skeletal Maturation and Imaging Pitfalls in the Pediatric Shoulder.  Radiographics. 2015 Jul-Aug;35(4):1108-22

Don’t forget the Christmas quiz

Cite this article as:
Team DFTB. Don’t forget the Christmas quiz, Don't Forget the Bubbles, 2020. Available at:

In the run-up to Christmas, we thought we’d bring you some festive fun in the form of a DFTB Christmas Quiz. To keep things fun, lighthearted and in the carefree spirit of the festive season, we’ve come up with four quizzes for you to complete (or compete) with your friends and colleagues who are keeping the fort running over the festive period.

The Don’t Forget The Christmas Quiz launches on Monday 21st December with the DFTB crossword, back by popular(!) demand, curated by Michelle Alisio, one of the fabulous DFTB fellows. And that’s a clue by the way – if you’re stuck for an answer, take a peek at the modules, the creation of which has been overseen by the fantastic fellows.

Tuesday 22nd December brings the Bubble Wrap Treasure Hunt. Damian takes us through 5 important paediatric papers, with a 6th Christmas question (because it’s Christmas and everyone deserves a present).

Wednesday 23rd December is the Picture Round. Dani and Becky have put together some minor injury pictures. If they’re tricky, all the answers can be found in our catalogue of DFTB posts (Editor:- There are over 1000 posts, you know!). And to make it a little less hard, these posts were all published in 2020.

And then our final quiz, on Christmas Eve, is going to be a great one. Kat Priddis and Mieke Foster take you on a tour through the DFTB website with the DFTB Holiday Hunt.