The 48th Bubble Wrap

Cite this article as:
Currie, V. The 48th Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-48th-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: An update on PIMS-TS/MIST-C

Flood J, Shingleton J, Bennett E, Walker B, Amin-Chowdhury Z, Oligbu G, Avis J, Lynn RM, Davis P, Bharucha T, Pain CE. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS): Prospective, national surveillance, United Kingdom and Ireland, 2020. The Lancet Regional Health-Europe. 2021 Apr 1;3:100075.

What’s it about? 

During the first breakout of PIMS-TS, Public Health England (PHE) and the British paediatric surveillance unit (BPSU) requested reports of PIMS-TS, Toxic shock syndrome (TSS) and Kawasaki Disease (KD) to be submitted for prospective national surveillance. This study looks at patients under the age of 16 who presented with symptoms between 1st March and 15th June 2020. The symptoms for the diagnosis of PIMS-TS was set out as per RCPCH guidance (fever >38, CRP>100, no infection proven and evidence of one at least system dysfunction) along with strict criteria for KD and TSS. From these reports, patients were excluded if they did not meet any PIMS-TS resulting in 268 cases of PIMS-TS meeting diagnostic criteria.

Why does it matter? 

Children have made up a small proportion of direct clinical burden due to COVID-19. However, cases all over the world began to appear of PIMS-TS associated with SARS-CoV-2 infection and more information was needed to be able to map this disease process and use clinical data to explain clinical characteristics of PIMS-TS and the epidemiology between these overlapping clinical conditions.

The results of the study showed the median age to be 8 years with PIMS TS/KD subgroup younger (5 years) and PIMS TS/TSS older (8 years) than PIMS TS only cases (7years). 60% of the population were male and patients from the BAME community seem to be disproportionately affected, especially within London.

Patients who exhibited PIMS-TS with features of TSS as well seemed to fair worse with a larger number of interventions, longer hospital stay and severity of illness. 35 cases were felt to be clinically in keeping with PIMS-TS despite not meeting the CRP criteria. Parental occupation was reported in just under half of the cases and more than 2 out of 3 were reported as healthcare workers. Just over 1 in 3 of the children had evidence of current or previous SARS-CoV-2 infection.

Clinically Relevant Bottom Line:

Presentations of PIMS-TS are strongly linked with SARS-CoV-2 infection, and those with features similar to toxic shock syndrome tend to be more unwell. Children in London, and in the BAME population, seem to be disproportionately represented, with the most having severe presentations. The epidemiological links are similar to that of other countries.

Reviewed by: Laura Riddick

Article 2: Screening adolescents for the risk of suicide attempts

Pediatric Emergency Care Applied Research Network (PECARN) King CA, Brent D, Grupp-Phelan J, et al., (2021) Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry. 2021 Feb 3:e204576

What’s it about? 

A prospective 2-part study with data collection being undertaken at different ED’s in the United States, which are part of the PECARN network. Introduction of computerised adaptive testing (CAT) which put simply is a tool that takes individuals responses to questions and determines their standing on the measured trait e.g., risk of suicide attempt. This offers the possibility of a more individualised, accurate screening tool.

Two studies ran independently:

Study 1(2015-2016): used CAT to develop a screening tool (computerised adaptive screen for suicidal youth CASSY) that targets items to the individuals personal risk profiles to provide a continuous risk score for the likelihood of suicide attempt (SA) within 3 months.

Study 2 (2017-2018): Prospectively validated CASSY.

In Study 1, adolescents aged 12 – 17 years who presented to ED were offered to complete the Ask Suicide Questions (ASQ) and Columbia Suicide Severity Rating Scale (C-CSSR). Depending on these responses the participants were stratified into low medium/ high risk for suicide attempt. Then a random selection of these were assigned to follow up which was done by interviewers who were blinded to the baseline data were responsible for the 3-month telephone follow up which assessed the number of suicide attempts made by the patient during this time.

CASSY was then developed using questions from these screening tools (questions which were identified to have high suicide attempt predictive value) and was cross validated in Study 1, before it’s use in Study 2. Subsequently, adolescents aged 12 – 17 years who presented to ED were offered to complete CASSY.

The authors have used a multivariate logistic regression model to predict suicide attempt during the 3 months follow up. Based on this, the Receiver Operating Characteristic (ROC) curve demonstrates a sensitivity of 82.4% for predicting suicide attempts using the CASSY score, at a specificity of 80% with an area under the curve (AUC) of 0.87 [95% CI, 0.85-0.89].

For a reminder on these type of stats take a look at this DFTB post.

Some important exclusions in this study population were being a ward of the state (e.g. adolescent in foster care) and non-English speaking participants which from previous studies are shown to be important risk factors for altered mental health.

Why does it matter? 

Data from Australia (and around the world) show that our adolescent population are suffering from increasing levels of mental health issues such as anxiety and depression. With those illnesses often comes suicidal ideation, and when these patients reach crisis point, they present to our emergency departments (ED). One of the biggest challenges to all suicidal risk screening is the accurate identification of young people at risk in a setting that efficiency is required. Existing screening tools such as (ASQ) have shown moderate sensitivity to predicting suicide risk, meaning some individuals at risk were not identified.

Clinically Relevant Bottom Line:

This study shows the CASSY tool has a good sensitivity (ability to pick up) those at risk of suicide attempt. Early and accurate recognition of mental health illnesses and suicidal ideation in primary health care settings and emergency departments is an essential first step in managing these issues.

Reviewed by: Tina Abi Abdallah

Article 3: The use of minimally invasive surfactant therapy

Roberts CT, Halibullah I, Bhatia R, Green EA, Kamlin CO, Davis PG, Manley BJ. Outcomes after Introduction of Minimally Invasive Surfactant Therapy in Two Australian Tertiary Neonatal Units. The Journal of Pediatrics. 2021 Feb 1;229:141-6.

What’s it all about?

This 18-month prospective audit collected data on patient demographics and clinical outcomes following the introduction of minimally invasive surfactant therapy (MIST) in two neonatal intensive care units (NICUs) in Australia. Infants were eligible for MIST if they received CPAP support with clinical or radiological diagnosis of respiratory distress syndrome (RDS), and were excluded if they had major congenital anomalies, circulatory compromise, recent apnoeas or a diagnosis other than RDS.

Why does it matter?

MIST is a less invasive method of administering exogenous surfactant for the treatment of RDS in premature infants compared to previous surfactant administration by endotracheal tube. Previous meta analysis highlighted that MIST is associated with reduced need for mechanical ventilation, and adverse events such as bronchopulmonary dysplasia and death compared to endotracheal intubation. However, it is difficult to make clear conclusions about the efficacy of MIST versus endotracheal tubing for surfactant administration, as a range of other factors can affect success rate. These include gestational age, surfactant dose and timing of procedure (as prophylactic after birth versus an early rescue approach within the first 24 hours of life. As MIST and endotracheal intubation require laryngoscopy, the authors stress the continued need to adequately train junior staff and suggest the use of routine video laryngoscopy regularly to allow for second operator confirmation and potentially increased rates of success.

135 MIST procedures were performed. The median gestation was 30 weeks, and median birth weight being 1439 grams. All infants received supplementary oxygen before MIST. The most common adverse event was peripheral oxygen desaturation to <80% which occurred in 3 out of 4 of MIST procedures. Other events included bradycardia <100 beats per minute (13 out of 100) and the need for positive pressure ventilation (1 in 10). Positively, over 2/3rds of infants treated with MIST did not require further intubation and mechanical ventilation and senior clinicians had higher rates of procedural success. Surfactant administration was successful in all but one MIST procedure due to patient apnoea requiring intubation.

The Bottom Line:

The authors determined that MIST can be successfully adopted into clinical practice in such settings where staff have limited prior experience. Rates of adverse events, mentioned above, were comparable to results from previous randomized trials. Over 2/3rd of infants in this study with MIST did not require further intubation and ventilation. 

Reviewed by: Ivy Jiang

Article 4: Can we perform phototherapy at home?

Pettersson M, Eriksson M, Albinsson E, Ohlin A. Home phototherapy for hyperbilirubinemia in term neonates—an unblinded multicentre randomized controlled trial. European Journal of Pediatrics. 2021 Jan 19:1-8.

What’s it about?

Within the first week of life, 60% of term babies and 80% of pre-term babies will have some degree of jaundice. This study looked at well term babies and if delivering phototherapy at home, with daily hospital reviews, would be an acceptable alternative to inpatient phototherapy.

This was an unblinded, randomised control trial of 147 jaundiced neonates across 6 hospitals in Sweden. To be included babies had to be well, >48 hours old, have a gestational age >36+0 and have a raised serum bilirubin (SBR). Parents also had to be capable to perform phototherapy at home and agree to return daily for review and blood tests. Babies were excluded if they had a high bilirubin result (>400µumol/L), weight loss of >10% of birth weight, any ongoing infection or illness, or if there was blood group incompatibility.

Babies were randomly selected to receive home phototherapy (78) vs hospital phototherapy (69). Babies in both groups were reviewed daily in the hospital, and a daily SBR and weight. Home treatment was done by Bilisoft (Bilibed) that was provided with eye protection and clear instructions. This study could not find any statistically significant differences that suggested that either therapy was superior to the other. Only 3 in 78 babies of the home phototherapy neonate were converted to hospital treatment. No one across either group had SBR’s high enough to require IVIG or blood exchange. There was no statistically significant difference regarding the duration of phototherapy, time until discharge, amount of blood tests, weight loss or adverse events.

Why does it matter?

Jaundice is one of the most common reasons for prolonged postnatal hospitalisation and readmissions in the postnatal period. Hospital management of jaundice can negatively impact bonding and attachment, it can be inconvenient for families and is associated with a significant cost to the healthcare system.

The bottom line

This study shows that with daily reviews and monitoring, home phototherapy could be an effective and safe alternative to hospital phototherapy for otherwise healthy, term, neonates. When determining appropriateness for home phototherapy bilirubin levels, geographic location and ability to commute, parental anxiety and the capability of parents/carers must all be considered.

Reviewed by: Phoebe Campbell

Article 5: How is procedural sedation performed in Europe?

Sahyoun C, Cantais A, Gervaix A, Bressan S, Löllgen R, Krauss B. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. European journal of pediatrics. 2021 Jan 28:1-5.

What’s it about?

 

This cross-sectional study of european paediatric procedural sedation and analgesia (PSA) was endorsed by the Research in European Paediatric Emergency Medicine (REPEM) network, with data collection between November 2019 and March 2020. 

The study aimed to describe PSA practice across europe, perform a needs assessment-like analysis and also identify barriers to PSA implementation.

Online questionnaires were distributed to a target number of either 10 or 5 emergency departments within each country (depending on their population size), via country specific lead research coordinators. The survey included a clinical case scenario with subsequent questions covering 8 key themes. These ranged from the management of a patient requiring PSA, protocols and safety and barriers limiting PSA implementation. The questionnaire was revised several times following input from each country lead, accounting for variations in relevance, language, and grammar between each country, until a consensus was achieved containing 30 questions. Questionnaires were completed by a senior clinician at each site with 171 hospitals contributing data from 19 countries. The UK and Ireland were not included due to a similar project running in these locations simultaneously.

Midazolam (100%) and Ketamine (91%) were the most available PSA medications, followed by propofol (67%), nitrous oxide (56%) and intranasal fentanyl (47%). 8 in 10 of sites reported sedation being performed by general paediatricians. However just over 1 in 3 of sites stated all staff performing PSA were paediatric advanced life support certified and only 1 in 2 required PSA specific course completion. Safety and monitoring guidelines for PSA were present in most  sites (7out of 10) and 1 in 2 had pre-procedural checklists in place, with these sites most likely to perform IV sedation. Capnography was present in just under half of the sites.

Barriers to PSA implementations included lack of physical space (1 in 2 of sites) and shortages of both nurses and clinicians (both more than 2/3rds of sites). Interestingly half of the sites reported nurse-led triage protocols in use for paracetamol and ibuprofen administration, with these sites experiencing the highest number of patient visits per year.

Why does it matter?

PSA is used widely across europe, however there is a large variation in the standard medications and safety measures in use.

Clinically Relevant Bottom Line:

 This study highlights the need for sharing of best-practice amongst sites with the potential for future trials to determine optimal staff training, medication use, procedural checklists and guidelines, nurse-led triage and staff and physical space allocation for PSA. The network generated as a consequence of this study could be used to facilitate such work in the future.

Reviewed by: Joshua Tulley

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

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

Proximal humeral fractures

Cite this article as:
PJ Whooley. Proximal humeral fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31855

“Slow down!” Joel’s mom shouts at him as he whizzes past on his scooter. Joel turns to answer and doesn’t see the curb which he hits, goes flying and puts out his hand to stop himself. Mom is already running to find him holding his arm.

Proximal humeral fractures are uncommon, accounting for less than 5% of all paediatric fractures. The anatomic characteristics of the proximal humerus can explain the various fracture presentations, complications and outcomes.

Anatomy

Ossification centres

The proximal humeral physis has three ossification centres. Head, lesser tuberosity and greater tuberosity. The capital centres appear at 3 months whereas the two others appear at 1 year of age and fuse between 3 & 5 years to produce tuberosity ossification. By the time the child’s 6, the capital and tuberosity centres fuse into a single proximal epiphyseal centre. At this point it acquires a characteristic ‘tent’ or inverted V shape. This results also in a double contour that can complicate the interpretation of the images. The proximal physis accounts for approximately 80% of the longitudinal growth of the entire bone.

Periosteum

This thick sleeve of periosteum is present along the shaft and limits fracture displacement and promotes healing.

Nerves

The axillary nerve, which supplies the sensory innervation to the regimental badge area, is at potential risk in displaced proximal humeral fractures. However, axillary nerve damage is rare, the majority being only a temporary neuropraxias.

Epidemiology

Proximal humeral fractures show an early modest peak at 10-14 years of age, account for up to 3.5% of all fractures, followed by return to low levels in young adults and then a second increase in later adulthood.

These fractures account for a third of all humeral fractures in neonates and are the second most common birth injury after clavicular fractures.  However, they are still rare, occurring in only 0.03 per 1000 births.

The pattern of injury varies with age. Metaphyseal proximal humeral fractures are proportionately higher in pre-pubertal children, compared to a higher proportion of epiphyseal separation in adolescents.

As with any fracture, be aware of the potential of a non-accidental cause. These fractures, can be associated with physical abuse.

Mechanism of Injury

Indirect

Proximal humeral fractures in non-newborns commonly result from a fall backwards onto an outstretched hand with elbow extended and wrist dorsiflexed or a direct blow to the lateral aspect of the shoulder. Pathological fractures  can occur as the humerus is a common location of bone cysts and other benign lesions. This might occur with minimal trauma.

Birth injuries

The upper arm can be hyperextended or rotated during delivery, occurring more commonly in infants of diabetic mothers and with shoulder dystocia.

Clinical Evaluation

Newborns

Typically, a newborn with a proximal humeral fracture will hold their arm in extension. Consider these fractures if a history of birth trauma is given. If noted, then infection, clavicle fracture, shoulder dislocation and brachial plexus injuries need to be ruled out. These little ones may be irritable, particularly when the upper limb is moved.

Children and adolescents

As with other upper arm fractures, the typical presentation is with pain, dysfunction, bruising and swelling with a painful range of movement. Displaced fractures result in significant anterior swelling and altered shoulder appearance relative to the contralateral side.

A detailed distal neurovascular examination is needed including evaluation of the radial, ulnar, median, axillary and musculoskeletal nerves. Be particularly vigilant for any axillary nerve deficit with decreased sensation over the regimental badge area and loss of the deltoid muscle function (shoulder ABDuction).

Radiology

Proximal humeral fractures are identified on routine AP and axillary views of the humerus. If there is clinical concern of a dislocation then dedicated shoulder views should also be taken. If there is tenderness over the physis and no obvious fracture, a suspicion of a Salter Harris (SH) I fracture can be made. Imaging the contralateral humerus may be helpful to determine if there is any widening of the physis.

Patterns of fracture

There are two variations of proximal humeral fractures: metaphyseal and epiphyseal separation.

  • Metaphyseal fractures (70%) usually occur at the surgical neck, although can also occur at the metaphyseal-diaphyseal junction, typically a transverse or short oblique fracture. These fractures typically occur in 5-12 year olds.
  • Epiphyseal fractures (30%) occur in the under 5s and over 12s. The type of epiphyseal fracture depends on skeletal maturity.

SH I fractures are less common and can be seen at all ages before growth-plate closure, most commonly in <5 year olds.

SH II fractures are the most common type, chiefly in adolescents over the age of 12.

SH III & IV fractures are exceedingly rare.

A metaphyseal fracture at the surgical neck of the humerus
Epiphyseal Salter Harris II fracture of the proximal humerus in a 6 year old

Pathological fractures

40% of pathological fractures involve the proximal humerus. The leading cause is a unicameral bone cyst, as this lesion develops in the proximal humerus in 51% of cases. Other causes are aneurysmal bone cysts, non-ossifying fibromas, fibrous dysplasia and bone malignancies.

Displacement

If a proximal humeral fracture displaces, it usually does so in a varus direction, with the humeral head moving medially and posterior to the shaft. This occurs due to pectoralis major traction pulling the distal segment medially, while the rotator cuff and deltoid pull the proximal component superiorly in a tendency towards flexion and external rotation. Displacement is often absent or minimal in 40% of metaphyseal fractures, but is more common in epiphyseal injuries, occurring in up to 85%.

Proximal humerus fracture in an 11 year old with varus deformity

Classification

The Neer-Horowitz classification is the most frequently used classification system for this type of fracture. It divides the proximal humerus into 4 parts, classifying fracture by the degree of displacement as well as the fracture line, consisting of:

  1. Humeral head
  2. Greater tuberosity
  3. Lesser tuberosity
  4. Humeral shaft

One-part fractures involve 1 – 4 undisplaced parts (<1cm AND <45 degrees)

Two-part fractures account for 20% of proximal humeral fractures, involving 2 – 4 parts, 1 of which is displaced (i.e. >1cm OR >45 degrees)

  1. Surgical neck – most common
  2. Greater tuberosity – often seen with anterior shoulder dislocation. A lower threshold for displacement (>5 mm) has been proposed.
  3. Anatomical neck
  4. Lesser tuberosity

Three-part fractures account for 5% of proximal humeral fractures and involve 3 – 4 parts, 2 of which are displaced (i.e. > 1cm OR > 45 degrees)

  1. Greater tuberosity and shaft displaced with respect to lesser tuberosity and articular surface which remain together.
  2. Lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together.

Four-part fractures are uncommon, occurring in less than 1% of proximal humeral fractures. They involve more than 4 parts, 3 of which are displaced (i.e. >1 cm OR > 45 degrees with respect to the 4th). Four-part fractures require operative reduction.

Management

Initial treatment

Displaced fractures can be very painful so ensure pain is addressed with adequate analgesia.

The aim of immobilisation is to keep the elbow by the side, flexed to 90 degrees with the forearm against the torso. A simple sling is sufficient plus / minus a swathe for younger ages. Straps and adhesive tape can be used as described by Durrajer. Other options include a shoulder immobiliser or a U-shaped coaptation splint.

Neurovascular status must be checked before and after immobilisation.

Orthopaedic consultation should be obtained if there is:

  • associated shoulder dislocation
  • intra-articular (SH IV) fracture
  • completely displaced fracture in a child over 12 years.
  • associated neurovascular compromise
  • open fracture (rare)
  • evidence of compartment syndrome

Definitive Treatment

Newborns usually have SH I fractures, which have an excellent prognosis. A sling and a swathe is sufficient for up to 4 weeks. The primary role of follow up is to ensure there is no brachial plexus injury.

Children and adolescents with minimally displaced fractures are usually managed with a sling or shoulder immobiliser. Gentle pendulum exercise is started between weeks 2 to 4 post injury and active range of movement at 4 to 6 weeks. We would expect near to normal function by 2 months.

Significantly displaced fractures in children 12 and under should be treated with a U-slab, sling and swathe.

Acceptable angulation

  • < 5 years – any degree is allowed as proximal humeral fractures in young children have excellent remodelling potential.         
  • 5 to 12 years – 40 to 70 degrees of angulation is acceptable
  • >12 years – up to 40 degrees of angulation or 2/3 displacement.

Operative

Fractures in which immobilisation would result in unacceptable alignment are managed with closed reduction +/- fixation. Open reduction and internal fixation (ORIF) is indicated if acceptable reduction is not possible due to soft tissue interposition. Most commonly this is caused by the long head of biceps tendon, but can also be caused by the joint capsule, infolded periosteum and deltoid muscle. ORIF is also indicated in open fractures, compound fractures and intra-articular displacement of the fracture.

Complications

Complicated are rare in children, but when do occur are more common in older children, with shortening of the humerus due to physeal damage. This usually has no functional affect. Radiographic malunion can occur but rarely has any functional affect.

Non accidental injury

And finally, as with any fracture, it is imperative that a mechanism inconsistent with an injury or fracture in an otherwise healthy child should prompt escalation and involve the child protection team.

Joel’s x-ray shows a proximal humeral fracture through the surgical neck, with 20 degrees of angulation. He’s placed in a shoulder immobiliser and followed-up in fracture clinic, where he’s advised to start gentle pendulum exercises after a couple of weeks. Two months later he’s back on his scooter, helmet on, flying down the pavement without a care in the world.

References

LA. Landin. Epidemiology of the children’s fractures. J Pediatric Orthop B. 1997;6(2):79

E.J. Ortiz, M.H. Isler, J.E. Navia, R. Canosa, Pathologic fractures in children. Clin Orthop Relat Res, 432 (2005), pp. 116-126

MW Shrader et al, Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4);431

Pectoral girdle, shoulder region and axilla | Clinical Gate

Femoral shaft fractures

Cite this article as:
Joanna Wawrzuta. Femoral shaft fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32484

An 18-month-old boy presents to the emergency department at 1am in the morning, brought in by ambulance with leg pain and inability to mobilise, with crying when being moved or attempting to move. His father tells you that he fell downstairs when they forgot to close the stairgate. On examination, his right thigh is swollen, possibly shortened and he is clearly guarding it. Given your high clinical suspicion of a femur fracture, you prescribe simple and opiate analgesia and organise an x-ray.

Incidence

Femoral shaft fractures account for 1.5 – 2% of paediatric fracture presentations. The average number of annual cases is 20 per 100,000. Despite accounting for a small proportion of all fractures, they are the most common cause for hospitalisation for a fracture.

Femoral shaft fractures can happen at any age depending on mechanism however, there is a clear bimodal age distribution with increased rates in toddlers (between 2-4 years of age) and adolescents (approximately greater than 10 years of age).  Any femur fracture before ambulatory age is uncommon and should be treated as suspicious for non accidental injury (NAI). This is especially true for femoral fractures in children less than 12 months of age (more on this later).

History

Toddlers commonly present as a result of a fall of some kind – sometimes from a height, but it can be from as little as 60cm or less. They are often running, or falling after tripping on an object.

Adolescents, on the other hand, tend to fracture their femur as a result of high mechanism trauma, such as motor vehicle accident or a fall or jump from a significant height.

Regardless of age, patients typically report thigh pain, swelling and an inability to weight bear.

Ask about the mechanism of injury, if it was witnessed, and the time of the injury particularly in the younger age group (<5 years). An unclear history, an unwitnessed fall and delay to presentation are risks factors for NAI.

Examination

The limb deformity may be gross or subtle. Significant swelling results in a tense, or firm-feeling, thigh on palpation and/or a shortened limb. Sometimes the swelling can be very mild, particularly in a toddler, but a clue to injury is a child who is not moving the leg. Always check for neurovascular compromise and for other injuries. One study by Rewers et al. (2005), suggested that 28.6% of children with a femur fracture had another associated injury.

Investigations

Plain radiograph with AP and lateral views of the femur. Imaging the ipsilateral knee and hip is recommended to rule out associated injuries.

Classification

There is no universal classification system for femur fractures so \ use description characteristics, location, stability of the fracture and whether it is open or closed.

Descriptive examples include: transverse, spiral, oblique, comminuted, greenstick, displaced/nondisplaced.

Location: proximal, middle, distal third

Stability:  stable or unstable. Stable fractures are typically transverse or short oblique; while unstable fractures are long spiral and comminuted.

Note: long spiral fractures occur when the fracture length is more than twice the diameter of the bone at that level.

Management

General principles should be adhered to as for any ED presentation. Start with a primary and secondary survey. These injuries occur as a result of trauma and other significant and life-threatening injuries need to be excluded. Next is analgesia, fracture reduction then immobilisation.

Adequate analgesia can be achieved with intranasal, oral and intravenous medications. Start with simple analgesia first (paracetamol, NSAIDS) as they are easy and quick to administer. Then move on to opioids via the oral, IV or intranasal route. Consider benzodiazepines, particularly diazepam, if muscle spasm is an issue (which it often is). While analgesia is taking its effect, start setting up for a regional nerve block. This can be a femoral nerve block (usually under ultrasound guidance), fascia iliaca block (landmark or ultrasound-guided) or a haematoma block.

Once adequate analgesia has been given, it is time to reduce the fracture using skin traction. Generally, femoral fractures are not put in a backslab in ED unless a traction splint is not available and transfer of the patient is required.

Skin traction

Skin traction requires 10% of the patient’s weight to be applied through an appropriate traction mechanism. This may occur in the ED if there are adequately trained personnel and equipment available. There are also traction splints available that can be used pre-hospital or if a traction bed is not available. Sedation may be required to apply skin traction or a traction splint.

There is a variety of traction splint available. The most common in use are the Thomas splint, CT-6 splint and Kendrick splint. Others include the Slishman Traction Splint, Mustang traction splint, Sager splint, Hare Splint and Donway splint.  The Thomas splint is recommended for transfer and is available in a paediatric size.

Taken from https://www.embeds.co.uk/

In Queensland, the ambulance service uses the CT-6 splint. It can also be used in the paediatric population. Have a look at this video by Queensland Ambulance Service on its application. The Slishman traction splint and Mustang traction splint are not specifically designed for children but the linked videos demonstrate brilliantly on child volunteers how you can adapt them for kids.

Definitive management

Spica cast application is typically done under general anaesthetic by the orthopaedic surgeons depending on the age of the child. Older children will require other definitive management.

The table summarises the guidance from The American Academy of Orthopaedic Surgeons (AAOS) of management of femoral fractures by age.

Complications

The most common complication is leg length discrepancy. This occurs due to overgrowth in younger patients. Conversely, shortening can also be an issue but is acceptable up to 2-3cm. Other complications include: osteonecrosis of the femoral head, non union, malunion and re-fracture. In terms of osteonecrosis of the femoral head, this can depend on the surgical procedure performed.

A note about other femoral injuries

Other types of fractures of the femur include proximal fractures (including neck of femur), distal femoral physeal fractures and slipped capital femoral epiphysis (SCFE, also known as SUFE)

Proximal femur fractures are rare in paediatric populations accounting for <1% of fractures. They most commonly occur due to high energy trauma such as motor vehicle accident [1,4,8]. They can occur with a low impact mechanism, but if this occurs a pathological fracture should be considered. Proximal fractures tend to need operative management with an ORIF. The most common complication for a proximal femur fracture is avascular necrosis.

The do not miss bits

Non accidental injury

The incidence of NAI in children with femoral fractures has been reported between 12-60%. In one study by Rewers et al. (2005), it was found that in children less than 3 years of age, NAI was the second most common cause of femoral fractures. This is supported by Schwend et al. (2000), who suggested that a femur fracture in children who are not yet of walking age was the strongest predictor of abuse.

Vigilance is the key to detecting NAI. The best predictors for NAI include: An unclear history, particularly with respect to the mechanism, a suspicious history, an unwitnessed fall (particularly in the younger age group), young age, a delayed presentation (typically >24hours), and associated injuries particularly of chest, abdomen and pelvis if not associated with a high speed mechanism. They also include physical and/or radiographic evidence of prior injury (multiple different aged bruises, old healing fractures on XR). In one study, 53% of children who had been abused and had a femoral fracture had evidence of polytrauma. 62% had physical and/or radiographic evidence of prior trauma and 33% had history suspicious for abuse. In terms of the risk factors listed above, children who had no risks factors had a 4% chance of NAI being the cause of their fracture compared to 24% with one risk factor, and 87% if they had 2 risk factors.

Is the type of femoral fracture a predictor of NAI? There is no current evidence that supports it being a strong predictor. Some evidence suggests that fractures associated with NAI are more likely to found in the distal femur, compared to diaphyseal fracture alone. In contrast to popular belief, there is no current evidence to strongly support that spiral fractures are more likely to be associated with NAI.

In essence, never forget to consider NAI. It is easy to miss if it isn’t thought about as a differential.

Associated injuries

Remember secondary and tertiary survey. Subtle injuries can be missed in patients with high velocity mechanisms or significant life-threatening injuries.

Pathological fractures

These should be considered if a femoral fracture occurs as a result of a low mechanism trauma. Children with metabolic disorders or malignancy are also at higher risk.

Traction

If considering applying a traction splint, don’t forget to assess for ankle/foot fractures as these are a contraindication to application. This is because the ankle and foot are generally support sites for the traction splint.

A femoral nerve block was completed with good effect after some intranasal opioid analgesia. The case was discussed with the orthopaedic team and concerns raised around NAI given the child’s age. The case was also discussed with the hospital child protection team. Traction was applied in the ED under ketamine sedation before he was admitted under orthopaedics and a spica cast was applied in theatre under general anaesthesia.

  1. https://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures–pediatric?expandLeftMenu=true
  2. Wright JG, Wang EL, Owen JL, Stephens D, Graham HK, Hanlon M, Nattrass, GR, Reynolds RK, Coyte P. Treatments for paediatric femoral fractures: a randomised trial. Lancet 2005;365:1153-58.
  3. Capra L, Levin AV, Howard A, Shouldice M. Characteristics of femur fractures in ambulatory young children. Emerg Med J 2013;30:749-753.
  4. https://radiopaedia.org/cases/paediatric-neck-of-femur-fracture
  5. Baldwin K, Pandya NK, Wolfgruber H, Drummond DS, Hosalkar HS. Femur Fractures in the Pediatric Population. Abuse or Accidental Trauma? Clin Ortop Relat Res 2011; 469:798-804.
  6. Clarke NP, Shelton FM, Taylor CC, Khan T, Needhirajan S. The incidence of fractures in children under the age of 24months in relation to non-accidental injury. Injury 2012;43(6):762-5
  7. Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Prevalence of abuse among young children with femur fractures: a systemic review. BMC Pediatrics 2014; 14:169
  8. Rewers A, Hedegaard H, Lezotte D, Meng K, Battan FK, Emery K, Hamman, RF. Childhood Femur Fractures, Associated Injuries, and Sociodemographic Risk Factors: A Population-Based Study. Pediatrics 2005; 115; e543.
  9. Davis DD, Ginglen JG, Kwon YH, et al. EMS Traction Splint. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  10. https://www.rch.org.au/clinicalguide/guideline_index/fractures/femoral_shaft_emergency/
  11. https://www.embeds.co.uk/2019/02/03/thomas-spint-how-to-apply/
  12. http://www.orthoguidelines.org/topic?id=1015
  13. Cooperman DR, Merten DF. Skeletal manifestations of child abuse. In: Reece RM, Christian CW, Eds. Child abuse: medical diagnosis and management, 3rd Ed. American Academy of Pediatrics, 2009;315.
  14. Hui C, Joughin E, Goldstein S, et al. Femoral fractures in children younger than three years: the role of nonaccidental injury. J Pediatr Orthop 2008;28:297-302.
  15. Shrader MW, Bernat nM and Segal. Suspected nonaccidental trauma and femoral shaft fractures in children. Orthopedics 2011; 34(5):360
  16. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop 2000;20:475-81.
  17. Coffe C, Haley K, Hayes J, Groner JI. The risk of child abuse in infants and toddlers with lower extremity injuries. J Pediatr Surg. 2005; 40:120-123
  18. Son-Hing JP and Olgun DZ. The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups? J Pediatr Orthop B 2018; 27(4): 366-388
  19. Thompson NB, Kelly DM, Warner Jr WC, Rush JK, Moisan A, Hanna Jr WR, Beaty JH, Spence DD, Sawyer JR. Intraobserver and interobserve reliability and the rold of fracture morphology in classifying femoral shaft fractures in young children. J Pediatr Orthop 2014; 34(3):352-8
  20. Leaman LA, Henrikus WL and Bresnahan JJ. Identifying non-accidental fractures in children aged <2 years. J Child Orthop 2016; 10:335-341
  21. https://coreem.net/core/pediatric-femur-fractures/

Period Problems: Menorrhagia

Cite this article as:
Tara George. Period Problems: Menorrhagia, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32371

Period problems in teens are common. They can cause significant disruption and distress to adolescents and their parents but rarely have a significant or medically worrying underlying cause. In this first of a series of articles I’ll try to provide a logical and systematic approach to assessing and managing period problems in teenagers (recognizing that this may often be able to be extrapolated to adults too for those of you who do not only see children).

Eloise is 14. She attends with her father complaining she is tired all the time.  When she saw her GP last, they arranged some blood tests – a FBC, haematinics, TFTs and coeliac screen.  The notes from the previous consultation are very sparse. It appears that mood (normal) and bowel habit (also normal) were discussed. Eloise’s dad had mentioned she eats a broad range of foods and is not vegetarian or vegan and she eats red meat 2-3 times a week. Her periods were not brought up by the last doctor. One of her aunts has coeliac disease is noted and that is why the GP had organised bloods. Eloise has come in today for her results.

Blood results showing iron deficiency anaemia

Iron deficiency anaemia (IDA) is common in young women. Paediatricians may be much more comfortable assessing dietary intake and encouraging iron supplementation or increasing iron in the diet than they are in talking about periods. 20-30% of all cases of IDA are caused by menorrhagia. Both NICE and the British Society of Gastroenterology advocate a trial of iron for menstruating females with iron deficiency, as long as coeliac disease has been ruled out and there are no red flags for cancer. Prescribing iron and advising Eloise to “eat more steak” isn’t going to address WHY she might have IDA. This could mean that she ends up on long term iron supplements unnecessarily. If she has menorrhagia significant enough to cause anaemia, it is likely to be having an impact on her education and her social life.

Approaching the subject is probably easier than you think, remembering if you are embarrassed the patient may well think there’s something to be embarrassed about”.

So let’s talk about periods….

First a little bit of nomenclature revision.

Menorrhagia – heavy periods

Dysmenorrhoea – painful periods

Oligomenorrhoea – scanty/sparse/irregular periods

Amenorrhoea – absence of periods (primary: failure to attain menarche by the age of 15 with the development of normal secondary sexual characteristics or failure to attain menarche by 13 with no development of secondary sexual characteristics. Secondary: cessation of menstruation for 3-6 months in someone who has previously had regular periods)

Intermenstrual bleeding (sometimes called metrorrhagia) – irregular and unscheduled bleeding including unexpected bleeding between periods

Menarche – the onset of menstruation (the last stage of female puberty)

The symptoms of problematic periods are not always found in isolation. Menorrhagia and dysmenorrhoea are very common and frequently coexist. It is not uncommon for periods to be irregular, painful and heavy especially in the first few months after menarche. In the UK, the average age of menarche is 12.9 years. The average girl will be in Year 8 at secondary school when she starts her periods. Most women will menstruate every 28 days, though irregular and prolonged cycles are common in early menstrual life.

The average period lasts for 2-7 days and on average 80ml of blood will be lost during the period. In developed countries a number of sanitary products are available. The majority of girls are likely to start off with disposable sanitary towels, though environmental concerns mean period pants and washable pads are gaining popularity. Tampons are often the easiest option for girls who do a lot of sport, especially swimming, and can be used from the onset of menstruation. Menstrual cups have a much greater capacity but can be tricky to get the hang of especially for young teenagers.

Absorbency of different products

Absorbency of sanitary products for menorrhagia

What to ask in a history of menorrhagia

Start with an open question (recognising that lots of teenagers are much more comfortable with closed questions and giving specific answers): 

Tell me about your periods…

If you need to be more specific:

  • On average, how long do your periods last for?
  • How often do your periods happen?
  • Do you think they are heavy?
  • Does the bleeding change over the course of the period?
  • How often do you have to change your sanitary protection?
  • What sort of sanitary products do you use? (Pads or towels? Tampons? Period pants? Other?)
  • When did you start your periods?
  • Do you leak though your tampons/pads? If so, how often?
  • Do you pass clots? If so, how big are they?
  • How often do you need to change your pads/tampon at night?
  • Do you have to change your sheets/pyjamas?
  • Can you manage your period at school? How often do you need to leave lessons to change your sanitary product? Do you ever stay home from school because the bleeding is too heavy?
  • Are there activities you enjoy that you’ve had to stop doing because of your periods?

Eloise looks embarrassed and keeps looking at her dad. He is staring firmly at the floor looking as if he wishes it would open up and swallow him. You ask her if she would prefer to talk to you without her dad there and she nods. He takes his newspaper to the waiting area and you reassure him you’ll come and find him in a few minutes. 

Eloise tells you she started her periods at 11. They last 5-6 days on average and she has one around every 30-32 days. She uses tampons backed up with period pants as she often leaks. She uses SuperPlus tampons and on the first couple of days needs to change them every 45 minutes or so. This can be very difficult at school. She passes clots the size of grapes for a day or so each month. She has to set an alarm at night to wake her to change her protection every 2 hours but can end up with bloodstained sheets. She has stopped gymnastics and now only swims socially but not competitively. She was dropped from the squad because she wasn’t comfortable training when she had her period – the other girls had laughed when she had leaked during training. Worse still, when at a gala with lots of other teams, blood poured down her leg and she had been jeered by the crowd. She thinks her periods are heavy (heavier than all her friends) but her mum has told her this is normal and to stop making a fuss.

Whilst there is no truly objective “test” for menorrhagia, with this history and the marked iron deficiency anaemia, it is pretty straightforward to assume Eloise has menorrhagia. This is likely to be the cause for her IDA as well as affecting her sport participation, her sleep and her schooling. She had normal thyroid function tests (TFTs) as part of her tiredness workup (though it is worth noting that NICE do not recommend checking TFTs routinely in cases of simple menorrhagia). You might want to ask about other bleeding history like epistaxis, bleeding after dental extraction, family history and to consider testing for von Willebrand’s disease. NICE recommend this is for patients who have had menorrhagia from the start of their menstrual life. Most cases of menorrhagia at this age are, however, idiopathic.

Other factors to consider in your assessment

It is so important that Eloise feels listened to and heard. Her perspective is vital for compliance with any plan you make. You’ve already asked her if she thinks her periods are heavy. Now is a good time to continue to explore her ICE (“ideas, concerns and expectations”) by finding out how worried she is about her periods, whether she thinks they are a problem and if she has any ideas for what might be available to fix the problem.

Family history and past medical history are relevant here too in terms of management options as you might well want to consider the combined pill or tranexamic acid both of which are contraindicated if there is a first degree relative family history of venous thromboembolism or a known prothombotic mutation and the COCP is contraindicated if she has focal migraine. It is important to take into account the thoughts and feelings of Eloise’s parent as well during this assessment but remembering that at aged 14 she is likely to have capacity to make decisions some about her own care and be fully involved in the process.

Management of menorrhagia

The NICE guidelines on heavy menstrual bleeding contain a useful interactive flowchart for managing menorrhagia. The first line according to NICE is a levnorgestrel IUS (e.g. Mirena) but this is not always going to be the best tolerated or most suitable in a young teenager. Pragmatically in teenagers we are much more likely to opt for the second line options of tranexamic acid +/- NSAID or the combined pill.

Tranexamic acid (TXA) may be familiar to people who work in haematology or with major trauma patients as an antifibrinolytic. It is licensed for menorrhagia management to be taken as 1g three times daily for up to four days starting on the first day of the period. There are few contraindications but it cannot be taken if there is a history of VTE and should be used with caution if the patient is on the COCP because both increase thrombotic effect. TXA will reduce menstrual blood loss by up to 50%.

NSAIDs for managing menorrhagia often causes confusion as surely they make people bleed don’t they? It’s worth going back to basic pharmacophysiology and revising how NSAIDs act on prostaglandins.  NSAIDs are cyclo-oxygenase inhibitors and cyclo-oxygenase is the enzyme involved in production of prostaglandins. In menorrhagia most women will have increased levels of prostaglandins which, as you might remember, are powerful vasodilators. The local effect of prostaglandin on endometrial blood vessels causes increased bleeding. By reducing the level of prostaglandins using oral NSAIDs the blood loss volume will be reduced by up to 40%. NSAIDs will also have a significant effect on dysmenorrhoea which will frequently coexist with menorrhagia.

The COCP is frequently prescribed for menorrhagia. It is important to be familiar with the UKMEC guidelines when prescribing the COCP. Whilst the licensed regimen for COCP is to take for 21 days with a seven day break, the RCOG FSRH and most menorrhagia guidelines recommend using extended or tailored regimens. This allows for shorter pill free intervals and reduced numbers of bleeding days. Tailored regimens are associated with less frequent bleeds, and in many cases a reduced number of bleeding days.  Satisfaction with tailored regimens is high. 

Eloise seems delighted that you think her periods might not be something she simply has to “put up with”. As she isn’t sure about her family history you call dad back in and he confirms that he knows of no family history of clotting or bleeding disorders. Eloise has had several dental extractions for orthodontic work and has never bled much after these and has never had epistaxis. Eloise has never had a migraine. Her blood pressure and BMI are normal and after discussions of options you prescribe her the levest COCP using an extended tricyling regimen with a five day break after 63 pills to minimise the number of bleeds she experiences and the volume. You also prescribe oral iron and arrange a repeat haemoglobin and ferritin in 3 months, with follow up consultation in four months time.

Selected references

Heavy menstrual bleeding: assessment and management (2018, updated 2020) NICE guideline NG88

Goddard, A.F., James, M.W., McIntyre, A.S. and Scott, B.B., 2011. Guidelines for the management of iron deficiency anaemia. Gut60(10), pp.1309-1316.

Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(2):CD000400. 

Nash, Z., Thwaites, A. and Davies, M., 2020. Tailored regimens for combined hormonal contraceptives. BMJ368.

Toddler fracture

Cite this article as:
Rhiannon McClaren. Toddler fracture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31170

A 2-year-old girl, Aila, presents to the emergency department with her mother. She had been running around at childcare playing with her friends when she fell over. She is upset, has refused to walk since and won’t weight bear on her right leg. On examination, there is no obvious swelling or deformity and on palpation and axial loading it appears that her pain is most likely localised to her right lower leg, but it’s hard to be sure.

A toddler’s fracture is a non-displaced spiral fracture of the distal two-thirds of the tibial shaft, with an intact fibula, occurring in children generally between the ages of 9 months and 3 years. The periosteum remains intact. It was first described in 1964 by Dunbar et al. It is thought to be due to new stresses on the bone due to increasing ambulation.

History and examination

The mechanism is usually trivial, a trip or a fall, and often involves a twisting mechanism. Sometimes a specific story of trauma is difficult to elicit. More commonly children present unwilling to bear weight or limping with non-specific examination findings. They may be tender to palpation of the tibia, have pain with dorsiflexion of the ankle or pain with gentle twisting of the lower leg. All joints of the lower limb should be examined. It is always worth examining both lower limbs as gait can be difficult to assess in toddlers and may be misleading regarding the side of the injury.

As part of a thorough history and examination, any history of fever, weight loss, recent illness, or recurrent presentations with minor injuries should be elicited. The child should have their spine and neurology examined as well as any bruising, petechiae, warmth and swelling of joints, and puncture wounds on the soles of the feet documented.

Imaging

Initial x-rays may show a non-displaced spiral fracture of the tibia, however, a fracture may not be seen despite multiple views. AP and lateral views should be adequate in children, however, an oblique view may help. A repeat x-ray in 1 week usually shows sclerosis or periosteal reaction. 

AP and Lateral of lower limb
Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 9317
Periosteal reaction and callus formation in healing toddlers fracture
Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org. From the case rID: 49123

But, a plain film x-ray may not be where it ends. Ultrasound is being explored as a possible diagnostic tool for toddler’s fracture, as sonography is used more and more for diagnosis of long bone fractures in children. The idea’s not a new one; a case report of three children in England in 2006 demonstrated that Point of Care Ultrasound Scan (POCUS) could be used to diagnose toddler’s fracture where initial x-rays did not show any fractures. They used the appearance of an elevated periosteum and a layer of low reflectivity superficial to the tibial cortex which suggests a fracture haematoma as a way of diagnosing an occult fracture. 

Cortical breach seen on ultrasound
Ultrasound image showing cortical breach in a toddler’s fracture. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

A recent pilot study by Carsen et al comparing ultrasound to radiographic diagnosis of toddler’s fractures looked at 27 children presenting with suspected toddler’s fractures. Five children had confirmed toddler’s fractures and of these five, three were identified correctly by x-ray at initial presentation and the other two were diagnosed with repeat x-ray at follow up appointments. All five children had their toddler’s fracture correctly identified using POCUS at their initial presentation. 

Radiograph showing Toddler fracture
AP x-ray of the same toddler’s fracture seen on ultrasound. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

Although there are limited studies evaluating the use of POCUS in the diagnosis of toddler’s fractures, the small number of studies and case studies available are promising. As a point of care test in someone with appropriate training, this is a convenient potential diagnostic tool, particularly given the potential to reduce radiation exposure for children.

Management

Toddler’s fractures do not need to be reduced and the management is largely supportive for 3-4 weeks. Standard treatment is a long leg back slab followed by a long leg walking cast. 

A number of retrospective studies have looked at rates of immobilising toddler’s fractures when the diagnosis is either confirmed or presumed. They show that children with confirmed toddler’s fractures are more likely to be immobilised. But… a series of 75 children with radiographic evidence of toddler’s fractures, by Schuh et al., looked outcome following a variety of treatments (cast/splint, controlled ankle movement boot, or no immobilisation). Those not immobilised had fewer follow up appointments and fewer repeat radiographs. Skin breakdown was reported in 17% of children, all of whom were in a splint or cast. Schuh et al. also found that children who were not immobilised walked much earlier than those who were immobilised in a controlled ankle movement (CAM) boot or splint. It was a mean of 4.1 days for the little ones not immobilised compared to 27.0 days for the smallies in a boot and a whopping 27.5 days for those in a cast or splint.  

Another retrospective study by Bauer and Lovejoy of 192 children, aged 9 months to 4 years, meeting criteria for a toddler’s fracture, showed an earlier return to weight-bearing in those immobilised with a CAM boot compared with a short leg cast (2.5 vs 2.8 weeks). Even when considering the seven children in this study who received no immobilisation, none of the fractures shifted. Sapru and Cooper also found that there were no complications with management in or out of a cast.  

There is now a move towards recommending immobilisation in a CAM boot or short leg cast or splint rather than in a long leg cast. Further studies are currently underway so watch this space!

What not to miss

A thorough history and examination should always be taken so as not to miss other diagnosis. If a child is not yet mobile, there must be a high suspicion for non-accidental injury. Fevers warrant consideration of septic arthritis or osteomyelitis. Malignancy and inflammatory conditions should also be considered. 

Aila’s initial x-ray showed a non-displaced spiral fracture of the distal third of her right tibia. She was placed in a long leg back slab and had a follow-up with the local orthopaedic service in the fracture clinic. Four weeks later she is running around and happily playing with her older brother.

 References

Alqarni, N., & Goldman, R. D. (2018). Management of toddler’s fractures. Canadian family physician Medecin de famille canadien64(10), 740–741. 

Bauer, J.M., Lovejoy, S.A. (2019) Toddler’s Fractures: Time to Weight-bear with Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop. Jul: 39(6), 314-317. 

Carsen, S., Doyle, M., Smit, K., Shefrin, A., Varshney, T. (2020) Point-of-care Ultrasound in the Emergency Department may provide more accurate diagnosis of toddler fractures than radiographs: A pilot study. Orthopaedic Proceedings. 102-B

Dunbar, J.S., Owen, H.F., Nogrady, M.B., McLeese, R., (1964) Obscure Tibial Fracture of Infants – The Toddler’s Fracture. Journal of the Canadian Association of Radiologists, Sep;15, 136-144. 

Fox, S. (2013) Toddler’s Fracture. Available at: https://pedemmorsels.com/toddlers-fracture/

Lewis, D. and Logan, P. (2006), Sonographic diagnosis of toddler’s fracture in the emergency department. J. Clin. Ultrasound. 34: 190-194. 

Pattishall, A.E. (2019) An updated approach to toddler fractures. J Urgent Care Med.  Available at: https://www.jucm.com/an-updated-approach-to-toddler-fractures/

Rasuli, B., Gaillard, F. Toddler Fracture. Available at: https://radiopaedia.org/articles/toddler-fracture

Royal Children’s Hospital Guidelines – Tibial Shaft Fractures. Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

Sapru, K., Cooper, J.G. (2014). Management of the Toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. Dec;21(6), 451-454. 

Schuh, A.M., Whitlock, K.B., Klein, E.J. (2016) Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatri Emerg Care.  Jul: 32(7), 452-454.

UpToDate – Tibial and fibular shaft fractures in children

Wang, C.C., Linden, K.L., Otero, H.J. (2017) Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 33(3), 200-207. 

Wijtzes, N., Jacob, H., Knight, K., Thrust, S., Hann, G. (2020) Fifteen-minute consultation: The toddler’s fracture. Arch Dis Child Educ Pract Ed. 0, 1-6. 

UTI whizzdom – the next steps

Cite this article as:
Felicity Beal. UTI whizzdom – the next steps, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32306

A 4-month-old baby presents with a temperature and urine microscopy suggestive of a urinary tract infection. He appears well and your plan is to discharge home on an oral antibiotic, whilst awaiting culture results. His mother asks you, “Does he need any other tests?”

Why does it matter?

Urinary tract infections (UTIs) are very common in children. Studies suggest that 6-8% of febrile, unwell children presenting to their GP have a UTI. Therefore it is important to carefully select which of these children need further investigations in order to identify those with underlying renal tract problems. It is estimated that up to 15% of children with a first UTI have evidence of scarring on follow up scans. If they are missed, these children may go on to develop hypertension and possible chronic kidney disease later in life.

Which children are more likely to get a UTI?

Before the age of 6 months, UTIs are more prevalent in boys. This is partly due to the increased chance of structural abnormalities within the urinary tract. Uncircumcised boys are particularly at risk, as bacteria on the foreskin are a reservoir for infection.

However, after 6 months of age, girls are at increased risk due to their shorter urethra and its proximity to the anus. This risk is increased again in females when they become sexually active.

Risk factors for UTIs

There are several other risk factors that increase the risk of developing a urinary tract infection. The main risk factor is something we see and manage on a daily basis, another really common presentation…constipation! If you haven’t yet read Chris Dadnam’s Conversations about Constipation post, now would be a great time to have a refresher as these two conditions go hand in hand.

As the colon and rectum fill with stool, the mass effect results in incomplete bladder emptying. This results in stasis of urine. Always ask about, and treat, constipation… If this is left unmanaged UTIs will continue to be a problem. 

After taking a good constipation history and examining the abdomen, it’s important you assess the spine looking for dimples, swellings, birthmarks or hairy patch lesions that can be associated with a neuropathic bladder. This should be followed by a lower limb neurological assessment. I think of this as running a bath after a hard day at work. You are unable to fully empty the tub afterwards but continue to add more bathwater to the tub every time… this will encourage infection to harbour. Recurrent UTIs may be the main presenting complaint in young children and should always prompt a review of the spine.

Foreign bodies such as intermittent or indwelling catheters also pose a risk. But it is essential to remember the last risk factor, not visible to the eye … namely urinary reflux.

Is this the same as vesico-ureteric reflux?

Yes. This is simply a term describing where, anatomically, the reflux occurs – from the bladder (vesico) to the ureters (ureteric). Urine flows back up from the bladder to the ureters causing a bidirectional flow of urine.

How vesico-ureteric reflux can cause a UTI

VUR can be primary, i.e. within a normal renal tract, or secondary, due to an abnormal renal tract – such as a neuropathic bladder. It is graded from 1 (mild) to 5 (severe.) Most mild to moderate reflux resolves by 5 years of age. However, surgery may be indicated if severe reflux is present, with worsening renal impairment or frequent pyelonephritis.

History and examination

As part of the history taking and examination, it is key to think about whether there could be underlying constipation, VUR or a neuropathic bladder. Asking about a family history of renal problems as well as considering antenatal renal scans is important to risk stratify for structural problems.

Ask about

  1. Constipation
  2. Urine flow
  3. Lower limb/back problems
  4. Antenatal renal abnormalities
  5. Family history of renal problems
  6. History of previous UTI/ fevers

Examine for

  1. Hypertension (complication)
  2. Poor growth
  3. Spine – for any spinal lesions
  4. Lower limb neurology
  5. Faecal masses
  6. Enlarged bladder / abdominal mass

What do we need to consider when further investigating UTIs?

NICE (the National Institute for Health and Care Excellence) ask the following three questions when considering a child’s risk of reflux and scarring:

How old is the child? Age is important. This may be a neonate or infant presenting with an infection as the first indicator of a possible underlying structural abnormality such as posterior urethral valves or VUR.

Is this an atypical UTI? 80% of paediatric UTIs are secondary to E.coli infection. An infection caused by an organism other than E.coli, or not responding within 48 hours of antibiotic therapy, is more unusual. Equally, if a child with a UTI looks unwell, has a palpable bladder, renal impairment or poor urine flow, your index of suspicion should be raised. These are uncharacteristic signs of a urinary tract infection.

Is this child having recurrent infections? Over 30% of children with UTIs will suffer from recurrent infections. Recurrent infections are defined as children who have either 2 or more upper UTIs (affecting the kidneys or ureters), 3 lower urinary tract infections (affecting the bladder or urethra) or 1 upper and 1 lower infection at any point up until the age of 16.

Investigations? Clear as M.U.D.

Key investigations to follow up children with a UTI
  • MCUG in 4 – 6 months
  • Ultrasound scan acutely or within 6 weeks
  • DMSA in 4 – 6 months

MCUG

An MCUG is a Micturating Cystourethrogram, which assesses for urinary reflux or obstruction. A catheter is inserted and radio-opaque contrast is administered via the catheter to fill up the bladder. X-rays are then taken during urination to see if urine is refluxing back towards the kidney.

Normal MCUG. Case courtesy of Dr Aditya Shetty, Radiopaedia.org. From the case rID: 27065
MCUG illustrating marked dilatation of the prostatic portion of the urethra consistent with posterior urethral valves. Case courtesy of Dr Andrew Dixon, Radiopaedia.org. From the case rID: 10432

DMSA

A DMSA scan is used to assess the function and location of the kidneys. An isotope that emits gamma rays is attached to ‘Dimercaptosuccinic acid’. This is administered via an intravenous cannula and is taken up by the kidneys a few hours later. If performed acutely it can show altered function consistent with pyelonephritis. In the UK, a DMSA scan is undertaken 4-6 months post-infection to assess for scarring.                       

A normal DMSA with equal isotope uptake in both kidneys. Case courtesy of Dr Yusra Sheikh, Radiopaedia.org. From the case rID: 69041

What does the guidance say?

In 2007, NICE published a guideline called “Urinary tract infection in the under 16s: diagnosis and management”, updated in 2018. When it comes to imaging, there are three main highlights.

1. Children under 6 months of age with a first typical UTI should have an ultrasound to assess for a structural cause. An MCUG is considered if this is abnormal.

2. All children with an atypical UTI, regardless of age, should have an ultrasound acutely. A DMSA is also performed if they are under 3 years of age to assess renal parenchyma. Children under 6 months are investigated more fully with an USS, DMSA and MCUG.

3. All recurrent UTIs require a DMSA scan within 4-6 months to assess for scarring.

This traditional approach for investigating children for reflux and scarring is safe yet adopts a different approach to imaging children with UTIs compared with other countries.

Controversial whizzarding….

The decision of who should be investigated further has caused great controversy. Different approaches are adopted around the world. This is due to conflicting evidence with clinicians balancing the risk of radiation, invasive imaging and cost with that of detecting children with an underlying congenital anomaly and preventing the development of chronic kidney disease.

There is conflicting data surrounding the risk factors for VUR in children with their first UTI. Ristola et al (2017) investigated risk factors for children with UTIs, finding the following 3 as the main risk factors for reflux: ultrasound abnormalities, recurrent infections and atypical infections. Interestingly, non-E. coli infections were the only statistically significant risk factor of infection recurrence.

Yılmaz et al (2016) were unable to identify risk factors associated with VUR, although did note that an abnormal renal scan at 6 months after the infection was closely related to the presence of VUR and recurrent UTIs.

In America, Canada, Poland and Italy, children up to 2 -3 years of age with their first UTI would be advised to have an ultrasound. The European Association of Urology advises every child presenting with a first UTI to be investigated with sonography. This is in comparison with the 6 month cut off advised by NICE, which is argued to be a more cost effective and risk stratified approach.

However, the American, Canadian and Italian guidelines do not investigate all children with recurrent UTIs as previously advised by the NICE guidance. Instead of all children with recurrent UTIs undergoing a DMSA scan, recent guidance suggests only performing a DMSA if there were concerns regarding an abnormal ultrasound or alternative diagnosis.

Therefore this makes me wonder, instead of investigating all children with recurrent UTIs, perhaps this decision should be made on an individual basis, using their ultrasound findings and considering risk factors.

How accurate are ultrasound scans in picking up VUR?

An ultrasound cannot exclude all cases of VUR as it is an observer-dependent investigation. Mahant et al (2002) reported low sensitivity of 40% and a specificity of 76% when diagnosing VUR, but the majority of these patients had lower grade reflux. There is now increasing awareness that low-grade reflux and mild scarring are unlikely to cause long term problems, therefore the argument presents itself: is there any benefit in investigating for them? Ultrasound scans are more likely to detect higher grade reflux and hence clinically significant cases, but further evidence is needed to support this approach.

The take homes

Some evidence suggests that children with ultrasound abnormalities or recurrent UTIS are at increased risk of complications from UTIs, regardless of their age or sex. There is no clear consensus on when to request a DMSA or MCUG but the latest evidence suggests that DMSA scans may not be necessary in all children with recurrent infections and a normal ultrasound scan. Clinicians should be aware of this existing controversy, weighing up the benefits and risks in order to make informed clinical decisions.

References

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