Searching for sepsis

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

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

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

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

Who did they study?

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

What did they do?

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

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

What did they look for? 

As a primary outcome the study determined:

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

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

What did they find? 

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

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

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

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

How did the sepsis guidelines fare?

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

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

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

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

What does this all mean?

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

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

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

We’ll end with some thoughts from the authors

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

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

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

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

Ruud Nijman

Intraosseous access

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

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

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

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

*EM/prehospital speak for foreign body airway obstruction

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

We discuss access options:

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

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

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

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

We voice our plan to the team:

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

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

When to IO?

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

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

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

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

Selecting the site

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

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

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

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

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

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

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

Contraindications

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

Landmarks

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

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

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

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

Surface anatomy for insertion around knee
Landmarks for proximal tibial insertion

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

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

But am I in the right space?

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

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

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

Medial view of ankle
Landmarks for distal tibial insertion

Distal Tibia

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

Distal femur surface anatomy
Landmarks for distal femoral site of insertion

Distal Femur

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

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

Humeral Head:

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

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

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

It is important to position the arm correctly.

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

Humeral IO placement techniques:

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

Site versus flow

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

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

An awake IO?

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

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

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

Size of IO – credit to Tim Horeczko

What about the gear itself?

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

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

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

Potential complications

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

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

The Super Smallies

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

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

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

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

What are the take homes?

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bubble Wrap PLUS – December 2020

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS – December 2020, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31117

Can’t get enough of Bubble Wrap? The Bubble Wrap Plus is a monthly paediatric journal club reading list from Anke Raaijmakers working with Professor Jaan Toelen and his team of the University Hospitals in Leuven. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. We suggest this list can help you discover relevant or interesting articles for your local journal club or simply help you to keep a finger on the pulse of paediatric research.

This month’s list features answers to intriguing questions such as: ‘Is shivering a relevant clinical sign in diagnosing serious bacterial infection?’, ‘Is a bulging fontanelle a good clinical marker for bacterial meningitis?’, ‘What is the value of follow-up blood cultures in children with S aureus bacteraemia?’, ‘What is a recurrence rate of infantile haemangioma after propranolol therapy?’ and ‘What is the prevalence of UTI in infants with URTI?’.

You will find the list is broken down into four sections:

1.Reviews and opinion articles

Understanding primary ciliary dyskinesia and other ciliopathies.

Horani A, et al. J Pediatr. 2020 Nov 23:S0022-3476(20)31452-9.

Opening doors: suggested practice for medical professionals for when a child might be close to telling about abuse.

Marchant R, et al. Arch Dis Child. 2020 Nov 24:archdischild-2020-320093.

‘I just wanted someone to ask me’: when to ask (about child sexual abuse).

Debelle G, et al. Arch Dis Child. 2020 Nov 24:archdischild-2019-317033.

Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care.

Jones VF, et al. Pediatrics. 2020 Nov 23:e2020034629.

When a Family Seeks To Exclude Residents From Their Child’s Care.

Largent EA, et al. Pediatrics. 2020 Nov 5:e2020011007.

Paediatric pancreatic diseases.

Coffey MJ, et al. J Paediatr Child Health. 2020 Nov;56(11):1694-1701.

Coeliac disease in childhood: An overview.

Bishop J, et al. J Paediatr Child Health. 2020 Nov;56(11):1685-1693.

Neonatal liver disease.

Evans HM, et al. J Paediatr Child Health. 2020 Nov;56(11):1760-1768.

Liver disease in the older child.

Ee LC. J Paediatr Child Health. 2020 Nov;56(11):1702-1707.

Diagnosis and management of severe sepsis in the paediatric patient.

Farrell CA. Paediatr Child Health. 2020 Nov 2;25(7):475-476.

Clinical management of sickle cell liver disease in children and young adults.

Kyrana E, et al. Arch Dis Child. 2020 Nov 11:archdischild-2020-319778.

Routine Neuroimaging of the Preterm Brain.

Hand IL, et al. Pediatrics. 2020 Nov;146(5):e2020029082.

Patent Ductus Arteriosus of the Preterm Infant.

Hamrick SEG, et al. Pediatrics. 2020 Nov;146(5):e20201209.

2. Original clinical studies

Shivering has little diagnostic value in diagnosing serious bacterial infection in children: a systematic review and meta-analysis.

Vandenberk M, et al. Eur J Pediatr. 2020 Nov 11.

Adverse Childhood Experiences and School Readiness Among Preschool-Aged Children.

Jackson DB, et al. J Pediatr. 2020 Nov 23:S0022-3476(20)31435-9.

Follow-up Blood Cultures in Children With Staphylococcus aureus Bacteremia.

Cardenas-Comfort C, et al. Pediatrics. 2020 Nov 25:e20201821.

Multisystem Inflammatory Syndrome in Children: An International Survey.

Bautista-Rodriguez C, et al. Pediatrics. 2020 Nov 24:e2020024554.

Implementing a new method of group toilet training in daycare centres: a cluster randomised controlled trial.

Van Aggelpoel T, et al. Eur J Pediatr. 2020 Nov 23.

Clinical Experience with Performing Esophageal Function Testing in Children.

van Lennep M, et al. J Pediatr Gastroenterol Nutr. 2020 Nov 20.

Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States.

Bailey LC, et al. JAMA Pediatr. 2020 Nov 23.

Randomized Controlled Trial of High-Flow Nasal Cannula in Preterm Infants After Extubation.

Uchiyama A, et al. Pediatrics. 2020 Nov 19:e20201101.

Adenovirus Infection-associated Central Nervous System Disease in Children.

Zhang XF, et al. Pediatr Infect Dis J. 2020 Nov 16.

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake.

Spencer JC, et al. Pediatrics. 2020 Nov 16:e20200395.

Recurrence rate of infantile hemangioma after oral propranolol therapy.

Frongia G, et al. Eur J Pediatr. 2020 Nov 13.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity.

Wiggins A, et al. Eur J Pediatr. 2020 Nov 13.

Use of a Procalcitonin-guided Antibiotic Treatment Algorithm in the Pediatric Intensive Care Unit.

Katz SE, et al. Pediatr Infect Dis J. 2020 Nov 10.

Abusive Head Trauma in Day Care Centers.

Rey-Salmon C, et al.  Pediatrics. 2020 Nov 10:e2020013771.

Low-dose or no aspirin administration in acute-phase Kawasaki disease: a meta-analysis and systematic review.

Chiang MH, et al. Arch Dis Child. 2020 Nov 10:archdischild-2019-318245.

Bulging fontanelle in febrile infants as a predictor of bacterial meningitis.

Takagi D, et al. Eur J Pediatr. 2020 Nov 9.

Smoking Intention and Progression From E-Cigarette Use to Cigarette Smoking.

Owotomo O, et al. Pediatrics. 2020 Nov 9:e2020002881.

Acute viral bronchiolitis as a cause of pediatric acute respiratory distress syndrome.

Ghazaly MMH, et al. Eur J Pediatr. 2020 Nov 7:1-6.

Predictors of hospital readmission in infants less than 3 months old.

Mace AO, et al. J Paediatr Child Health. 2020 Nov 6.

The Effectiveness of Working Memory Training for Children With Low Working Memory.

Spencer-Smith M, et al. Pediatrics. 2020 Nov 6:e20194028.

Survival and causes of death in extremely preterm infants in the Netherlands.

van Beek PE, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Nov 6:

Longitudinal Association Between Participation in Organized Sport and Psychosocial Development in Early Childhood.

Neville RD, et al. J Pediatr. 2020 Nov 3:S0022-3476(20)31376-7.

In children with a facial port-wine stain, what facial distribution warrants screening for glaucoma?

Mehan A, et al. Arch Dis Child. 2020 Nov 5:archdischild-2020-319931.

New diagnostic approach of the different types of isolated craniosynostosis.

Kronig SAJ, et al. Eur J Pediatr. 2020 Nov 5.

Eating disorders double and acute respiratory infections tumble in hospitalised children during the 2020 COVID shutdown on the Gold Coast.

Jones PD, et al. J Paediatr Child Health. 2020 Nov 5.

Nephrolithiasis during the first 6 months of life in exclusively breastfed infants.

Yılmaz N, et al. Pediatr Nephrol. 2020 Nov 5.

Perceptions of non-successful families attending a weight-management clinic.

Cox JS, et al. Arch Dis Child. 2020 Nov 2:archdischild-2020-319558.

How Are They Doing? Neurodevelopmental Outcomes at School Age of Children Born Following Assisted Reproductive Treatments.

Farhi A, et al. J Child Neurol. 2020 Nov 2:883073820967169.

Breastfeeding and Infections in Early Childhood: A Cohort Study.

Christensen N, et al. Pediatrics. 2020 Nov;146(5):e20191892.

Gut Microenvironment and Bacterial Invasion in Paediatric Inflammatory Bowel Diseases.

Zaidi D, et al. J Pediatr Gastroenterol Nutr. 2020 Nov;71(5):624-632.

The Gut Microbiome and the Triple Environmental Hit Concept of Inflammatory Bowel Disease Pathogenesis.

Kellermayer R, et al. J Pediatr Gastroenterol Nutr. 2020 Nov;71(5):589-595.

Feasibility Study of a New Magnetic Resonance Imaging Mini-capsule Device to Measure Whole Gut Transit Time in Paediatric Constipation.

Sharif H, et al. J Pediatr Gastroenterol Nutr. 2020 Nov;71(5):604-611.

Prevalence of Urinary Tract Infection in Febrile Infants With Upper Respiratory Tract Symptomatology.

Bolivar P, et al. Pediatr Infect Dis J. 2020 Nov;39(11):e380-e382.

Macrolide and Nonmacrolide Resistance with Mass Azithromycin Distribution.

Doan T, et al. N Engl J Med. 2020 Nov 12;383(20):1941-1950.

4. Case reports

Unusual position of the umbilicus in a neonate.

Tsoi SK, et al. Arch Dis Child Fetal Neonatal Ed. 2020 Nov 20:fetalneonatal-2020-321003.

Acholic stools and a small gallbladder: Not always a case of biliary atresia.

Singh H, et al. J Paediatr Child Health. 2020 Nov;56(11):1812-1813.

An unexpected revelation in a child with recurrent severe headaches.

Loke KY, et al. J Paediatr Child Health. 2020 Nov 13.

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

Acromio-clavicular joint injuries

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

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

AC joint anatomy

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

Mechanism of injury

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

Examination 

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

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

Young boy trying to hurt his sister (and failing)

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

AC injury infographic

Radiology

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

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

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

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

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

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

Classification

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

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

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

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

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

Management

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

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

Complications

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

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

References

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

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

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

Talk ortho like a pro

Talk ortho like a pro

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

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

History

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

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

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

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

Examination

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

The examination should be broken down into:

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

Imaging

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

Apply rule of two’s:

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

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

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

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

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

Describing fractures

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

Describing the site

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

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

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

Describing the extent

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

Describing the distal fragment

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

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

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

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

Finally, perfecting your referral

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

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

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

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

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

Done!

Fracture terminology

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

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

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

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

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

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

Greenstick fracture: Only one cortex is fractured.

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

Comminuted: There are more than two fragments.

Transverse fracture: A fracture across the bone.

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

Wrist x-rays

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

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

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

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

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

How to best remember the carpal bones

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

Sam Likes To Push The Toy Car Hard

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

Mnemonic for remembering carpal bones

Ossification

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

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

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

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

1. Check the soft tissues

Look for signs of swelling or any incidental findings.

2. Trace the bony cortices

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

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

Buckle fracture of radius
Buckle fracture

3. Check bony alignment

On the AP view:

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

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

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

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

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

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

Labelled AP view of wrist
AP view

On the lateral view:

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

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

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

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

References

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