Bubble Wrap PLUS

Cite this article as:
Anke Raaijmakers. Bubble Wrap PLUS, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33092

Here is a new Bubble Wrap Plus, our monthly paediatric Journal Club List provided by Professor Jaan Toelen of the University Hospitals in Leuven (Belgium). This comprehensive list of ‘articles to read’ comes from 34 journals, including Pediatrics, The Journal of Pediatrics, Archives of Disease in Childhood, JAMA Pediatrics, Journal of Paediatrics and Child Health, NEJM, and many more. This month’s list is an anniversary list! The list exists for 10 years… And hopefully many more to come. There is also an April fool’s day link included – can you find it? 

Prof. Jaan Toelen

This month’s list features answers to intriguing questions such as: ‘Can AI help in the diagnosis of otitis media or ROP?’, ‘Can fathers influence the duration of breastfeeding?’, ‘Does a high milk intake correlate with iron deficiency?’, ‘What are the best nonpharmacological interventions for migraine?’ and ‘Do doctors need sleep?’.

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

1.Reviews and opinion articles

2.Original clinical studies

Machine Learning for Accurate Intraoperative Pediatric Middle Ear Effusion Diagnosis.

Crowson MG, et al. Pediatrics. 2021 Mar 17:e2020034546

Can Machine Learning and AI Replace Otoscopy for Diagnosis of Otitis Media?

Pichichero ME. Pediatrics. 2021 Mar 17:e2020049584

Applications of Artificial Intelligence for Retinopathy of Prematurity Screening.

Campbell JP, et al. Pediatrics. 2021 Mar;147(3):e2020016618. 

Artificial Intelligence for ROP Screening and to Assess Quality of Care: Progress and Challenges.

Gilbert C, et al. Pediatrics. 2021 Mar;147(3):e2020034314. 

From dyad to triad: a survey on fathers’ knowledge and attitudes toward breastfeeding.

Crippa BL, et al. Eur J Pediatr. 2021 Mar 29. 

Breastfeeding patterns and effects of minimal supplementation on breastfeeding exclusivity and duration in term infants: A prospective sub-study of a randomised controlled trial.

Bond DM, et al. J Paediatr Child Health. 2021 Mar 25. 

Does cystic fibrosis make susceptible to celiac disease?

Emiralioglu N, et al. Eur J Pediatr. 2021 Mar 25. 

Clinical, sonographical, and pathological findings of pediatric thyroid nodules.

Cimbek EA, et al. Eur J Pediatr. 2021 Mar 26. 

Association of Race/Ethnicity and Social Disadvantage With Autism Prevalence in 7 Million School Children in England.

Roman-Urrestarazu A, et al. JAMA Pediatr. 2021 Mar 29:e210054. 

Vaccine hesitancy and reported non-vaccination in an Irish pediatric outpatient population.

Whelan SO, et al. Eur J Pediatr. 2021 Mar 27. 

Respiratory Virus Surveillance in Infants Across Different Clinical Setting.

Haddadin Z, et al. J Pediatr. 2021 Mar 24:S0022-3476(21)00274-2. 

Cutting Ties With an Old Friend: Omphalitis and Bacteremia With Umbilical Cord Nonseverance.

Lanni L, et al. Pediatrics. 2021 Mar 26:e2020008938. 

Clinical Epidemiology and Outcomes of Pediatric Musculoskeletal Infections.

Yi J, et al. J Pediatr. 2021 Mar 23:S0022-3476(21)00266-3. 

Gestational hypertension and childhood atopy: a Millennium Cohort Study analysis.

Henderson I, et al. Eur J Pediatr. 2021 Mar 26. 

Association Between Hypertensive Disorders of Pregnancy and Neurodevelopmental Outcomes Among Offspring.

Brand JS, et al. JAMA Pediatr. 2021 Mar 22. 

Self-Inflicted Dermatoses In Adolescence: A Case Series.

Sarti L, et al. J Paediatr Child Health. 2021 Mar 25. 

Contamination rates of different methods of urine culture collection in children: A retrospective cohort study.

Guri A, et al. J Paediatr Child Health. 2021 Mar 24. 

Prevalence and associated factors of iron deficiency in Spanish children aged 1 to 11 years.

López-Ruzafa E, et al. Eur J Pediatr. 2021 Mar 23. 

The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department.

van de Maat JS, et al. Eur J Pediatr. 2021 Mar 22. 

Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children.

Shapiro DJ, et al. J Pediatr. 2021 Mar 18:S0022-3476(21)00231-6. 

Rightsizing Treatment for Pneumonia in Children.

Tsay SV, et al. JAMA Pediatr. 2021 Mar 8. 

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial.

Pernica JM, et al. JAMA Pediatr. 2021 Mar 8:e206735. 

Acute kidney injury in children hospitalized for community acquired pneumonia.

Marzuillo P, et al. Pediatr Nephrol. 2021 Mar 20. 

Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial.

Golden NH, et al. Pediatrics. 2021 Mar 22:e2020037135. 

Prior administration of chocolate improves the palatability of bitter drugs: The Choc-with-Med study.

Truong S, et al. J Paediatr Child Health. 2021 Mar 19

Family and Child Risk Factors for Early-Life RSV Illness.

Fitzpatrick T, et al. Pediatrics. 2021 Mar 18:e2020029090. 

Early Life RSV: Can Vaccines Help Fix Societal Ills?

Caserta MT, et al. Pediatrics. 2021 Mar 18:e2020038356. 

Effect of a Novel Oxygen Saturation Targeting Strategy on Mortality, Retinopathy of Prematurity and Bronchopulmonary Dysplasia in Extremely Preterm Neonates.

Srivatsa B, et al. J Pediatr. 2021 Mar 15:S0022-3476(21)00219-5. 

Influence of agents and mechanisms of injury on anatomical burn locations in children <5 years old with a scald.

Javaid AA, et al. Arch Dis Child. 2021 Mar 16:archdischild-2020-320710. 

A Brief Home-Based Parenting Intervention to Reduce Behavior Problems in Young Children: A Pragmatic Randomized Clinical Trial.

O’Farrelly C, et al. JAMA Pediatr. 2021 Mar 15. 

Ingestion of metallic foreign bodies: A Paediatric Emergency Research in the United Kingdom and Ireland survey of current practice and hand-held metal detector use.

Lafferty M, et al. J Paediatr Child Health. 2021 Mar 15. 

Nonpharmacological Interventions for Pediatric Migraine: A Network Meta-analysis.

Koechlin H, et al. Pediatrics. 2021 Mar 9:e20194107. 

Leukemia Risk in a Cohort of 3.9 Million Children With and Without Down Syndrome.

Marlow EC, et al. J Pediatr. 2021 Mar 5:S0022-3476(21)00212-2. 

Incidence of allergen-specific and total immunoglobulin E positivity in children undergoing adenotonsillectomy.

Lam ME, et al. J Paediatr Child Health. 2021 Mar 8. 

Rectum sizes: Assessment by ultrasonography in children with functional constipation.

Pop D, et al. J Paediatr Child Health. 2021 Mar 4

Evaluation of Fecal Incontinence in Pediatric Functional Constipation: Clinical Utility of Anorectal and Colon Manometry.

Morera C, et al. J Pediatr Gastroenterol Nutr. 2021 Mar 1;72(3):361-365. 

Neonatal morbidities in infants born late preterm at 35-36 weeks of gestation – a Swedish nationwide population-based study.

Mitha A, et al. J Pediatr. 2021 Mar 1:S0022-3476(21)00205-5. 

Uncertainty at the Limits of Viability: A Qualitative Study of Antenatal Consultations.

Kaemingk BD, et al. Pediatrics. 2021 Mar 3:e20201865. 

Clinical presentations of Kingella kingae musculoskeletal infections in South Australian children.

Awwad E, et al. J Paediatr Child Health. 2021 Mar 3

Oropharyngeal Carriage of Kingella kingae and Transient Synovitis of the Hip in Young Children: A Case-control Study.

Gravel J, et al. Pediatr Infect Dis J. 2021 Mar 1;40(3):182-185. 

Are psychological symptoms a risk factor for musculoskeletal pain in adolescents?

Andreucci A, et al. Eur J Pediatr. 2021 Mar 2. 

Adverse events associated with pediatric complementary and alternative medicine in the Netherlands: a national surveillance study.

Vos B, et al. Eur J Pediatr. 2021 Mar 1. 

Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial.

Mahant S, et al. AMA Pediatr. 2021 Mar 1:e206141. 

Should We Prioritize Deimplementation of Continuous Pulse Oximetry in Bronchiolitis Care?

Cheston CC, et al. JAMA Pediatr. 2021 Mar 1

Doctors Also Need Sleep: Is It Time to Take Another Look at Our ROSTERS?

Dairo Oguntebi A, et al. Pediatrics. 2021 Mar;147(3):e2020034017. 

Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians.

Rahman SA, et al. Pediatrics. 2021 Mar;147(3):e2020009936. 

Childhood and Adolescent Bullying Perpetration and Later Substance Use: A Meta-analysis.

Vrijen C, et al. Pediatrics. 2021 Mar;147(3):e2020034751. 

Puberty Is Associated with a Rising Hemoglobin A1c, Even in Youth with Normal Weight.

Kelsey MM, et al. J Pediatr. 2021 Mar;230:244-247. 

Effect of Antibiotic Use Within First 48 Hours of Life on the Preterm Infant Microbiome: A Randomized Clinical Trial.

Kim CS, et al. JAMA Pediatr. 2021 Mar 1;175(3):303-305. 

Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19.

Feldstein LR, et al. JAMA. 2021 Mar 16;325(11):1074-1087. 

COVID-19 and primary immunodeficiency: One-year experience.

Al Yazidi LS, et al. J Paediatr Child Health. 2021 Mar 10. 

Cardiorespiratory fitness in adolescents before and after the COVID-19 confinement: a prospective cohort study.

López-Bueno R, et al. Eur J Pediatr. 2021 Mar 17:1-7. 

Bronchiolitis Admissions to Intensive Care During COVID.

Rambaud J, et al. Pediatrics. 2021 Mar 17:e2021050103

Bronchiolitis and SARS-CoV-2.

Milani GP, et al. Arch Dis Child. 2021 Mar 11:archdischild-2020-321108

The impact of lockdown on pediatric ED visits and hospital admissions during the COVID19 pandemic: a multicenter analysis and review of the literature.

Kruizinga MD, et al. Eur J Pediatr. 2021 Mar 15:1-9

COVID-19 related increase in childhood tics and tic-like attacks.

Heyman I, et al. Arch Dis Child. 2021 Mar 6:archdischild-2021-321748. 

Infants Born to Mothers With COVID-19-Making Room for Rooming-in.

Kaufman DA, et al. JAMA Pediatr. 2021 Mar 1;175(3):240-242. 

Evaluation of Rooming-in Practice for Neonates Born to Mothers With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Italy.

Ronchi A, et al. JAMA Pediatr. 2021 Mar 1;175(3):260-266. 

4.Case reports

A 9-year-old boy with severe motor and intellectual disabilities and prolonged abdominal distension.

Higuchi Y, et al. J Paediatr Child Health. 2021 Mar 26. 

Severe acute anaemia in an infant: An unusual finding.

Nogueira A, et al. J Paediatr Child Health. 2021 Mar 27. 

‘Starry sky’ rash in a child.

Conversano E, et al. J Paediatr Child Health. 2021 Mar 16. 

Adolescent with right axillary swelling.

Trombetta A, et al. J Paediatr Child Health. 2021 Mar 24

A 17-year-old With Trismus and Neck Pain.

Vatansever G, et al. Pediatr Infect Dis J. 2021 Mar 16. 

Hiding in plain sight: A case of lower abdominal pain.

Scheier E, et al. J Paediatr Child Health. 2021 Mar 4. 

Behavioural changes in an adolescent boy: Not always as it seems.

Linhares RE, et al. J Paediatr Child Health. 2021 Mar 17. 

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

Distal femoral physeal fractures

Cite this article as:
Sinead Fox. Distal femoral physeal fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31852

Marcus is a 13-year-old boy who sustained an injury to his right leg during a rugby match, describing a hyperextension injury at the knee during a tackle. He is brought to your ED via ambulance. He is complaining of a significantly painful right leg which is quite swollen and exquisitely tender at the distal thigh and knee. Marcus is treated using advanced paediatric trauma protocols and no other injuries are identified. The injury to his leg is a closed injury and his distal neurovascular status is intact. An IV cannula is inserted. IV Morphine is administered for pain and an above knee back-slab is applied to splint the injury. An X-ray is suspicious for a Salter Harris type III fracture to his distal femur. Marcus is kept nil by mouth and referred to the orthopaedic team for urgent review.

Epidemiology

Distal femoral physeal injuries are uncommon. They represent approximately 7% of lower extremity injuries in children and less than 1% of all paediatric fractures. Although rare, distal femoral physeal fractures have a high incidence of long-term complications. These injuries must be considered in patients with open physes to avoid misdiagnosis as collateral ligament injuries and minimise the risk of complications.

Anatomy

Bones

The epiphysis of the distal femur is the first epiphysis to ossify and is present at birth. From birth to skeletal maturity the distal femoral physis contributes 70% of the growth of the femur and 37% of the growth of the lower extremity. The distal femoral physis has an average growth of 1.0 cm/year, making it the fastest growing physis. Growth ceases at a mean skeletal age of fourteen years old in girls and sixteen years old in boys. Compared with ligamentous structures, the physis is generally considered weaker within joints of children, therefore most periarticular injuries involve the growth plate.

Muscles

Both heads of the gastrocnemius and plantaris muscles originate just proximal to the physis of the distal femur.

Ligaments

The collateral ligaments of the knee attach distal to the physis at the level of the epiphysis of the distal femur. The ACL and PCL attach to epiphysis at the intercondylar notch and can be injured.

Blood supply

The popliteal artery is an important vessel in this area and can be prone to injury. It is important to undertake a careful neurovascular exam in children with confirmed or suspected distal femur fractures. Although rare, injury to the popliteal artery can result in loss of lower limb viability.

Nerves

The sciatic nerve divides into the peroneal and tibial nerves proximal to the popliteal space. 

Mechanism of injury

Distal femoral physeal injuries can be caused by hyperextension of the knee, with or without varus or valgus strain, or can occur by direct impact to the area. In the days of horse drawn wagons, this injury was coined ‘wagon-wheel injury’ or ‘cartwheel injury’ because it occurred when children attempted to jump onto a moving wagon and the leg became entrapped between the spoke of the moving wheel. Nowadays, most distal femur fractures are as a result of significant trauma such as motor vehicle accidents or sports related trauma. This is especially true for children between the ages of 2-11 years old, however less force is required for physeal disruption in infants and adolescents.

Children with underlying conditions such as neuromuscular disorders, joint contractures, difficult deliveries, or nutritional deficiencies can be more predisposed to distal femur physeal injuries.

Evaluation

Children with distal femur fractures will have significant pain and may be quite anxious, especially if assessment is undertaken in a resus situation. Make sure to follow advanced trauma protocols and ensure the child has had adequate analgesia.

Children with distal femoral physeal fractures generally present with pain, swelling and tenderness to the distal femur or knee and an inability to weight bear. Displaced separation of the distal femoral epiphysis may produce clinical deformity. Abrasions or lacerations of the overlying soft tissues may be a clue to the mechanism of injury or to an open fracture. Children with distal femur fractures may hold the knee in a flexed position due to hamstring muscle spasm. There may be varus or valgus knee instability on exam also.

A careful neurovascular exam of the lower limb including pulses, colour, temperature and motor and sensory status should be undertaken. Swelling in the popliteal space may be a sign of a vascular injury which requires urgent orthopaedic intervention. Although rare, injury to the popliteal artery is most commonly associated with an anterior displacement of the epiphysis or a posterior spike at the fracture site. The use of doppler ultrasound may be helpful in evaluating circulation distal to the injury but one of the most important screening tools for a vascular injury is measurement of the ankle-brachial index ratio.

The ankle-brachial index ratio involves comparing differences in systolic BP between the lower and upper limb. The cuff systolic blood pressure of the ankle should be >90% of the arm’s (brachial) systolic blood pressure. If the ankle’s cuff systolic blood pressure is <80-90% of the arm’s cuff systolic pressure, further investigation with a flow doppler ultrasound or arteriogram may be indicated.

If either the ankle-brachial index ratio or clinical exam suggest a vascular injury, then formal imaging with CT angiography should be carried out as soon as possible and repair of any defect to revascularize the distal limb must be undertaken as soon as possible but certainly within 6 hours of the initial injury. Urgent referral to orthopaedics is essential.

Evaluate the patient for signs and symptoms of compartment syndrome.

Assessing for compartment syndrome – the 5 Ps

  • Pain – the most important indicator.  Often diffuse and progressive, not resolved by analgesia, worsened by passive flexion of the injury.
  • Pallor – assess distal to the injury.  Dusky or cool skin (compared to the other side) or delayed capillary return.
  • Pulse – weak or absent pulse indicates poor perfusion,
  • Paralysis – assess active movement of the toes and foot.  This may cause pain, but the purpose is to assess ability to move.
  • Paraesthesia – ask about pins and needles or a feeling of the leg/foot “falling asleep”.  Assess sensation with light touch or using an object such as a pen lid.

Any concerns about potential compartment syndrome must be escalated to an ED or orthopaedic senior without delay as this is a time-critical situation.

Injury to the peroneal nerve can be caused by anterior or medial displacement of the femoral epiphysis. The nerve can become stretched resulting in neurapraxia. Spontaneous recovery can be expected following reduction or fixation of the fracture. The exception to this is a transected nerve in association with an open injury which requires urgent orthopaedic input.

Testing motor and sensory function of the lower limb

Radiology

Most distal femur fractures can be identified on plain X-ray. AP, lateral and oblique views are recommended. Stress radiographs for suspected physeal injury are no longer routinely performed, MRI or ultrasound have replaced stress views in this setting. CT may be necessary for evaluation of intra-articular extension and to define fracture fragments to plan fixation.

Classification

The standard Salter Harris (SH) classification is used to describe distal femoral physeal fractures.

Salter Harris Type I (SHI)

A SHI fracture is a separation through the distal femoral physis. A non-displaced SHI fracture may be difficult to diagnose on X-Ray. A slight fleck of bone adjacent to the physis, a slight widening of the growth plate, or other irregularities of the physis can indicate a SHI fracture of the distal femur. Sometimes diagnosis is only made or confirmed during follow up when subperiosteal new bone formation along the adjacent metaphysis is identified on subsequent X-rays.

Non-displaced SHI fractures should be suspected when knee tenderness is localised circumferentially to the distal femoral physis. To help guide examation it is helpful to know that when the knee is in extension the waist of the patella overlies the distal femoral physis. Gentle varus/valgus stress to the knee may elicit pain.

Patients who have tenderness of the growth plate and are unable to weight bear should be treated as having a presumptive physeal fracture and should be casted and referred to a fracture clinic for follow up. If in doubt, seek advice by discussing your clinical findings with orthopaedics.

Distal femoral epiphyseal widening. Courtesy of Orthobullets.com

Salter Harris Type II (SHII)

Distal femoral physeal fractures are most commonly SHII fractures. This fracture pattern is characterised by an oblique fracture that extends across the metaphysis of the distal femur. The metaphyseal corner that remains attached to the epiphysis is called a Thurston-Holland fragment.

Salter Harris II fracture of the distal femur. From Orthobullets.com

Salter Harris Type III (SHIII)

A SHIII fracture involves the physis and extends vertically through the epiphysis. These injuries can be produced by valgus stress during sports activities and may have an associated injury to the cruciate ligaments.

Salter Harris Type IV (SHIV)

SHIV fractures of the distal femur are uncommon. This injury pattern involves a fracture that extends vertically through the distal femoral metaphysis, physis and exits through the articular surface of the epiphysis.

Salter Harris Type V (SHV)

SHV fractures occur when the physis is crushed. This injury is rare and similar to SHI fractures in that they are often diagnosed retrospectively, when growth disturbance is observed following injury to the knee.

Management

Non-operative

Non-operative management may be considered in the case of non-displaced fractures. The injured leg is immobilised in a long leg cast for 4-6 weeks. Close clinical follow up by orthopaedics is essential to minimise complications.

Operative: closed technique

Closed reduction and percutaneous fixation followed by casting is used in cases of displaced SHI or SHII fractures. Some SHIII and SHIV fractures may be treated in this manner if anatomical reduction can be achieved. Again, the patient is followed closely post-operatively by orthopaedics to monitor for complications.

Operative: open technique

Open reduction internal fixation (ORIF) is indicated in the case of SHIII and SHIV fractures with weightbearing articular involvement or in the case of irreducible SHI or SHII fractures.

Complications

Growth arrest and arthritis

Any physeal fractures of the distal femur can be complicated by growth arrest. SHI and SH II fractures in other areas of the body usually have a low risk of growth arrest but in the case of distal femoral physeal fractures even minimally displaced SHI and SHII type fractures should be followed closely for physeal injury leading to growth arrest.

A complete growth arrest can lead to limb length discrepancies. A partial growth arrest can lead to angular deformities at the knee. SHIII and SHIV fractures that heal with displacement can produce post-traumatic arthritis because of their joint surface involvement. The risk of these complications can be minimised by maintaining anatomical physeal alignment and close follow up following non-operative and operative treatment.

Popliteal artery injury, peroneal nerve palsy and compartment syndrome

Although rare, vascular injuries can be associated with anterior displacement of the epiphysis or a posterior spike at the fracture site. Some studies have suggested that peroneal nerve palsy is observed in approximately 7.3% of distal femoral physeal fractures and compartment syndrome is noted in approximately 1.3% of these injuries.

Classic metaphyseal lesions

While discussing distal femur fracture patterns, it is important to mention classic metaphyseal lesions (CML). These fractures, also known as ‘bucket handle fractures’ or ‘corner fractures’, are highly specific for non-accidental injury (NAI) in children <1 year old. CMLs are most common in the tibia, femur and proximal humerus and can result from shearing forces applied to these long bones, which causes avulsion of the metaphysis. Shearing forces can be produced by holding a child by their trunk and shaking them causing their limbs to move back and forth. Any fracture in a non-mobile child should raise suspicion for NAI but be vigilant for the subtle findings of CMLs on X-ray. If you have concerns regarding NAI, escalate your concerns to the most senior clinician, contact the relevant social work / safeguarding department and discuss fracture management with the orthopaedic team. Refer to local hospital guidelines to give you an idea of what teams the child should be admitted under and what investigations should be carried out. See these DFTB resources related to child safeguarding for more information: skeletal surveys and NAI and safeguarding module facilitator guide.

Metaphyseal corner fracure of the distal femur. Courtesy of Orthobullets.com

The orthopaedic team review Marcus and a CT of his distal femur and knee is ordered to evaluate the degree of intra-articular extension and to define fracture fragments to plan fixation. Following CT he undergoes open reduction and internal fixation (ORIF) of the SH III fracture to distal femur and he is discharged home after a couple of days in a long leg cast. He will be closely monitored in fracture clinic during his recovery to minimise the risk of complications.

References

Amick A. (2019, Oct 7). Non-Accidental Trauma. [NUEM Blog. Expert Commentary by Riney C]. Retrieved from: http://www.nuemblog.com/blog/nonaccidental-trauma.

Ilharreborde, B., Raquillet, C., Morel, E., Fitoussi, F., Bensahel, H., Penneçot, G.F. and Mazda, K. (2006). Long-term prognosis of Salter–Harris type 2 injuries of the distal femoral physis. Journal of Pediatric Orthopaedics B15(6), pp.433-438.

Kareem, S., Shirley, E. and Skaggs, D. (2020). Distal Femoral Physeal Fractures- Pediatrics. Retrieved from: https://www.orthobullets.com/pediatrics/4020/distal-femoral-physeal-fractures–pediatric

McKenna, S.M., Hamilton, S.W. and Barker, S.L. (2013). Salter Harris fractures of the distal femur: Learning points from two cases compared. Journal of investigative medicine high impact case reports1(3), p.2324709613500238.

Price, C.T (2020). Extra-Articular Injuries of the Knee. Retrieved from: https://teachmeorthopedics.info/extra-articular-injuries-of-the-knee/

Wall, E.J. and May, M.M. (2012). Growth plate fractures of the distal femur. Journal of Pediatric Orthopaedics32, pp.S40-S46.

Crash course in stomas

Cite this article as:
Georgina Bough, Susan McDowell, Nikki Webber + Ana Waddington. Crash course in stomas, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32832

Thank you to the Paediatric Stoma Care guidebook 2019 written by The members of the Global Paediatric Stoma Nurses Advisory Board (GPSNAB).

You are working in A&E and a child comes in with a ‘funny looking stoma’. Parents have been told to come to ED because it’s the weekend and no speciality teams are available.  Where do you start?

Children, babies and even premature neonates can have a stoma.  A stoma is a surgically formed ‘mouth’ or opening into a hollow organ.

Do you know the difference between stomas?

Faecal Stoma

  • End ileostomy/colostomy
  • Loop ileostomy/colostomy
  • Stoma with mucous fistula

Urinary Stoma/ Diversions

  • Vesicostomy
  • Ileal conduit
  • Ureterostomies

Continence Stomas

  • Mitrofanoff/Monti
  • Antegrade continence enema (MACE/ACE)

Feeding Stomas

  • A gastrostomy or jejunostomy is a type of stoma, they often have the same problems as other stomas even though we often think of them in a different way.  They are covered in more detail here.

Why do Children/Young Adults need Stomas?

The majority of the stomas made in neonates and children are reversed.  The length of time with the stoma varies from a few months to a few years depending on the diagnosis, the situation, and the family and medical team’s preferences. 

Indications for faecal stoma

Neonates

  • Anorectal malformation/ cloacal malformation:  A stoma (colostomy) is often formed to allow them to poo until the baby has the operation to create a new bottom.
  • Hirschsprung’s disease: Most babies with Hirschsprungs’ disease will be managed without a stoma but if the washouts don’t work a stoma (ileostomy) can be formed.  A stoma can also be formed as part of the operation to work out how much bowel is affected (a levelling stoma).
  • Necrotising enterocolitis (NEC): If a baby needs an operation for NEC they often need part of their intestine removed. Joining the ends may not be safe straight away.  They will then have a stoma (ileostomy/ jejunostomy).
  • Other causes of bowel injury in babies: Faecal stomas are also formed if a baby has a bowel blockage, bowel damage or perforation for another reason and the bowel cannot be safely joined back together at the first operation.  Other reasons include: small bowel atresia, malrotation and volvulus, meconium ileus.

Children / Young Adults

  • Constipation: Occasionally constipation is so bad that children need a continence stoma or a faecal stoma.  This can still be reversed in the future if it is not needed any more.
  • Inflammatory bowel disease: when medical management doesn’t work or in an emergency situation a stoma can be formed to divert the poo and rest the bowel.
  • Accidents: Occasionally in trauma a stoma can be formed as part of a damage-control laparotomy in a very sick child or when there is extensive damage to either the bowel, the pelvis or the bottom.  The stoma allows control of contamination (phase 1 DCS) before full resuscitation (and further investigations / operations).

Indications for urinary stomas

  • Posterior urethral valves: If a baby is born with posterior urethral valves is too small for cystoscopy and catheters aren’t an option a vesicostomy can be formed.
  • Neuropathic bladder: If a baby has a neuropathic bladder and catheterisation is not an option a vesicostomy allows the bladder to drain without creating a high pressure which can damage the kidneys
  • Trauma: Supra-pubic catheters are typically used to divert the urinary stream in trauma but other forms of urinary stomas are an option if a suprapubic catheter is not.

Continence stomas:

The appendix or a small piece of intestine can be used to make a tube that connects the bladder (Mitrofanoff / Monti-mitrofanoff) or bowel (ACE – antegrade continence enema) to the abdominal wall.  This forms a continent stoma (one that doesn’t leak) and allows a tube to be passed to drain urine or to give an enema.  This allows children who would otherwise be incontinent to be clean e.g. with severe constipation or a neuropathic bladder.

A beginners guide to stoma spotting

The aim is to work out what type of stoma this is (it is often written in the notes or the parents/carers know but that’s not the point!).  Helpful questions are: what is coming out of the stoma, how many holes does it have, does the end stick out and is it a happy stoma?

What is coming out?

How many holes does it have? 

Does the end stick out?

Is it a happy stoma?

What could have gone wrong?

Stoma complications either happen early after a stoma is formed or later.

  • Early – Necrosis, wound breakdown, infection,
  • Later – Prolapse, retraction, stricture, bleeding, granulation tissue, leakage around the bag/ bag not sticking.

What are the risks? 

  • Skin irritation Although the stoma itself has no sensation, the skin surrounding it does and it can become irritated by both the adhesive of the stoma bag, and also by the stool itself. Often, these irritations can be minor, but in some cases they can start to cause the skin to break down. The nursing staff and the stoma nurse specialists will observe for early signs of irritation.
  • Prolapse A prolapse is when the bowel becomes longer and protrudes through the opening of the stoma. Although this can be very frightening for parents, it is not usually serious. As long as the bowel remains pink and active, we will simply keep a close eye on it.
  • Retraction Retraction (also known as inversion or ‘moating’) of the stoma is when the stoma sinks below skin level. This can lead to problems with applying the bag. The nursing staff and stoma nurse specialists will have suggestions on how to help.
  • Bleeding The stoma will occasionally bleed, especially when touched. This is normal unless the bleeding does not stop. 



Trouble shooting

Not happy taking a stoma bag off

It can be intimidating taking off a stoma bag especially if you’re not happy putting it back.  The parents will often be expert at this even if they are reluctant to take the bag off because it is sore for the child.  It is worth having someone else come with you and having a camera to take a picture of the stoma (this can be the parent’s phone) so that the bag is only taken off once. Here’s a happy stoma bag change…

Leaking stoma bag

This can be really tricky to manage and stoma nurses are essential. Some basic tricks are: 

Make sure that the stoma bag is warm before you put it on – warm it up under your arm or in your pocket. This makes it more flexible and sticky and the seal will be better.  

Prepare, take your time and have enough help.  If the child is wriggling, changing a stoma bag is really hard so get all the kit together beforehand including plenty of cleaning supplies. Cut the new bag before you remove the old one and use stoma bag removing spray. Remember to dry the skin completely.

There are many products that are designed to help with different bags, fillers to even the skin around the stoma, powders to help the seal.

Make friends with your stoma nurse.  If they have written a plan follow it if at all possible.

Skin breakdown

When a bag leaks, is changed frequently or is cut poorly the skin around the stoma breaks down.  Barrier wipes / sprays and stoma removal sprays are a good start but it takes time and expert help to heal.

Rectal discharge

It is normal to have some rectal discharge after stoma formation. It can be due to leftover stool in the rectum, spill over from a loop stoma, ongoing mucous production from the bowel or diversion colitis.  If the discharge is foul smelling or bloody the medical team looking after the child should be made aware and can often help with diversion colitis.

High output faecal stoma

Stomas can have a high output if they are made close to the stomach or if the child is sick for any reason (like a form of diarrhoea).  It is important that they don’t get dehydrated, stoma losses >20ml/kg typically need replacing intravenously.  

Prolapse

Some stomas prolapse all the time (chronic) and some prolapse acutely.  If the stoma is pink and healthy and working (passing gas and stool/urine depending on the type of stoma) that is reassuring.  If it is not, then the child should be transferred urgently to a surgical centre.  If the stoma is acutely prolapsed then it should be reduced.  Put lignocaine gel / lots of sugar on the stoma to draw the swelling out, leave it alone for around 40 minutes and then try and push the stoma back5.  Sometimes the stoma will need an operation to revise it. If this is a chronic problem then revision is usually an elective procedure.

Poor growth

If the colon is bypassed by a stoma the body often doesn’t take up enough salt and this can slow growth. The serum sodium will be okay but in the urine they will be low.  It is worth checking a urinary sodium and supplementing with oral sodium if the levels are below 20mmol/l.

Selected references

1. Farrugia MK, Malone PS (2010) Educational article: The Mitrofanoff procedure. J Pediatr Urol 6:330–337. https://doi.org/10.1016/j.jpurol.2010.01.015

2. Fracs SKK, Krois W, Lacher M, et al (2020) Optimal management of the newborn with an anorectal malformation and evaluation of their continence. Semin Pediatr Surg 150996. https://doi.org/10.1016/j.sempedsurg.2020.150996

3. Hutton KAR (2004) Management of posterior urethral valves. Curr Paediatr 14:568–575. https://doi.org/10.1016/j.cupe.2004.07.013

4. Okada T, Honda S, Miyagi H, Taketomi A (2011) Technical Points Regarding New Enterostomy Formation for Incarcerated Stomal Prolapse in Loop Enterostomy. Surg Sci 02:488–792. https://doi.org/10.4236/ss.2011.210107

5. Landim Júnior JA, Moura Júnior JV, Lima Forte HB, et al (2020) Topical osmotic therapy for a prolapsed incarcerated ostomy. J Pediatr Surg Case Reports 57:101454. https://doi.org/10.1016/j.epsc.2020.101454

6. Forest-lalande L, Vercleyen S, Fellows J (2018) Paediatric stoma care: Global best practice guidelines for neonates, children and teenagers. 3–70

7. Holcomb III GW, Murphy JP, Ostlie DJ (2014) Ashcraft’s Pediatric Surgery, 6th ed. Elsevier Saunders

Don’t Forget about Malaria…

Cite this article as:
Emma Hulme and Chris McKenna. Don’t Forget about Malaria…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32891

Sunday (April 25th) is a day to refocus our lens of the past 14 months living and working through the global COVID-19 pandemic and be reminded of the ongoing global battle countless countries are continuing to fight against Malaria. Today is World Malaria Day, a day to celebrate the victories, reflect on the challenges, stand in unity with our global colleagues and remember those many children and individuals who are still losing their lives to a preventable disease. 

Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. It is preventable and curable.

My first experience of how dangerous malaria could be was in Kenya in 2003. I was a febrile third-year medical student, sitting in the back of a pick-up truck following a seemingly endless dirt track to the nearest Health Centre with my unconscious friend who had just had a seizure.  Whilst we both had a rocky few days, we both made full recoveries and are counted amongst the privileged few to survive without ongoing sequelae. Malaria had managed to get through the defensive mosquito nets and antimalarials, but we had access to a vehicle for rapid transport, access to money for treatment, and some knowledge as medical students to ensure we got to the right place, at the right time, and got the right treatment. Many are not so fortunate.

Fast forward five years to Uganda in 2008. I would never get used to the cries of mothers who had carried their children unimaginable distances to our rural hospital only for it to be too late and then to watch the sight of them carrying their lifeless bodies home to be buried. It all just seemed so futile – if only they had a bed net or could have gone to a clinic sooner. Sadly, as in many preventable diseases, the most deprived communities are affected disproportionately and children under five years old carry the biggest death toll.

This year we have been bombarded with daily infection rates and death tolls as increasingly large figures appear on our screens. Clinicians and the public alike were shocked and horrified by these growing numbers. Have we become “statistic-fatigued”? Do the numbers no longer hold their impact? For those of us not living in a malaria-endemic area, the personal experiences are few and far between. These malaria statistics hold the stories of many but the identity of none. Let’s look afresh at these huge numbers and allow ourselves to be shocked and horrified, figures that have remained unacceptable for years, decades, and millennia.

The current yearly figures from WHO report 229 million cases of Malaria worldwide with a death toll of 409 000 the majority (67%) of these being children under 5 years old. That means a child is dying from Malaria every 2 minutes. This is not OK!

Data taken from Targetmalaria.org

 

A concerted global effort over the past few years has saved hundreds of thousands of lives with preventative malaria programmes. The World Health Organisation (WHO) estimates in excess of 1 billion malaria cases and 7 million deaths have been prevented since 2000. The number of countries being declared malaria-free is also increasing. This helps reduce huge systems and economic burdens on a country. The WHO’s E-2025 report is announcing that 26 countries and territories are within reach of zero malaria cases by 2025. This is really encouraging yet there is still a long way to go for many countries, particularly in Africa.  

Every Win Counts

Rural Bo District – Sierra Leone, 2011, Sitting in the shell of a clinic that had been built and subsequently abandoned by an NGO after the civil war, we see over one hundred children, sixty of these testing positive for malaria. A simple treatment, but with no health providers for two hours, one exceedingly difficult to access. 


Fast forward nine years, and I’m sitting in a similar rural setting in Bonthe District, but there is finally a referral process to ensure these children and their mothers can get to the referral hospitals in the major population centres for appropriate management and treatment. 

One of the most effective weapons in continuing this fight is the younger generation, those that grew up in a time where Malaria is no longer an unconquerable giant, but something that can be overcome.  The ‘Zero Malaria’ and ‘Drawing the Line’ campaigns empowered young people to keep taking ground. ‘’Malaria we will not let you steal from us anymore… We are the generation that can end Malaria!’’

Young people across Africa have seen the impact of malaria on their lives and futures and are motivated to take action. Even if malaria doesn’t kill, it prevents young people from going to school, realising their full potential, and building their futures. Recent surveys have shown that young people are keen to volunteer in distributing mosquito nets, sharing information about malaria, as well as engaging with their community and national policymakers to prioritise malaria. 

Malaria experiences from our colleagues at Mbarara University EMIG

As a medical student who has been trained in Uganda – a country where malaria is a major public health problem that is associated with slow socio-economic development and poverty, and the most frequently reported disease at both public and private health facilities. One always hears ‘Common things occur commonly and rare things occur rarely”. Malaria goes beyond being common in our communities; “You can’t just convince a senior house officer or attending that you have learnt something from their ward if you don’t know how malaria manifests in their speciality– for example malaria in pregnancy or severe malaria in paeds. We are expected to be “singing” (having them at our fingertips) the signs and symptoms, investigations, laboratory findings, the treatment plans, and the complications of malaria, like nothing else.

“It goes beyond experiencing malaria as clinicians—some of our colleagues had to become caretakers during their younger years to care for their parents suffering from malaria, which can leave some of them with traumatizing experiences. CoArtem and Panadol are like some food in the home. They should always be there” – Fourth Year Medical student MUST-EMIG.

“Complications of malaria are one of the popular things that we are commonly tested on about on ward rounds” – Fourth-year medical student and founder of MUST-EMIG

So back to 2021, COVID-19, and the challenges ahead…

There are real fears that the challenge of COVID-19 has been a huge threat to the progress made in eliminating Malaria. Many places have faced an increased burden on already fragile health systems. There have been disruptions to the distribution of materials including mosquito nets and antimalarials, as well as reports of increasing reluctance to seek medical care for patients with a fever due to the fear of the stigma of COVID-19. The WHO’s estimates that malaria interventions have been reduced by between 15 and 25 per cent during the pandemic. Furthermore, in 2020, the COVID-19 pandemic likely caused 40-50,000 excess deaths from malaria that otherwise could have been prevented. 

Behind the scenes underreporting also exists and the reality of the global refugee crisis and countless internally displaced persons (IDP) means many are facing ‘syndemics’ of COVID-19 and malaria, combined with any other crisis du jour in a variety of environments. 

So what has been happening with malaria elsewhere? 

Unsurprisingly, the number of malaria cases identified in 2020 in those with recent travel history to an endemic area have fallen. Malaria tests performed (on adults and children) at the Manchester Foundation Trust have fallen by 68% compared to 2019, with 92% fewer positive cases. As travel corridors start to re-open, those working in malaria-free countries will need to start thinking ‘could this be malaria?’ once again. While this fall in testing numbers is not surprising, it doesn’t mean that you shouldn’t include malaria on your list of differentials when warranted.  There is a great refresher on the website and here’s a memory jog for those of us who haven’t thought about malaria for a while.

Think Malaria

  • Fever or anaemia in a child who has recently returned from a malaria-endemic area
    • Ordering appropriate investigations (ideally timed with fever spikes)
    • Familiarise yourself with local protocols
    • Microscopy (thick and thin smears) remains the gold standard. Rapid Diagnostic tests are valuable, particularly in resource-limited settings, but are less sensitive
  • Involve infectious disease services early if required!
  • Severe malaria includes the clinical suspicion with confirmed parasitological and at least one of the following: 
  • High parasite density (≥5%)
  • Impaired consciousness
  • Seizures
  • Circulatory collapse/shock
  • Pulmonary oedema or acute respiratory distress syndrome (ARDS)
  • Acidosis
  • Acute kidney injury
  • Abnormal bleeding or disseminated intravascular coagulation (DIC)
  • Jaundice (must be accompanied by at least one other sign)
  • Severe anemia (Hb <7 g/dL)

OR

  • The inability to take any oral antimalarials even after administration of an antiemetic.
  • A child with malaria can have a bacterial co-infection, be sure to address that if suspected!
  •  It is vital to differentiate uncomplicated vs complicated (severe) malaria early.
  • Oral outpatient management for uncomplicated malaria is reasonable, but urgent inpatient management for severe malaria is required. 

A call to action

Moving forwards there is a call to urgent action to ensure that all the progress that has been made is sustained and built upon. Global and national leaders need to continue to prioritise funding and facilitate research and development into new interventions as well as the delivery of effective prevention and treatments to the most vulnerable areas. There needs to be ongoing recognition and support for those health care workers delivering care in such challenging circumstances to ensure access to Malaria prevention, testing and treatment for all. 

Ultimately, there is hope. The end is in sight and malaria eradication is possible. We had a great start with the Global Malaria Eradication Programme started in the 1950s, but the reality of the times prevented further success. Let’s not forget every child and family behind the statistics. Be outraged by the numbers but also encouraged by the wins. Keep talking about malaria. Encourage and support our global colleagues. Listen to their experiences, learn from them, and keep standing united together to eradicate Malaria.

What can you do today?

Share the post. Encourage our global colleagues today – we stand with you #endmalaria #zeromalaria #drawtheline #zeromalariastartswithme #worldmalariaday. Remember Malaria! Listen to your patients, take a travel history, ensure you make referrals appropriately. Engage the ID team early if you are unsure! 

Selected references

Dyer O. African malaria deaths set to dwarf covid-19 fatalities as pandemic hits control efforts, WHO warns. BMJ 2020; doi:10.1136/bmj.m4711

Mendenhall, E., 2020. The COVID-19 syndemic is not global: context matters. The Lancet, 396(10264), p.1731.

RBM Partnership to End Malaria. (2021). World Malaria Day 2021 Key Messages.

Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. The Lancet, 389(10072), 941–950. doi:10.1016/s0140-6736(17)30003-x 

World Health Organization. (2020). World malaria report. Geneva, Switzerland: World Health Organization.

https://targetmalaria.org/ Accessed 13/4/2021

https://endmalaria.org/ Accessed 13/4/21

https://www.theglobalfund.org/en/ Accessed 13/4/21

Haematology Laboratory Manchester University Foundation Trust (personal communication)

Dr Emma Hulme

MBChB, MPH, MRCGP, DTM&H, DCH, DRCOG, DFRSH

Emma works as a GP in a city practice and in the Emergency Department at the Royal Manchester Children’s Hospital. Before training in General Practice she worked in a number of countries overseas in maternal and child health roles and currently leads the Global DFTB Bubble. The rest of her time is spent chasing after her 3 little people and trying to find a quiet corner for 5 minutes peace!

Christopher McKenna, MPH

Chris is a former critical care paramedic turned final year medical student at the University of Queensland – Ochsner Clinical School in New Orleans, Louisiana. Originally from NJ, he has spent time working on pre-hospital system development in Somaliland and Sierra Leone, as well as time with various NGO/IGO in the Philippines. He is eager to return to Australia for his internship in 2022 with the ultimate goal of pursuing a career in PEM/EM. When not at the hospital, he can be found dreaming about travelling post-COVID, avoiding falling into the Gulf of Mexico/Mississippi River in the search of the perfect burger, or at pub trivia with his partner at a local brewery.

Fibula fractures

Cite this article as:
Shah Rahman. Fibula fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31860

Romesh, a 6 year old boy, was playing on some monkey bars at school when he slipped, and landed on his legs, and has been unable to weight bear since. The bars were approximately 1m high, and on examination, positive findings include an area of bruising over the lateral aspect of the right lower leg and marked tenderness on palpation.

Incidence

Isolated fibula shaft fractures are rare. More commonly, they are associated with tibia fractures, or with an ankle fracture affecting the distal fibula.

How might the patient present?

History

The mechanism is key to the injury pattern identified:

  • Direct trauma to the lateral aspect of the lower leg resulting in a transverse or comminuted fracture.
  • Twisting injuries producing a spiral fracture.
  • Repeated stress such as in long-distance runners can cause a fatigue fracture, usually just above the inferior tibiofibular ligament. Think of the cross-country running teenager who usually wouldn’t present but has new lower leg pain or antalgic gait

Examination

  • The normal process of look, feel, move is a good step after an initial history. Always examine the knee and the ankle as well as evaluating for other areas of injury. Gait is a useful assessment, as isolated fractures are likely to be treated conservatively.

Investigations

  • X- ray is the initial imaging modality of choice
  • Point of care ultrasound could be used to confirm the presence of a fracture, but given the risk of other associated bony injuries, patients will still require imaging.
  • Patients with complex injuries involving other bones or joints may warrant cross sectional imaging
  • Does the history match the injury – is there a risk for NAI?

Classification

Fibula fractures are classified by fracture type, whether there is an associated tibial fracture, whether they’re displaced or not and whether they’re open or closed,

  • Displacement i.e. 0-50% displaced, >50% displacement with bony contact, or fully displaced
  • Open/Closed
  • Greenstick type patterns can occur
  • Toddler’s fracture (Spiral fracture of the tibia) may uncommonly have an associated fibula fracture

Treatment

  1. Analgesia
  2. Remove significant contaminants from open wounds and administer antibiotics early
  3. Isolated shaft fractures – treat with either a supportive dressing, a cast or a boot
  4. As the fibula is rarely fractured in isolation, the need for surgical management (such as open reduction and internal fixation) if usually dictated by that of any associated tibial fractures

Potential complications

As with any fracture, union issues (delayed, malunion and non-union) is a risk, made worse if there’s infection. Compartment syndrome is a risk, but is more relevant if there is an associated tibial fracture. Be suspicious of an isolated spiral fracture at the proximal fibula; it may be associated with a distal tibia fracture, called a Maisonneuve fracture. These do poorly with conservative treatment, meaning the ankle must be imaged in those with an apparently isolated fracture of the fibula to prevent a missed tibial fracture. Although rare, these can occur in older adolescents with closed physes.

Ensure associated nerves (common peroneal if the fibular neck is fractured), arterial territory (the anterior tibial pulse) and lateral collateral ligament is intact with normal function. The lateral collateral ligament joins the femur and fibula, so whilst not as important as the other collateral ligaments, if damaged, it has a high co-incidence of stiffness or pain in other areas such as knee, ankle and foot can delay full rehabilitation.

Do not miss…

  • Compartment syndrome
  • Other associated fractures – namely at the ankle and tibia
  • Fibular head dislocation – the mechanism is usually a fall on a flexed knee, and can be managed with closed or open reduction.

And a bit of trivia

Some patients can be born without a fibula (fibula hemimelia). This will be picked up on ultrasound screening or on newborn screening, but may be relevant for those patients who haven’t presented to healthcare or have migrated.

Romesh was given loading doses of paracetamol and ibuprofen, as well as intranasal diamorphine. His lower leg x-ray, which also included ankle views, and his right lower leg shows a minimally rotated spiral distal tibia fracture and proximal fibula fracture – a Maisonneuve. He was taken to the emergency trauma list and managed with open reduction and internal fixation.

References

Emergency Care of Minor Trauma in Children, 1st Edition, Davies F

Lecture Notes Orthopaedics and Fractures, 4th Edition, Duckworth T and Blundell CM

Essential Orthopaedics and Trauma, 5th Edition, Dandy DJ and Edwards D

Acute pelvic pain

Cite this article as:
Tara George. Acute pelvic pain, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32492

Acute pelvic pain in females is a common presentation. Whilst it often seems to drive terror into the hearts of clinicians patients are often a lot more straightforward to assess that you think they will be.  In fact, the whole of non-specialist gynae is a topic that lends itself well to Bayesian decision modelling. Your patient is either “pregnant” or “not pregnant” and that she might have pain, bleeding, discharge or a combination of these things. Today I want to focus on acute pelvic pain as the primary presenting symptom.

Alina is 15. She presents to A&E in significant pain and is tearful.  She describes a 2-3 day history of intermittent lower abdominal pain which doesn’t appear to localize to any particular side but which is possibly slightly worse on the left. She’s been having 1g paracetamol four times a day for the last 48 hours as well as maximum doses of ibuprofen. They seem to dent the pain a bit but when they wear off she is left crying with pain and unable to cope. She describes it as “like the worst period pain I’ve ever had” but is adamant it isn’t her period as “that was 2 weeks ago”. It is a lot worse today and she has been vomiting with the pain.  Alina is struggling to stand as she sobs her way through triage leaning on her mum.

At this point it is probably worth having a list of possible differential diagnoses in your head to help to tailor your assessment to come to a diagnosis and most importantly to rule out the life threatening “never miss” causes of severe pelvic pain. 

Possible diffentials for acute pelvic pain in the adolescent:

  • Ectopic pregnancy
  • Pelvic Inflammatory Disease
  • Miscarriage
  • Dysmenorrhoea
  • Ruptured or torted ovarian cyst
  • Torted ovary
  • Mittelschmerz
  • Endometriosis
  • Appendicitis
  • UTI
  • Sickle cell crisis
  • Porphyria
  • Haematocolpos
  • Unexplained

Ectopic pregnancy

Top of your list of things to look for and rule out in a case of acute pelvic pain in a female of childbearing age has got to be ectopic pregnancy.  A negative urine pregnancy test, especially in the context of a young person with a reliable menstrual history AND with a LARC method of contraception on board AND/OR a sexual history of not being sexually active is a good way to rule out pregnancy rapidly.  In this presentation there would be little, if any, justification for not doing a urinary pregnancy test. In many A&E departments a pregnancy test is a standard triage investigation along with a urine dip for blood/protein/WBC and nitrite before a clinician even starts their assessment. If the pregnancy test is positive, she needs a comprehensive assessment to exclude other causes of acute pain. But until an ectopic has been fully excluded, it must remain the working diagnosis of the moment with anything else coming second. 

The NICE guidelines from 2019 provide an extremely useful and user-friendly guide to managing ectopic/early miscarriage.  NICE remind us that PV bleeding and pain, whilst common symptoms of an ectopic, are not always present.  In order not to miss it we need to have a low threshold for doing a urinary pregnancy test in any female of reproductive age. This table from the guidelines is a helpful summary of other less common presenting symptoms in which a pregnancy test may well be indicated.

Causes of acute pelvic pain
Presenting complaints of a ruptured ectopic pregnancy

Advice around examining patients with a suspected ectopic pregnancy seem to vary from department to department and, interestingly, NICE make no comment on this. In primary care, the traditional teaching is not to do a bimanual examination in case the pressure of the physical examination on the adnexal mass ruptures the ectopic. In a hospital setting, with resus and surgical facilities, a bimanual looking for cervical excitation and guarding may help make the diagnosis.  If they are stable an expectant approach looking for B-hCG doubling (for a normal pregnancy) or falling (for a failed pregnancy) may be adopted. If medical management with methotrexate is chosen a baseline B-hCG is vital.

A patient with a probable ectopic needs to have bloods taken for FBC, crossmatch and B-hCG and should be referred on the on call gynae service promptly.

Alina’s pregnancy test is negative and she shows you the Nexplanon contraceptive implant she has in her left arm. You start to relax. An ectopic pregnancy is highly unlikely and this almost certainly isn’t a threatened miscarriage.

Pelvic inflammatory disease

Next one down in the serious/scary things to rule in or out urgently is Pelvic Inflammatory Disease.  The British Association for the Study of Sexual Health (BASSH) recommend that acute pelvic pain in a non-pregnant woman aged <25 is PID until proven otherwise.  1 in 60 primary care consultations in women aged under 45 is for PID.  Youth is a major risk factor especially if associated with multiple or new sexual partners.  Taking a sensitive but full sexual history is vital. Asking direct questions such as “when was the last time you had sex?”, “who was it with?”, “did you use a condom?”, “how many other people have you had sex with in the last 3 months?” are likely to yield clearer answers. 

In teenagers try and avoid the phrase “are you sexually active?”. Most won’t understand the nuance of the question and the number of teenagers who answer “no” but later turn out to be “sexually active” is high.  You may well need to ask these questions more than once, ideally without the parent present. Acknowledging that they are having sex, especially with multiple partners, may well not be anything they want their parent to know.  In the UK and the USA the incidence of chlamydia, in the 14-24 age group, is quoted as 1 in 20 women.

Table showing signs and symptoms of PID
Signs and symptoms suggestive of PID. Abnormal bleeding may manifest as post-coital bleeding, menorrhagia or secondary dysmenorrhoea

The Commonest pathogens in PID are chlamydia (4-35%), gonorrhoea (2-3%), mycoplasma genitalium.  Pathogen negative PID is not uncommon (but is a diagnosis of exclusion).  BASSH advice is that “A diagnosis of PID should be considered, and usually empirical antibiotic treatment offered, in any sexually active woman who has recent onset, lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified

Any patient with suspected PID needs cervical and HVS “triple swabs” taking for chlamydia, gonorrhoea, trichomonas and M. genitalium.  The treatment of choice in PID is IM ceftriaxone 1g stat.  If M. genitalium is found the treatment is moxifloxacin 400mg daily for 14 days.  M genitalium is difficult to isolate and culture and is best seen on NAAT swabs done urgently.  All patients with PID need to be referred to the local GUM clinic for ongoing treatment and contact tracing.  Complications of PID include sepsis, pelvic abscess, chronic pain, infertility as well as ectopic pregnancy so it is really important to suspect, identify and treat to prevent disability or serious illness.

When to admit in PID:

  • Pyrexia >38⁰C.
  • Signs of tubo-ovarian abscess (e.g. fluctuant mass in adnexa).
  • Signs of pelvic peritonitis (rebound, guarding, cervical motion tenderness).
  • No response to oral treatment.
  • Pregnancy

Endometriosis

This is an easily missed diagnosis and a common cause of pelvic pain. Ectopic deposits of endometrial tissue appear in locations outside the uterine cavity, typically on the ovaries, fallopian tubes, and in the peritoneum.  These deposits respond to hormonal changes during the menstrual cycle and during menstruation they bleed, causing irritation and pain. The pain, classically, is cyclical, and at its worst in the day or two before menstruation. As the condition progresses and becomes more chronic adhesions can form and the pain can become more severe and constant.  It is worth being aware that laparoscopy findings do not always correlate well with symptoms. Some women can have severe symptoms with what appears visually to be small/minimal deposits and other woman can have minimal symptoms with quite “severe disease”.  On average it can take 6 years from first presentation to make a diagnosis.  Management is usually symptomatic with the combined contraceptive pill, analgesia and sometimes surgery.

Haematocolpos

This is a really rare condition that is worth bearing in mind even though it may well be a once in a career diagnosis presentation. Menstrual blood builds up in the vagina and uterus due to presence of a thick complete vaginal membrane – an “imperforate hymen”. Classically the adolescent presents with cyclical pelvic pain and primary amenorrhoea.  An ultrasound will show a grossly distended uterus filled with old blood and treatment involves surgical division of the vaginal membrane under a general anaesthetic.

Mittelschmerz

Translated literally from the German as “middle pain”, Mittelschmerz is cyclical pain occurring mid-cycle at the point of ovulation. It is uncommon. It will not occur in someone on an anovulant contraception, and whilst painful, is unlikely to render someone unwell enough to present to ED.

Alina’s abdominal examination reveals tenderness globally over the lower abdomen but worst in the left iliac fossa with some guarding.  She tells you she has not had sex for 3-4 months and has no PV bleeding or discharge.  You attempt a bimanual and speculum examination with verbal consent and the support of her mum and a nurse, but she is crying in severe pain and you have to stop. She is tachycardic with a HR of 122 but her other observations are normal. Her FBC, CRP and urine dip are normal as was the urinary pregnancy test. 

You suspect ovarian pathology, either a ruptured or torted cyst or an ovarian torsion and arrange an ultrasound scan.

Ovarian cyst

Ovarian cysts occur in around 10% of pre-menopausal women and are often an incidental finding on an ultrasound scan done for an unconnected reason. The vast majority are benign in nature, asymptomatic and require no treatment.  The RCOG Green Top guideline 63 from 2011 advises that the majority of asymptomatic incidental cysts should be managed conservatively reassuring us that “the overall incidence of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1000”. Most of us remember the ovarian teratoma from our embryology and pathology lectures as undergraduates. Ovarian teratomas are almost always benign, though scary looking if well differentiated, and containing teeth or hair. This is in contrast to testicular teratomas which have a high risk of malignancy.

An ovarian cyst can rupture or can twist on its pedicle – leading to torsion of an ovarian cyst. Both can result in acute pelvic pain associated with peritonism and vomiting.  Diagnosis is usually be made on ultrasound scan though occasional a diagnostic laparoscopy is the only way to identify the situation. Management of a ruptured or torted cyst will usually be surgical though a small ruptured cyst in a haemodynamically stable patient may be managed conservatively with observation.

Ovarian torsion

Ovarian torsion occurs when an ovary twists on its ligamentous supports compromising the blood supply and presenting as acute pain. This is often associated with peritonism and vomiting. A rapid diagnosis is important in to save the ovary and conserve future fertility.  The twisted pedicle may be visualized on ultrasound scanning or may only be seen on diagnostic laparoscopy.  Treatment is always surgical and the ovary may not always be salvageable.

An urgent ultrasound scan reveals an enlarged left ovary, dopplers with minimal venous flow but preservation of arterial flow, and a twisted vascular pedicle referred to as the whirlpool sign, there is free fluid in the Pouch of Douglas. Alina is consented for a laparoscopy to include attempt to untwist and fix the ovary but with consent to perform oophorectomy if this is unsuccessful.  Unfortunately the surgeon is unable to save the ovary and an oophorectomy is required. Alina makes a good recovery and is discharged home 36 hours post operatively.

Selected references

NICE NG126 April 2019 – Ectopic Pregnancy and Miscarriage, initial presentation and management 

RCOG Green Top Guidelines on ectopic pregnancy 2016 

BASSH 2019 guideline update on PID 

https://www.aafp.org/afp/2010/0715/p141.html