Uterine (decidual) Casts

Cite this article as:
Tara George. Uterine (decidual) Casts, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32416

Lucy, 15, arrives in the ED sobbing hysterically clutching a wad of toilet paper. “I thought it was my period… only I had the worst period pains ever. I went to bed with a hot water bottle and it got worse and then… this came out”. She sobs, opening the tissue to show you a fleshy, pale triangular thing. approximately 5cm long.  “What is it? It’s disgusting. Have I got cancer? I’m not pregnant am I?”

Bodily secretions in tissues are rarely a source of delight but are common opening gambits. Vomit, faeces, sputum, vaginal discharge, worms, lice, blood clots and products of conception may be saved up and brought to the doctor to add colour to the history.    They present a challenge as often we don’t want to look. We don’t trust ourselves not to recoil or be disturbed and being presented with a “sample” early on can catch us off guard. It plays havoc with the “history, examination, management plan” structure we like to impose on our consultations.  In presentation terms, though, this is a gem of a presentation. We have an “Idea”, a “Concern” and it won’t be long before we elicit an “Expectation”.  Avoiding the enormous cue as it is thrust into your orbit, whilst tempting, risks dismissing the concerns. This can destroy any fledgling rapport and make the whole encounter even harder.  It is going to be necessary to take a history, but right now we have a distressed teenager, an unidentified object in a tissue and a lot of emotion. It may well be easiest to address this gift up front and just take a look. This is the time address the upset and the fear head on.

The “thing” looks like this:

Photo of uterine or decidual cast

A uterine or decidual cast occurs when the entire endometrial lining is shed in one piece. They are uncommon but frequently cause distress to the patient and can be extremely painful to pass.  A cast looks almost triangular in shape and if shed whole you can see the contours of the uterine cavity in a sort of fleshy model if you look closely.

Lucy tells you she had a Nexplanon contraceptive implant fitted about 6 weeks ago. She is not currently sexually active.  Her last period started the day before she had her implant fitted. She’s well otherwise with no past medical history. She had some light PV spotting yesterday and this morning but it has been light.  Since she passed the mass her pain has settled completely. Her observations are normal. She is happy to do a pregnancy test which is negative.  She just wants to know what it was, why it happened and if she can go home now.

The vast majority of uterine casts have no identifiable precipitating causes though there are case reports in association with Ectopic Pregnancy and they may be slightly more common in users of Hormonal Contraception though having had a cast is not a contraindication for continued use, nor are recurrent casts likely with continued use. The pain associated with passage of the cast is often severe – remember they are passing a 5cm mass through their cervix.

You reassure Lucy that this is not cancer, that she wasn’t pregnant and that this was a cast.  You explain what a cast is and that it is unlikely to recur.  She goes home much reassured and relieved.

You decide to send the cast to the lab for histology and a few days later a report lands in your in-tray which reads “extensively decidualized endometrial tissue with minimal glandular structures lined by low cuboidal epithelium, consistent with a uterine or decidual cast. No chorionic villi were identified.

References

Nunes, R.D. and Pissetti, V.C., 2015. Membranous Dysmenorrhea–Case Report. Obstet Gynecol Cases Rev2, p.042.

Strauss, L., 2018. Fleshy Mass Passed Vaginally by a Young Woman. American family physician98(7), pp.449-450.

Following bronchiolitis guidelines

Cite this article as:
Ben Lawton. Following bronchiolitis guidelines, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32798

In 2016 our friends at PREDICT produced a robust, evidence-based guideline for the management of bronchiolitis. They assembled a diverse team of experts, decided on the key questions we ask ourselves when managing babies with bronchiolitis and then did a deep dive of the literature to provide answers to those questions. You can read the guideline here, or the DFTB summary here but the key messages will be familiar to regular readers of DFTB. The list of things that do not help babies under 12 months with bronchiolitis includes salbutamol, chest x-rays, antibiotics, nebulised adrenaline and steroids. In the real world, however, these ineffective treatments continue to be used – so what can we do about that? 

The authors of a new PREDICT study released in JAMA Pediatrics on 12 April 2021 sought to demonstrate whether a group of interventions they developed using theories of behaviour change would be effective in reducing the number of ineffective interventions given to bronchiolitic babies. 

Haskell L, Tavender EJ, Wilson CL, et al. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. Published online April 12, 2021. doi:10.1001/jamapediatrics.2021.0295

Who did they study? 

This was an international multicentre cluster randomised controlled trial (RCT) involving 26 hospitals in Australia and New Zealand. It is described as a “cluster” RCT as randomisation was by hospital rather than by patient. The randomisation was a bit complicated. It was stratified to make sure secondary and tertiary hospitals from each country were represented in each group. Baseline data was collected from 8003 patient records from the three bronchiolitis seasons prior to the start of the intervention period. A further 3727 charts analysed from the season in which the intervention took place. The data from the three prior seasons were used to ensure baseline similarity between groups and to establish patterns of practice change that were already occurring. In short, this was a big study that ensured representation of both specialist children’s hospitals and mixed general hospitals. 

What did they do? 

Hospitals randomised to the intervention group received a package of interventions based on the Theoretical Domains Framework (TDF), developed following an earlier qualitative study that investigated why we do what we do when managing bronchiolitis infants. The TDF is one of the most commonly used frameworks in implementation science and is considered particularly good at identifying interventions to address barriers and facilitators that influence behaviour change. The package included:

  • Appointing clinical leads from medical and nursing streams in both emergency departments and inpatient paediatric units.
  • The study team meeting with those clinical leads to explore the local practice and any anticipated barriers to change.
  • A one day train-the trainer workshop to ensure clinical leads were comfortable using the educational materials provided to train local staff.
  • An education pack including a PowerPoint with scripted messages specifically designed to promote change, a clinician training video, evidence fact sheets, promotional materials and parent/caregiver information sheets.
  • Monthly audits of the first 20 bronchiolitis patients with the results shared and compared to the best performing hospital.

What about the control group?

Hospitals randomised to the control group were just left to their own devices for the year of the intervention period. They had access to the guidelines and were welcome to share that information as they would in any other circumstances. The intervention package was made available to control hospitals in the season following the study period. 

What did they show? 

The primary outcome was the proportion of infants who complied with all five of the Australasian Bronchiolitis Guideline recommendations known to have no benefit (chest x-ray, salbutamol, steroids, adrenaline, antibiotics). There was an 85.1% compliance rate in the intervention group compared to a 73% compliance rate in the control group. In other words, in hospitals that were part of the intervention group, an average of 85.1% of kids received care in line with the guidelines, compared to only 73% receiving guideline compliant care in control hospitals. This was a significant difference.

Secondary outcomes showed improvement was consistent in both the ED and inpatient phases of care. Unsurprisingly, there was no difference in hospital length of stay or admission rates to ICU. 

The DFTB verdict

On the surface this is a robust, well designed study showing that if we put some thought and some resources into supporting our colleagues in doing the right thing then babies with bronchiolitis will get better care in our hospitals. They won’t leave hospital any quicker and they won’t have a lesser chance of needing ICU but they will be exposed to fewer interventions that will not do them any good and may do them some harm. Dig a little deeper though and the big messages in this paper go way beyond the management of bronchiolitis. The implementation science based interventions used in this study can be adapted to anything, and though they have been shown to be effective in getting us to do the right thing here, we haven’t shown that their efficiency has been optimised yet. Great breakthroughs in novel medical science are exciting but there are huge improvements in care to be gained through getting the best care that we do know about to every patient every time. This paper should serve as fuel for the fires lighting implementation science’s journey from the shadows to the centre stage of improvement in clinical care. 

From the authors

The study’s senior author, Prof Stuart Dalziel gave DFTB the following take: 

“The key finding is that we can do better. By using targeted interventions, based on established behaviour change theories and developed from work looking at why clinicians manage patients with bronchiolitis the way they do, we can improve the management of patients with bronchiolitis such that it is more consistent with evidence based guidelines.

In the field of implementation science (IS) and knowledge translation (KT) a 14% improvement in care is a large change.

Changing clinician behaviour is complicated, this is especially so for de-implementation of medical interventions. Many factors influence clinician behaviour and it is thus perhaps naïve to think that a single intervention can cause a significant change to behaviour. For a number of decades the majority of clinical guidelines for bronchiolitis have emphasised that chest x-ray, antibiotics, epinephrine, corticosteroids and salbutamol are low-value care and not evidence based. Yet despite this consistent messaging from guidelines the use of these interventions has remained considerably higher than what it should be. While the interventions delivered in our study were not unique (site based clinical leads, stake holder meetings, train-the-trainer workshops, targeted clinical education, educational material, and audit and feedback) they were specifically developed, using an established framework for behavioural change, following a qualitative study that determined why clinicians managed bronchiolitis they way they do. This prior study, addressing the barriers and enablers to evidence based care, and the subsequent step wise approach to developing the targeted interventions that we used was critical in achieving the change in clinician behaviour observed in our randomised controlled trial”.

The study’s lead author, Libby Haskell, stated:

“Bronchiolitis is the most common reason for children less than one year of age to be admitted to hospital. We can improve the care of these infants, such that they are receiving less low-value care. In order to de-implement low-value care we need to first understand barriers and enablers of care, and then develop targeted interventions, built on robust behavioural change models, to address these. This approach can be used to improve care for other high volume conditions where we see considerable clinical variation in care and with clearly established clinical guidelines on appropriate management.”

Let us know what you think in the comments below 

Foot and toe injuries

Cite this article as:
Taskin Kadri. Foot and toe injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32663

A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.

Normal anatomy

The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.

The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The part of the calcaneus most prone to fracture is its large posterior facet.

The midfoot includes the navicular, cuboid and the three cuneiform bones.

The forefoot includes the metatarsals and phalanges.

Evaluation of foot injuries

History

The following specific enquiries should be made about the injury:

  • The mechanism of injury (high/low velocity, twisting, compression, direct blow)
  • Characteristics of pain (worse at the time of injury vs late onset)
  • Location of pain
  • Consistency and plausibility of the history, excluding concerns about non-accidental injury
  • The effect of the injury on the child (limping, the distance the child can move)
  • The efficacy of pain relief

Examination

Clinical examination should be tailored to the history.

Look

For external skin abrasions or obvious open fractures.

Feel

Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.

Palpation for tenderness along the ligaments: deltoid ligament on medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.

Move

The active movement should be followed by passive movement as much as pain allows.

The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.

Neurovascular examination

Two pulses: dorsalis pedis and posterior tibial.

Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).

Imaging

The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to weight bear both immediately after the injury and in the ED, plus bony tenderness over the base of 5th metatarsal or the navicular.  

Accessory ossicles

Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles, arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).

Os tibiale externum

This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify.  It is present in 4-14% of patients.

The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.

Os tibiale externum

Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.

Investigations include plain films and, occasionally, MRI scan.  

Treatment is initially conservative with orthotics and casting. The ossicle is excised if these measures fail to resolve the pain.

Os trigonum

This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.

Hindfoot fractures

These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from height or after a motor vehicle injury. The talus can be fractured in multiple places including avulsion fracture.

Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 77140

‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.

Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.

Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.

Treatment of talus and calcaneus fractures is dependent on the degree of displacement.

  • Non or minimally displaced avulsion fractures, or extra-articular fractures should be managed in a posterior short leg splint and should be non–weight bearing with crutches for 3 to 4 weeks.
  • Displaced fractures require reduction, by an orthopaedic surgeon, followed by immobilisation with a splint or cast. Severely displaced, comminuted or intra-articular fragments may require ORIF.

Midfoot fractures

These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.

Treatment depends on the severity of displacement of the fracture and associated injuries.

  • Non or minimally displaced fractures (the majority of these fractures) can be treated with a walking cast.
  • Displacement of the fracture fragment greater than 2mm should be managed with reduction and stabilisation before immobilisation.

Midfoot fractures have minimal long term sequelae.

Forefoot fractures

Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high energy trauma causing other significant injuries.

Lisfranc fracture

Lisfranc fractures occur due to axial loading with forced plantar flexion (commonly seen in bicycle or horseback riders where a foot gets caught in a pedal or stirrup) or with a crush injury.

Clinical examination

  • Tenderness over the dorsum of the foot with swelling and inability to bear weight.
  • Plantar bruising is a consistent sign and if present should raise suspicion of the injury.  

Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable and hence it is an important not to miss this injury. Due to the ligament attachment, there is often associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.

https://emergencymedicineireland.com/

Treatment depends on the degree of severity of the injury.

  • Partial tears with < 2mm malalignment require immobilisation or a walking boot for 4-6 weeks. The patient should be referred to orthopaedic surgeons within 3-5 days due to the high rate of late complications.
  • More severe injuries require operative treatment with internal fixation.

There is a high rate of residual pain in children with a Lisfranc injury.

Metatarsal fractures

Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.

Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position, during sports and tend to fracture the 5th metatarsal.

Pseudo-Jones fracture

A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.

Treat with a short walking boot or hard sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.

Jones fracture

The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common of metatarsal fractures (40%), representing about 25% of all paediatric foot fractures.

Jones fracture (metaphyseal-diaphyseal junction fractures of the 5th metatarsal).

Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight bearing cast, with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.

The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally whereas pseudo-Jones fracture runs transversely.

Normal apophysis of the 5th metarasal (note it runs longitudinally rather than transversely). Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 8802

Toe fractures

Toes fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.

The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.

Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.

The big toe

The big toe plays an important part in bearing weight. Fractures of the big toe are therefore managed slightly differently.  Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.

Urgent orthopaedic consultation for closed or open reduction for K wiring if:

  • more than one third of the joint surface is involved or
  • displacement is more than 2-3mm

In other cases, toe platform cast or a walking boot is used.

The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.

Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis.  A nail-bed injury to the germinal matrix will require surgical repair.

Long term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.

References

Boutis K: Paediatric metatarsal and toe fractures. Up to Date 2019

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Eiff, M. and Hatch, R. Fracture management for primary care and emergency medicine. Elsevier.

Halai, M., Jamal, B., Rea, P., Qureshi, M. and Pillai, A., 2015. Acute fractures of the pediatric foot and ankle. World Journal of Pediatrics, 11(1), pp.14-20.

Horner K and Tavarez M, 2016. Paediatric Ankle and Foot Injuries. Clin Pediatr Emerg Med, 17 pp. 38-52

Juliano, P., 2018. Lateral Talar Process Fractures – FootEducation. [online] FootEducation. Available at: <https://footeducation.com/lateral-talar-process-fractures/> [Accessed 4 April 2021].

Malanga, G. and Ramirez – Del Toro, J., 2008. Common Injuries of the Foot and Ankle in the Child and Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America, 19(2), pp.347-371.

Metaizeau, J. and Denis, D., 2019. Update on leg fractures in paediatric patients. Orthopaedics & Traumatology: Surgery & Research, 105(1), pp.S143-S151.

Smit, K. Foot Fractures – Phalanx | Pediatric Orthopaedic Society of North America (POSNA). [online] Posna.org. Available at: <https://posna.org/Physician-Education/Study-Guide/Foot-Fractures-Phalanx> [Accessed 4 April 2021].

Lost Tampons

Cite this article as:
Tara George. Lost Tampons, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32273

Maddy is 15. She presents with a one week history of a brown smelly discharge from the vagina. Her period ended eight days ago. At first, she thought it was just some spotting tailing off but now it’s heavier and smelly. Maddy is a gymnast and swimmer and has used tampons since she started her periods at 13. She has never been sexually active. Shyly, she admits that she “felt up inside” herself and thinks there might be a tampon up there. She’s not sure she removed the last one at the end of her last period, but she’s scared by the discharge and has come to see you for help.

Retained tampons are a common presentation to the emergency department and to GPs. Most GPs will tell you that the first retained tampon case they encounter is a rite of passage into the “real world of GP” and is usually a learning experience.

Here are some top tips for your first time

Classic Presentation

  • May or may not remember having “forgotten” a tampon
  • Foul smelling PV discharge, often watery and brownish
  • Usually well but embarrassed however don’t forget the risk of Toxic Shock Syndrome (TSS) – you will need to check observations/sepsis criteria and if scoring high consider this within your differential

Top Tips for Managing

There are no official published guidelines….

Management consensus from a group of GPs nationally:

  • Firstly encourage her to try and remove it herself by bearing down on the toilet slightly and using her fingers to grasp either the string or the tampon itself.
  • Have a look with a speculum +/- a bimanual exam (preferably in someone else’s room because the smell will linger).
  • Pull it down (with sponge-holding forceps) to where she can reach herself and send her to the toilet to remove and dispose of it.
  • If you must remove yourself have a specimen pot half full of water to put in in and shut the lid immediately.
  • It may be sensible to check that there are no more up there, especially if the patient reports that this has happened before, or if she tells you she habitually uses more than one tampon at a time. This is not advisable or safe, but sadly not uncommon especially in adults with menorrhagia.

In the context of the emergency department and Maddy:

  • Reassurance is key – she is embarrassed. If you are embarrassed too this is only going to end badly.
  • Reassure her that exploring her own body, including her vagina is completely normal.
  • Remind her that the string is sewn through the tampon so it is unlikely to have fallen off. Feeling inside for it and pulling it down is likely to be effective.
  • Encourage her to go to the patient toilet in private and to try to bear down and pull on whatever is up there to get it out. Lots of teenagers are embarrassed and ashamed to have touched their own vulva or vagina. Understanding that this is okay may be all you need to give her the confidence to solve her own problem.
  • If this is unsuccessful and you need to examine her and intervene, make sure you have all the kit you need. In some departments this may mean you have to refer to Gynae for them so it’s worth knowing what they will do.

What you need

  • A chaperone/assistant
  • A room with a lockable door
  • Disposable gloves
  • Speculum – probably a small/”virgin” size for Maddy
  • Lubricating jelly
  • A specimen pot, half full of water
  • Sponge-holding forceps
  • A decent light source

What to do

  • Examine externally first. If the tampon is just inside the vagina you may well see it and be able to easily remove it.
  • Pass the speculum and have a look – if you see the tampon then grasp it with sponge-holding forceps, pull it out and put it straight into a specimen pot with water in and dispose. 
  • If you insert the speculum and cannot see the tampon but can see the cervix clearly it is probably worth pulling back slightly and reinserting to ensure you visualise the posterior fornix too.
  • If she is unable to tolerate opening the speculum blades a gentle bimanual examination may allow you to feel the tampon and grasp it between your fingers to remove it.

Provided she is well and her observations are normal, she does not need antibiotics or any follow up other than reassurance and safety netting. If she is sexually active and/or the discharge is profuse or typical you may wish to consider swabs. If she has symptoms of TSS or Pelvic Inflammatory Disease you need to manage as per these conditions.

Maddy and her mum disappear to the toilet in the department. They return 10 minutes later. Maddy is tearful and says the tampon is definitely there but she’s too scared to pull it down. She says it feels really low down and uncomfortable. You take her to a quiet lockable room with one of the nurses and the kit list above. Explaining carefully what you are going to do you examine her vulva externally and can see the tampon just inside her vagina. You use some forceps to remove it, and having been well-educated by this article you put it straight into a pot of water and shut the lid tightly. You chat about whether there is a possibility there might be another tampon up there and Maddy assures you that this is not possible. You discharge her from the department, relieved, with some safety netting advice about remembering to remove future tampons and to come back if the discharge persists or if she becomes unwell.

Shoulder examination

Cite this article as:
Mark Webb. Shoulder examination, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31287

Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.

Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.

Look

  • Deformity
  • Swelling
  • Atrophy: Asymmetry  
  • Wounds
  • Bruising
  • Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial) 

A chaperone may be needed to expose the joint adequately in older children.

Feel

Feel for warmth, which could indicate septic arthritis.

From the front:

Start medially at sternoclavicular joint

Anatomy of the acromio-clavicular joint

From the back:

  • Scapula: spine, supraspinatus, infraspinatus muscle

Neurovascular assessment:

  • Check for distal pulses: brachial/ radial.
  • Always check the regimental patch for axillary nerve injury and document it.

Move

Assess for range of motion, both active and passive.

Girl flexing and extending at shoulder showing range of movement

Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.

Extension: 45-60 degrees. Stretch the arm out behind them.

Girl showing range of adduction and abduction at the shoulder

ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.

ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.

Girl showing range of internal and external rotation

External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.

Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.

Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.

Some special tests

It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)

Girl performing Apley scratch test

“Appley Scratch” test: (1) Ask the child to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.

Girl performing empty can test

Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.

Girl performing lift off test

Lift off test: The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.

Girl and boy performing scarf test

Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.

Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.

Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.

Selected references

Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67

Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10) 

https://fpnotebook.com/Ortho/Exam/ShldrExm.htm [Accessed April 2019]

McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.

NationwideChildrens.org/Sports-Medicine

https://shouldercomplexgocatsnmu.weebly.com/range-of-motion.html [Accessed April 2019]

Forget the Bubbles? Never

Cite this article as:
Neelakshi Ghosh. Forget the Bubbles? Never, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32252

How did we feel when we were told to ‘Forget the bubbles’ and infection control policies binned those slippery soapy solutions and golden rings of plastic? COVID-19 led to innovations in the workplace and we changed practice almost overnight to ensure the safest care was being delivered to our patients. Perhaps the team that demonstrated this to the fullest are the play specialists.

A chat with Maxine Ovens, Play Service Manager at the Royal Brompton Hospital showcased stories of innovation coupled with cycles of constant evolution as the team adjusted to a different way of life. Before COVID-19, Maxine had been the playroom boss for 16 years. She startied with a team of just 2 and is now running a 7-day service with 9 team members.

They have been working on the ward, and in children’s outpatients, supporting not just children and young people, but also their families, ‘to make their hospital experience positive and productive. During the initial surge of the pandemic, PICU beds at the Royal Brompton were allotted to adult ITU services. The playroom on the children’s ward became the storeroom for paediatric equipment as the original storeroom now fell in the ‘red zone’. Play had to be put back on the shelf and staff redeployed. Maxine’s aim was to ‘stay as a team and not be broken up during these difficult times’. The play specialists volunteered at the donning and doffing station at the PICU and actively engaged in boosting staff morale.

Behind the scenes, Maxine continued to push for restoring the playroom services. Working closely with the Infection Control team, she drafted new ‘playroom guidelines’ keeping with national policies and social distancing norms. With relatively fewer admissions, Maxine could arrange for one-to-one play sessions for everyone. These were time-tabled on a daily basis by the play team. The main focus was on the daily cleaning schedule with particular members allotted to be in-charge. All surfaces and toys were cleaned with Chloro-clean solution at the beginning of the day and in between play sessions. All members maintained the daily cleaning logs strictly, signing out for toys used in each session and putting them back after a thorough clean. ‘This was not just to demonstrate to Infection Control that the playroom is hazard-free, but also to reassure parents and carers that it is safe for the children.’ The staff were commended by parents for the clean environment of the playroom. One parent mentioned that ‘such varied activities were not possible even at home with all the recommended hygiene measures’.  And Maxine would quietly remind us of the marathon clean up the team had to do when a young patient decided to start a bit of ‘slime fight’ during a slime time session. Children on respiratory support had their playroom time towards the end of the day. Aerosol generating procedures required the playroom to be closed for an hour after.

Toys and playthings have to be compliant with the new cleaning regime. Staff members laminated books for bed-time stories before cleaning and returning them every day. The Brompton Fountain Charity donated single-use activity packs and colouring sets. Cardboard boxes for the board games were discarded, and playing cards were laminated and stored in plastic containers. All effort was made to ensure traditional play tools were not missed in this ‘new normal’. And, of course, plastic bubble machines appeared on the shelves to replace the old stand by.

Play is about innovation. Just as children grow and learn to explore their environment through play, Maxine and her team invented Covid-safe ‘things to do’. Group play was put on hold. The team used this opportunity to engage more children in one-to-one sessions, exploring their unique ideas. When admission rates started picking up, ‘bay bubbles’ were created so that two children from the same bay could be in the playroom together, using time and space more effectively. Children were engaged in activities like biscuit icing so that they could keep their creations for themselves rather than handing over the products of their labour for cleaning. Over the Christmas period, children made decorations which were then laminated by the team and hung on the ward.

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But to Maxine, the biggest challenge was the PPE. During bedside sessions, the team had to adhere to guidelines which made play a little more clinical than they would like. Visors were donned with cut-out tiaras and Mickey Mouse ears. Badges were pinned to uniforms bearing the photo of team members. The smile behind the mask had to be seen. There were picture books of health care staff in PPE explaining to children the new ‘superhero costumes’. The play team helped prepare the young patients for a procedure before junior doctors walked in donned.

So, what does hospital play look like now? Her team has always been creative with new and innovative ideas catering to the varied interests and abilities of her young patients. They have been constantly evolving as a team and will continue to do so.

Take every opportunity to be creative and be flexible. Play doesn’t need to stop. Fight for your service and work closely with the teams that can support you. After all, we all need a little play in our lives.’

Maxine Ovens