Wrist Examination & Pathology Module

Cite this article as:
Segn Nedd. Wrist Examination & Pathology Module, Don't Forget the Bubbles, 2020. Available at:
TopicWrist Examination and Pathology
AuthorSegn Nedd
Duration2 hrs
Equipment requiredSplints, soft bandages, plaster of paris sets

  • Basics (10 minutes)
  • Main Session (2 x15 minutes) case discussions covering key points and evidence
  • Advanced  Session ( 2 x 20 minutes) case discussions covering diagnostic dilemma, advanced management
  • Sim scenario – (30 minutes) 
  • Quiz (5 minutes)
  • Infographic sharing (5 minutes): 5 take home learning points

(From TeachMeAnatomy and LITFL)

The wrist is a common place for injuries in children often occurring following a Fall Onto an OutStretched Hand (FOOSH). The wrist joint connects the hand to the forearm. It is made up of the radius and 8 carpal bones. Although commonly included, the ulna is not technically part of the wrist joint. The ulna articulates with the radius just proximal to the wrist at the radio-ulnar joint. It is separated from the carpal bones by a fibrocartilaginous ligament (articular disk). The wrist joint is a synovial joint. It therefore has a capsule. Its internal membrane secretes synovial fluid to lubricate the joint. 

When describing injuries of the wrist (and hand) for documentation or referral purposes it is important to know the terminology widely in use in order to convey an accurate description to others. Injuries present on the palmar surface would be described as Palmar or Volar. Injuries on the back of the hand are dorsal. The proximal part of the wrist is more towards the forearm, whereas the distal end is towards the fingers. The thumb lies on the radial side and the little is the ulnar side. 

Anatomy: (from Radiopedia, NYSORA & teachme anatomy)

In order to understand what you are examining and the associated pathologies that need to be considered it is important to have knowledge of the underlying structures that form the wrist. The wrist and hand have a complex anatomy with bony structures surrounded by a matrix of soft tissues including, muscles, tendons and ligaments. It additionally has an intricate blood and nerve supply. We will focus on the structures most important when assessing paediatric wrists in the emergency department.


The radius is on the side of the thumb, the ulna on the side of the little finger. A good mnemonic to remember the position of the carpal bones is to describe them starting from the base layer thumb to little finger, followed by the top layer little finger to thumb.

So             Long     To                 Pinky,     Here       Comes    The            Thumb

Scaphoid, Lunate, Triquestrum, Pisiform, Hamate, Capitate, Trapezoid, Trapezium

Ligaments: (from Radiopedia)

There are multiple ligaments of the wrist. These play a vital role in the stability of the wrist joint. They are specifically important in holding the carpal bones together. Those most clinically important in wrist joint stability are labelled as above. Ligaments of the wrist are not visible on X-ray and to be fully examined are best assessed with a dedicated wrist MRI. However, increases in the spacing between bones on plain X-rays can indicate a ligament injury with clinical correlation. 

The Nervous System: (from NYSORA)

The ulnar, median, and radial nerves innervate the hand. The course of these nerves traverse the wrist. They therefore have the potential to be damaged following wrist injuries. The median, anterior interosseous nerve (a branch of the median) and the ulnar nerve specifically although rare can be compromised following wrist fractures. The nerves of the wrist and hand also have an important role in functionality of the wrist (and hand). The radial nerve facilitates extension of the wrist and metacarpophalangeal joints. The ulnar nerve facilitates movement of the small muscles of the hand. The median nerve supports finger extension and anterior interosseous branch enables thumb flexion at the interphalangeal joint and flexion of the index finger at the distal interphalangeal joint.

The corresponding dermatomal innervation of the wrist and hand is illustrated below.

Vasculature: (from teachmeanatomy)

Arising from bifurcations of the brachial artery in the cubital fossa are the radial and ulnar arteries (and their branches) to supply blood to the forearm, wrist and hand. These two arteries merge in the hand forming the superficial palmar and the deep palmar arch. The radial artery supplies the posterolateral aspect of the forearm and is important in contributing to the blood supply of the carpal bones. The ulnar artery supplies the anteromedial aspect of the forearm. It mostly supplies blood to the elbow joint, but its branches do however help supply some of the deeper structures in the forearm.

Examination: From Geeky Medics 

The look, feel, move & function approach is generally used to examine the hand and wrist. Always offer analgesia prior to your examination of a child with an injury.

As functions involve both areas they are often examined together

1Perform general inspection
2Inspect the dorsum of the hands
3Inspect the palms of the hands and elbow

Careful note should be taken to ensure that full inspection is undertaken. This may identify any bruising, overlying skin changes, swelling or deformity. Remember also to always examine the joint above and the joint below.

1Asses and compare temperature of wrist and small joints of hand
2Palpate radial and ulnar pulse & check capillary refill
3Palpate thenar and hypothenar eminence
4Asses median nerve sensation
5Asses ulnar nerve sensation
6Asses radial nerve sensation
7Perform MCP squeeze
8Bimanually palpate hand and finger joints
9Palpate anatomical snuff box
10Bimanually palpate the wrist joints

It is important not to miss any neurovascular compromise when examining the wrist and hand. Findings to suggest compromise may include colour change, coolness to touch, prolonged capillary refill time and altered sensation.

1Assess finger extension
2Assess finger flexion
3Assess active wrist extension
4Assess active wrist flexion
5Assess wrist/finger extension against resistance (radial nerve)
6Assess index finger ABduction against resistance (ulnar nerve)
7Assess thumb ABduction against resistance median nerve)

Where possible movements should be actively undertaken by the patient. Take notice of any movements that are undertaken with difficulty or cause pain in undertaking.  

1Assess power grip
2Assess pincer grip
3Assess picking up small objects
4Supination and pronation- twisting key movement or ‘turning the key’

An 8 year old boy is brought to ED with his father. He had been outside roller-skating but fell over onto the concrete patio within the last hour. He is complaining of pain in his wrist and has difficulty moving it. An x-ray was done following triage: and it’s a buckle fracture

What would be your approach to examining his injury?

What type of fracture do you suspect and how would you differentiate on x-ray?

What type of immobilisation would you use?

Historic studies have shown that radial tenderness, focal swelling, or an abnormal supination/pronation were the clinical signs most often associated with correctly identifying children who had  wrist fractures. In 2016, in a multicenter study by Slaar et al. a clinical decision tool known as the Amsterdam paediatric wrist rules was created for use in children presenting with wrist trauma to determine clinically whether a radiograph was required or not.  

The prediction model had high sensitivity and moderate specificity of 95.9% and 37.3%, respectively. It was calculated that through using this model there would be a 22% absolute reduction of radiographic examinations. Although not perfect, the use of the paediatric Amsterdam wrist rules may therefore be a useful aide memoir in facilitating clinicians to rationalise which children who present with wrist trauma to x-ray.

The clinical prediction model used eight variables to analyse those at risk of any wrist fracture. These were increasing age; sex (if male), swelling of the wrist; swelling of the anatomical snuffbox; visible deformation; distal radius tenderness on palpation; pain on radial deviation and painful axial compression of the thumb. The more of these factors that were present resulted in the increased probability of a fracture. Painful axial compression of the thumb however decreased the probability of a fracture.

This study also further analysed those with distal radius fractures. Children with increasing age, swelling of the wrist, visible deformation, distal radius tender to palpation, pain on palmar flexion, pain on supination and or painful radioulnar ballottement test were more likely to have distal radius fractures. However, pain on ulnar deviation was found to decrease the likelihood of a distal radial fracture.

Always ensure adequate analgesia is given when first assessing an injury. Ensure that the examination is systematic. It is best to use the look, feel, move, function process when examining the wrist. As with any orthopaedic examination however it is always important to also assess and assess the join above and below the affected area.

Look – for any deformity, swelling, bruising, colour change or overlying lacerations

Feel – assess for radial tenderness, remember to assess for any signs of neurovascular compromise and check sensation in the forearm and hand. Neurovascular compromise is rare in distal radius fractures but can occur in greenstick fractures.

Move – making tasks quick and easy to reproduce will assist in making identification of pathologies easier when assessing children. A combination of movements described by Dawson can be used to assess motor and neurological function in the hand and wrist. This can be done by starting a game of rock, paper, scissors. The addition of the O.K sign and also encouraging pronation and supination by “turning the key”, turning the door handle” or “turning the lightbulb” will allow easy testing of wrist and hand movement and functionality

Types of distal radius and ulna fractures

(from DFTB and Radiopaedia)

Buckle fractures are common in children especially in the 5-10 year old age range. Following a fall (often onto an outstretched hand) the force is transmitted from the carpus to the distal radius and as this is the point of least resistance fractures occur. Fractures are also often around the dorsal cortex of distal radius.

Greenstick fractures are incomplete fractures of the long bones in children. They are usually only seen in those under 10 years of age. The integrity of the bone cortex is breached on the convex side. The concave surface remains intact. It resembles the break that occurs when a young green branch of a tree is bent and breaks incompletely. One side snaps whilst the other side is still intact.

Buckle/torus and greenstick fractures are often discussed together as they have similarities; they are unique to children due to their softer compressible bones. However they also have clear differences. 

Buckle/torus fractures:

  • In buckle fractures only one side of the bone is affected, strictly speaking both sides are affected in a torus fracture. However the terms are often used interchangeably
  • In buckle/torus fractures the bone cortex crumples/buckles but does not crack
  • Buckle/torus fractures are caused by longitudinal force through a long bone often following a fall a FOOSH
  • Buckling of the bone occurs due to paediatric bone softness

Greenstick fractures:

  • In greenstick fractures there is a clear cortex breach but only on one side of the bone
  • There may also be some degree of angulation
  • There may be visible deformity in greenstick fracture where often not present in a buckle fracture

More difficult to recognise distal radius fracture features on lateral wrist x-rays include:

  • A crinkle, or any irregularity of the cortex of the dorsal aspect of the distal radius
  • In an impacted and undisplaced fracture, the only abnormality may be a very slight increase in the density of the radial metaphysis and/or loss of the normal palmar tilt of the radial articular surface

What is the normal volar tilt of the radial articular surface?

In a lateral view of the distal forearm

The distal radius, the lunate and the capitate articulate with each other and lie in a straight line, like an apple in a cup sitting on a saucer.

The radius holds the lunate (cup) and the cup contains the capitate (apple)

The articular surface of the radius has a palmar tilt and is usually about 10 degrees with a normal range of 10-25 degrees

Controversies in management:

Rest, support and analgesia are the mainstay of treatment for buckle fractures. Buckle fractures often heal well without complication. There is however much variance in how these are treated in different departments. Removable splints are widely used for up to 3 weeks in children old enough to keep them on (hard casts may be required in younger children). There is however uncertainty as to whether immobilisation is actually really needed or if early mobilisation to reduce stiffness is preferable. The FOrearm fracture Recovery in Children Evaluation (FORCE) Study is currently in its final stages. It will evaluate outcomes (pain, functional improvement and complications) between encouragement of use of the wrist, an optional bandage, and a point of contact for any ongoing concern versus hard splints use and local hospital outpatient fracture follow up (https://force.octru.ox.ac.uk/).

Buckle fractures often heal well with minimal complication. There is however a risk of refracture. General advice includes avoidance of sports for three to six weeks and contact sports for 6 weeks post injury. You should also refer to your local guideline on the management of buckle fractures.

A 12 year old girl is brought to ED with her mother. She was jumping on her trampoline but fell out. She had immediate pain and has not been able to use her left hand since.  Her mum gave her some paracetamol and ibuprofen prior to arrival. An  x-ray was then done and is as follows:

What does this fracture show?

How  would you further classify this type of fracture?

How would you manage these fractures?

Mum asks you if she should let her 6 year old daughter use the trampoline. What is your advice?

(from Royal Children’s Hospital Melbourne)

In contrast to adult bones, children’s bones are still developing. They have cartilaginous discs which separate the epiphysis from the metaphysis of long bone. This area is called the growth plate (physis). Physeal injuries are very common in children and can account for up to 15-30% of all bony injuries. Physeal injuries occur most commonly in the pre-adolescent growth spurt age.

Physeal fractures are classified by the Salter-Harris classification. A Type II fracture is the most common type. Distal radial physeal fractures are uncommon in children younger than five years. The most common mechanism of injury is a fall on an outstretched hand. Extension of the wrist at the time of injury causes the distal fragment to be displaced dorsally (posteriorly). Commonly this also causes an associated ulna fracture (greenstick, physeal or styloid).

Always give appropriate analgesia prior to assessment and x-ray. Ensure both AP and lateral views are undertaken of the wrist AND distal forearm.

See the Salter-Harris Classification below;

(from Royal Children’s Hospital Melbourne & First10EM)

Type II is the commonest type of Salter-harris fracture and accounts for around 75% of physeal fractures. Reduction is required for distal radial physeal fractures that are angulated >20 degrees. Salter-Harris type I and II injuries rarely cause growth problems. The risk of growth arrest is higher in type III-V injuries. The risk of physeal arrest is rare in young children but the risk is higher if the child is near the end of growth. It is therefore increasingly important to correct any angulation in adolescents especially where there is less than two years of growth remaining.

For type I and II injuries, closed reduction may be required. A fracture clinic review is required within five days with x-ray. RICE advice and instruction to monitor for any swelling should be given. This as there is a risk of early compartment syndrome due to restriction by the cast.

Urgent orthopaedic review is required when there is an open fracture, a fracture is associated with neurovascular compromise (most notably in the median nerve distribution), any Salter-Harris type III and IV (lower or through) fracture is seen. Additionally referral should be made when there is an associated fracture in the same upper limb or if there is any difficulty achieving acceptable reduction. This should only be attempted with adequate supervision or clinical competence. However, for children presenting with distal radial physeal fractures after 5 days since the injury closed reduction should not be attempted and specialist input from the appropriate orthopaedic team must be arranged.

After any reduction or immobilisation of a fracture, repeat x-rays should be undertaken.

(from RSPA and GPPaedsTips)

Trampolines are thoroughly enjoyed by children of all ages. Especially in current times many families have invested in trampolines for their gardens. However injuries sustained whilst playing on trampolines contribute greatly to injury presentations in the children’s emergency departments.  There are however steps that can be taken to try and minimise the chances of injuries occurring. The first advice would be that children should take turns to bounce. 60% of injuries have been found to have occurred when more than one person is on the trampoline. Often it is the smallest (lightest) person who is (five times) more likely to be injured. If they are not alone they should be of similar age and size. 

The Royal Society for the Prevention of Accidents suggests that Trampolining is only suitable for children over six years of age when they can are sufficiently developed to control their bouncing. Adult supervision cannot prevent all injuries but may prevent children engaging in dangerous practices. Additionally having some formal training such as joining a local trampolining club to learn new skills will help children who are keen to learn how to attempt advanced trampolining skills and tricks safely.

A 14 year old boy was skateboarding and dismounted, landing on his outstretched hand. He had significant pain in his wrist around the distal radius. Following analgesia in the emergency department an x-ray was undertaken. No fracture was identified and he was reassured that he had sustained a soft tissue injury. He was discharged with RICE advice. 

Four weeks later he is still in pain – the original x-ray is re-reviewed – a scaphoid fracture is seen.

What are thoughts surrounding soft tissue injuries in children and how should they be defined and managed ?

Are there any other pathologies you should consider when x-rays appear normal

Many times when there are no overt fractures on an x-ray we conclude that the patient has a “soft tissue” injury or  sprain. A scaphoid series (not wrist views) should be requested when there is ‘snuffbox tenderness’. Even when bony pathology cannot be identified on X-rays it is important to consider that the muscles, ligaments and tendons of the wrist, if damaged, can have a significant impact on a child’s ability to undertake daily activities, especially if the injury is to their dominant hand. As with any injury presenting to the emergency department pain should always be assessed and managed. Fractures through the waist (middle) of the scaphoid jeopardise the blood supply of the proximal fragment. If the patient is managed incorrectly then non-union, delayed union or avascular necrosis of the proximal fragment may result.

Elvey et al. conducted a single centre study of MRI studies of children who had presented in the two weeks prior with wrist injuries. X-rays undertaken at the time had not identified any fracture. Although a small study of 57 cases, over 75% of cases had a positive finding on MRI. There were no cases at all of isolated soft-tissue injury. Occult fractures and bony contusions (focal oedema and haemorrhages which occur following microfracture) accounted collectively for almost 70% of the pathologies seen on MRIs in these children. Following MRI almost ⅓ of cases required additional further management changes.  This study raised questions about the best modality and timing of imaging in children presenting with wrist pain following an injury. Fracture lines may not be apparent in children on initial X-rays and may only become visible weeks later following callus formation. Alternative imaging options considered have included ultrasound, CT and nuclear medicine scintigraphy. The cost-effectiveness, time constraints, risk-benefit analysis of radiation exposure and operator feasibility in the emergency setting is however difficult to justify. Additionally, some of these modalities have excellent sensitivity, but low specificity and operator-dependency. 

It is important to remember that even when no injury is seen on X-ray wrist injuries often classified as sprains can have clinical sequelae. At 5–6 weeks in the Elvey et al. study children who had had occult cortical fractures typically had resolution of their pain. However, those who had bone contusions typically had continued pain on palpation. 

Carpal instability injuries: (From LITFL)

Some non-fracture pathologies are visible on x-ray but sometimes missed. Scapholunate injuries include scapholunate dissociation which is caused by damage of the ligament between the scaphoid and lunate bones. It is very uncommon in children but may occur in adolescent age groups. These will often be very painful.

The carpal bones on a normal plain X-ray are evenly spaced. Where there is a scapholunate dissociation there will be a large gap (>3mm) between scaphoid and lunate bones. This is also known as the Terry Thomas sign (named after a famed comedian who had a large gap between his two front teeth). 

Other ligament bands may tear between carpal bones causing carpal instability. These can lead to the following 4 stages of pathology; perilunate dislocation, perilunate dislocation with triquetrum dislocation and lunate dislocation. Injuries of these ligaments can cause long term damage including chronic pain and arthritis. PA views with help with Terry Thomas sign. Lateral views are most useful in helping to identify any misalignment and potential dislocation of the other carpal bones (mostly lunate and perilunate dislocations).

A lunate dislocation can be a devastating injury. There is loss of articulation between the lunate and radial head and lunate and capitate. This injury would be excruciatingly painful. However most importantly there is also a high risk of median nerve damage as the dislocated lunate bone causes pressure on the median nerve which would usually run freely through the carpal tunnel. This can cause an acute carpal tunnel syndrome. Due to pain it should be hard to miss but needs urgent management.

Scaphoid fractures (from LITFL and pedemmorsels)

A scaphoid fracture is uncommon in 4-11 year olds as ossification centres appear to be protective against scaphoid fractures. However, the scaphoid bone is the most easily broken carpal bone and is easily broken in the adolescent age group. The fracture occurs via transference of force onto the scaphoid following FOOSH where the wrist deviates radially during impact. It is a more common injury following extreme sports. Where a scaphoid fracture has occured X-ray a lucency will be apparent running through the scaphoid bone.

The scaphoid is positioned beneath the anatomical snuff box. On examination it is important to check for pain here.Tenderness of the Scaphoid Tubercle (on the volar aspect), pain with radial deviation, pain on axial loading to the thumb and pain with active wrist range of motion may also point to this diagnosis. It is important not to miss scaphoid fractures. The reason being is that the scaphoid bone is at high risk of non union and avascular necrosis if fractured and left untreated. 

Although simplistic to attribute all blood supply to the scaphoid from the radial artery a fracture especially at the distal end of the scaphoid has been associated with compromise in the blood supply to the rest of the scaphoid. Complications of missed scaphoid fractures can be bone growth arrest and chronic pain. 

Controversy is however present as to whether surgical treatment is preferential to conservative management. A recent systematic review of randomised controlled trials surrounding this question in 2018 by Al-Ajmi et al suggested that surgical management of minimally or non-displaced scaphoid fractures resulted in better functional outcomes than conservative management. However, the findings were not significantly strong enough to make concrete conclusions. It is however generally accepted that scaphoid fractures which are unstable due to being at the proximal pole, having displacement > 1 mm, those with associated carpal bone dislocation and those with significant angulation or clinical deformity will need referral to orthopaedics and surgical intervention.

Scaphoid fractures in children are generally believed to heal well. Casting of non-displaced, acute fractures leads to high rates of scaphoid union. Where there is clinical suspicion of a scaphoid fracture but uncertain or negative x-ray findings generally early immobilisation is initiated by application of a thumb spica splint or cast with follow-up imaging 2 weeks later.  Casting may however need to be applied for 3 months or more. The videos on thumb splints and hard cast spica’s from Don’t Forget the Bubbles and Orthofilms can be used for demonstration and to assist in practical sessions. (Please see the simulation section for full details). 

Conversely Porter et al suggested that symptomatic treatment is sufficient with those who have normal x-rays. This paper advocated using a removable splint with follow-up only arranged if symptoms do not improve. This was however a single centre study and advocated for a larger multicentered prospective clinical trial on this matter.

If in doubt and there is high clinical suspicion of a scaphoid fracture it is not unreasonable to consider application of a thumb spica cast with a plan to bring back the child for review in 2 weeks. 

A 13 year old girl is brought to ED following a fall from a tree she has significant pain, swelling and deformity of the distal shaft of the radius. Analgesia is given and she is taken to x-ray:

Case courtesy of Radswiki, Radiopaedia.org. From the case rID: 12221

What type of fracture has occurred?

How would you manage this fracture?

(from the Royal Children’s Hospital Melbourne)

Distal radius fractures can be classified according to:

  • Presence of displacement (whether they are displaced or nondisplaced)
  • Bone involvement (an isolated radius fracture only or if both radius and ulna are involved)
  • Fracture type
    • Buckle and greenstick fractures: – see previous sections for further information 
    • Complete fractures:  These fractures extend through both cortices of the radius. Most complete metaphyseal fractures of the distal radius also involve the ulna with either an associated complete fracture, greenstick fracture, or bowing deformity.

From RCH Clinical Guidelines: distal radius fractures

With complete fractures generally if there is clear deformity on examination, reduction is likely to be indicated. Acceptable angulations of the distal radius fracture are dependent on the age of the child. Coronal plane angulation (seen on AP view) has a poorer prognosis as it does not remodel as well as angulation in the sagittal plane (seen on lateral views).

As a rule of thumb, if the deformity is clinically visible, reduction (non-operative or operative) may be indicated. Acceptable angulations are dependent on the age of the child.

In the 0 – 5 year age group, an acceptable angulation for a distal radius metaphyseal fracture is < 20 degrees.

Acceptable angulations in the 5 – 10 year old group is < 15 degrees.

Acceptable angulations in the 10 – 15 year old group is < 10 degrees.

Where no reduction is required for a complete distal radius fracture a below elbow plaster of paris back slab should be applied, fracture clinic follow-up arranged within a week and a cast may be required for up to 6 weeks.

Those needing closed reduction may be able to be undertaken in the emergency department using local anesthetic or procedural sedation. However this should only be attempted with adequate supervision or clinical competence. These children will also need a hard cast applied but with extra moulding in the opposite direction to any angulation.

Following any reduction of a fracture X-rays should be taken. Angles of the fracture should be within the same parameters for acceptable angulation. An orthopaedics referral should be made for any child presenting with an open fracture, signs of neurovascular compromise or if there is over 10 degrees of angulation of the fractured segments. In children where there has been difficulty in reduction (be that due to ED team inexperience or difficulty in procedure) and those with an associated fracture in the same or opposite limb an orthopaedics referral must also be made. 

A Galeazzi fracture-dislocation is one such instance where an urgent orthopaedic team referral should be made. Galeazzi fracture-dislocations are often missed and may be difficult to recognise. It is however really important that a Galeazzi fracture is identified as it must be repositioned prior to casting. If there is an isolated radius fracture, always examine the distal radioulnar joint (also known as DRUJ) on x-ray.

A Galeazzi fracture-dislocation is a fracture of the distal third of the shaft of the radius with a disruption to the DRUJ. This by ulnar displacement which can occur in the volar or dorsal direction. True Galeazzi fractures are very uncommon in children but can occur after a FOOSH with forearm rotation. However, the Galeazzi equivalent is more common and is when there is a distal radius fracture with an associated distal ulna physeal fracture. There is however no disruption of the DRUJ.

Most Galeazzi-equivalent fractures can often be managed with closed reduction in children. However, in some adolescents especially where there is a true Galeazzi fracture-dislocation then open or percutaneous fixation to stabilise the distal radioulnar joint after reduction may be required. Children with Galeazzi-type fractures should be placed in an above elbow cast following any manipulation.

The majority of these fractures will do well.  However outcomes can be poor if there is a delay in diagnosis and or the fracture of radius has been immobilised without  correct alignment of the ulnar dislocation or inadequate support such as a below-elbow cast. Nerve injury is uncommon but there have been some case reports of ulnar nerve injury. Neurovascular status must therefore be carefully examined and assessed. This however does usually resolve with observation.

Depending on the experience of the learners in your group please choose and adapt the following practical elements

  1. Role play hand examinations in pairs. Identifying techniques to follow and signs to exclude. Can be done in OSCE format. 
  2. Removable casts – demonstration by facilitator of rigid casts and soft bandages available in your department alternatively videos from below could be used prior to a learner practice session:
  3. Plaster of Paris hard cast application- demonstration by facilitators or alternatively videos from below be used prior to a learner practice session:

Which of the following is false?

A: A buckle fracture occurs due to longitudinal force along long bone

B: Greenstick fractures do not have any breach in the bone cortex

C: A buckle fracture will have an intact cortex

D: A torus fracture is always circumferential

B: Greenstick

Greenstick, torus and buckle fractures occur due to longitudinal forces exerted along a long bone. Whilst generally used interchangeably with a buckle fractur, a torus fracture actually involves both sides of the bone whereas a buckle fracture generally involves on side. What differentiates a torus or buckle fracture from a greenstick fracture is that there is a breech in the cortex of the bone in greenstick fractures. The cortex itself remains intact in buckle and torus fractures. 

Which nerve is most likely to be affected by a lunate dislocation?

A: Radial nerve 

B: Ulnar nerve

C: Median nerve

D: All of the above

Answer C

The ulnar, median, and radial nerves innervate the hand. The course of these nerves all traverse the wrist. They therefore have the potential to be damaged following wrist injuries. It is important to assess neurovascular status in wrist and hand injuries. However, the median nerve runs through the middle of the palmar side of the hand through the carpal tunnel. This can cause an acute carpal tunnel syndrome. Radial nerve damage may be associated with supracondylar and humeral shaft fractures, whilst Ulnar nerve damage although rare may be seen supracondylar and Galeazzi-type fractures. 

Which statement is true?

A: A Galeazzi fracture-dislocation is one in which the radius is fractured and also dislocated from the radioulnar joint.

B: Scaphoid fractures always require surgical intervention

C: The ulnar nerve may be affected following a Galeazzi fracture-dislocation

D: Bayonet apposition is when the two portions of a fracture are aligned end to end with some angulation

Answer C

A Galeazzi fracture-dislocation is where the distal third of the shaft of the radius is fractured. There is also a disruption to the distal radioulnar joint. The ulna (not radius) bone is displaced. This can occur in the volar or dorsal direction. The Galeazzi equivalent fracture-dislocation is more common and is when there is a distal radius fracture with an associated distal ulna physeal fracture. The ulnar nerve may be affected in a Galeazzi fracture dislocation as it is entrapped by the ulna displacement. Bayonet apposition is a terminology used to describe fractured bone portions which are aligned side by side and not end to end. Depending on the patient’s age and degree of angulation it may be acceptable to leave a fracture in the Bayonet position to heal. Scaphoid fractures may be managed conservatively, however unstable fractures (due to being at the proximal pole, those having displacement >1mm, those with associated carpal bone dislocation and those with significant angulation or clinical deformity will need referral to orthopaedics and are more likely to need surgical intervention. 

  1. https://litfl.com/bscc/clinical-anatomy/hand-anatomy/ video series on hand and wrist injuries
  2. https://teachmeanatomy.info/upper-limb/joints/wrist-joint/
  3. https://teachmeanatomy.info/upper-limb/vessels/arteries/
  4. https://www.nysora.com/techniques/upper-extremity/wrist/wrist-block/
  5. https://geekymedics.com/hand-examination/
  6. https://radiopaedia.org/cases/buckle-fracture
  7. Slaar A, Walenkamp MM, Bentohami A, et al. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol. 2016;46(1):50‐60. doi:10.1007/s00247-015-3436-3
  8. Davidson AW. Rock-paper-scissors. Injury. 2003;34(1):61‐63. doi:10.1016/s0020-1383(02)00102-x
  9. https://www.peminfographics.com/infographics/rock-paper-scissors-ok
  10. https://force.octru.ox.ac.uk/
  11. https://www.rch.org.au/fracture-education/growth_plate_injuries/Physeal_growth_plate_injuries/
  12. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radius_and_or_ulna_metaphyseal_fractures_Emergency_Department_setting/
  13. https://first10em.com/ebm-lecture-handout-6-salter-harris-1-injuries/
  14. https://www.researchgate.net/figure/Salter-Harris-type-III-fracture-in-a-15-year-old-male-patient-Frontal-radiograph-of-the_fig11_260716406
  15. Elvey M, Patel S, Avisar E, White WJ, Sorene E. Defining occult injuries of the distal forearm and wrist in children. J Child Orthop. 2016;10(3):227‐233. doi:10.1007/s11832-016-0735-7
  16. http://gppaedstips.blogspot.com/search/label/Injury
  17. https://www.rospa.com/leisure-safety/Advice/Trampoline
  18. Little, Jason & Klionsky, Nina & Chaturvedi, Abhishek & Soral, Aditya & Chaturvedi, Apeksha. (2014). Pediatric Distal Forearm and Wrist Injury: An Imaging Review. Radiographics : a review publication of the Radiological Society of North America, Inc. 34. 472-90. 10.1148/rg.342135073. 
  19. https://litfl.com/bscc/clinical-anatomy/hand-and-wrist-injuries/
  20. https://pedemmorsels.com/scaphoid-fracture/
  21. Shaterian A1, Santos PJF1, Lee CJ1, Evans GRD1, Leis A1. Management Modalities and Outcomes Following Acute Scaphoid Fractures in Children: A Quantitative Review and Meta-Analysis. Hand (N Y). 2019 May;14(3):305-310. PMID: 29078712.
  22. Porter J, Porter R, Chan KJ. Scaphoid Fractures in Children: Do We Need to X-ray? A Retrospective Chart Review of 144 Wrists. Pediatr Emerg Care. 2018 Mar 12. PMID: 29538268.
  23. https://www.orthobullets.com/hand/6034/scaphoid-fracture
  24. Al-Ajmi TA, Al-Faryan KH, Al-Kanaan NF, et al. A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures. Clin Orthop Surg. 2018;10(1):64‐73. doi:10.4055/cios.2018.10.1.64
  25. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Galeazzi_fracturedislocations_Emergency_Department_setting/
  26. https://www.paediatricpearls.co.uk/wp-content/uploads/minor-injuries-series-wrist.pdf
  27. Clinical Anatomy –hand, wrist (palmar aspect/flexors) Armando Husudungan https://www.youtube.com/watch?v=3aIHxXqKzcU 
  28. http://www.emdocs.net/hand-expedited-examination-key-points-regarding-ed-diagnoses/

Please download our Facilitator and Learner guides

Cervical Spine Injuries Module

Cite this article as:
Ronán Murphy. Cervical Spine Injuries Module, Don't Forget the Bubbles, 2020. Available at:
TopicCervical spine injury
AuthorRonán Murphy
DurationUp to 2 hours
Equipment requiredComputer with projector for imaging
  • Introduction and Basics: (10 mins) pre-reading, glossary of terms, anatomical considerations
  • Main session: (2 x 15 minutes) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

EMS – Emergency Medical Services

CSI – Cervical Spine Injury

SCIWORA – Spinal cord injury without radiological abnormality

XR – X-radiography

ED – Emergency Department

NEXUS – National Emergency X-radiography utilization study

PECARN – Paediatric Emergency Care Applied Research Network

GCS – Glasgow Coma Scale

MILS – Manual in line stabilization

MVC – Motor Vehicle Collision 

ATV – All terrain vehicles

NPV – Negative Predictive Value

PEM – Paediatric Emergency Medicine

TBI – Traumatic Brain Injury

NICE – National Institute for Health and Care Excellence, United Kingdom

MRI- Magnetic Resonance Imaging

The incidence of cervical spine injury is low and represents only 1-2% of all paediatric major trauma (1). 

The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column (2-4). Other features also make it susceptible to injury: ligamentous laxity, incompletely ossified vertebrae and more horizontally orientated facet joints (5). 

The incidence of ligamentous injury is thought to be higher in younger, non-communicative children under 3 years of age (6).

The precise location of injury in the cervical spine can be variable across the age range (7-9).

Four injury patterns are common in children with cervical spine trauma:

  • Fracture
  • Subluxation with fracture
  • Subluxation without fracture

Dislocations or subluxations are more common in upper cervical spine injuries and associated with greater morbidity (9). To compare with adults, children are over twice as likely to suffer atlanto-axial injury (8).

Weaker musculature and underdeveloped interlocking bony processes contribute to the subluxation/dislocation and SCIWORA (spinal cord injury without radiological abnormality) type injury patterns we see in children (10). SCIWORA refers to CT and plain film. A lesion may be detected on MRI.

SCIWORA is the presence of myelopathy as a result of trauma with no evidence of fracture or ligamentous instability on imaging. The mechanism relates to the flexibility of the paediatric spine being greater than that of the spinal cord which becomes damaged as it is stretched beyond its limits. Neurological signs or symptoms even if transient must be elicited in the history to make this diagnosis (2). 

Manage the cases below as you would in your own setting using local guidelines and procedures to make this whole exercise as realistic as possible and also to stimulate further analysis and discussion. 

A 13 year old boy arrives in your ED. He came off his bicycle at speed whilst engaged in a downhill mountain racing contest. He was wearing a helmet and protective clothing but hit his head against a tree as he landed. He did not lose consciousness. He describes immediate onset neck pain which now persists. Volunteer ambulance services were supervising the event and treated his pain with paracetamol and ibuprofen whilst preparing him for transfer in full spinal precautions. He is brought into your ED strapped to a spinal stretcher with a hard cervical collar in place as well as head blocks and tape. On handover it is noted that he felt a weird sensation in his right arm at the time of the event which lasted perhaps 3-5 mins and has not returned. The crew found his neck to be diffusely tender on examination.

What features in history and on examination are we concerned about regarding the potential for cervical spine injury?

How do we take handover of these patients and protect them whilst we work up their injury?

Predisposing vulnerability to bony or ligamentous failure: Down Syndrome(T21), Rheumatoid Arthritis, Rickets, Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Marfans Syndrome, Renal osteodystrophy, Klippel Feil disease, Morquio Syndrome, Grisel syndrome.

A high risk MVC is one of the following: Head on collision, rollover, patient ejected from the vehicle, death of another passenger occurred, speed of collision over 88kph (55mph).

Distracting injury is vaguely defined by NEXUS to include burns and long bone fractures etc. It can be refined to mean any substantial injury of the upper torso due to proximity to the cervical spine (14).

As described above (11), the Viccelilo study (2001) looked at the performance of NEXUS in the paediatric subgroup. In 2017 however, Cochrane (2017) found there was conflicting evidence to support use of NEXUS in children and called for additional well designed studies with larger sample sizes to better evaluate this population (15). 

Some points to consider regarding immobilization: 

Where a cervical spine injury is suspected, appropriate immobilization must be achieved. 

Ask the co-operative child to lie still. Apply gentle manual in line stabilisation (MILS) and give lots of encouragement (age appropriate) to minimise movement. The neck should reside neutrally or in a position of comfort for the child. Bear in mind that babies may require a pad or similar thoracic elevation device laid onto the trauma mattress to elevate the torso and preserve neutral alignment of spine due to their relatively larger heads. This will prevent any forced flexion occurring.

While providing MILS and reassurance, we must address pain as a matter of urgency. Immobilisation may increase leverage on the neck in a sore and struggling child.  Once deemed safe to do so (and rapport has been established where applicable), radiolucent blocks and straps can be applied to free up that team member from the task of MILS. As well as helping limit movement, blocks also serve as a communication tool / visual reminder to the team that we are worried about this spine and to handle with care.

Transfer: If coming in by EMS, transfer using scoop from ambulance mattress to radiolucent ED trauma mattress. During transferring manoeuvres, the team leader should ensure that the minimal number of movements and gentle max 30 degree tilts are all that’s needed to get them on and off a scoop stretcher. The leader should also ensure that all team members understand their role and are given adequate prompts prior to any movements being performed “ready, steady, move”. Use the opportunity allowed by tilting to complete your standard assessment of the spine (and the patients back for other injuries or relevant findings). Document appropriately. Sometimes children 6 years old and above (not possible to put on below this age) may come in via EMS wearing cervical collars. These are removed to assess the cervical spine in ED while MILS is being applied and hard collars should not be placed back on as they can have a number of negative effects, particularly with prolonged use (16).Two piece collars are different and are often recommended by spinal specialists as a treatment modality for stable fractures or as a bridge to definitive management. 

A 10 month old girl who was a back seat occupant in a rearward facing baby seat is involved in a head on RTC at 30kph (18mph). The incident occurred in a housing estate. She presents with her Mother who was the restrained driver for review at a mixed Adult and Paediatric ED. You have already assessed and cleared Mum from any serious injury. You now examine her baby who is crawling away from you on the bed saying “mama”. 

Discuss how we need to adapt our assessment to suit younger children. 

Are we worried about this baby and do we want imaging? 

Outside of the factors looked at in the large studies, are there any other items which we should consider important in history and on physical examination for all children? 

The studies we have looked at so far don’t have many children under the age of three years old. We will now explore some which do:

Expert Consensus on factors which are suspicious for CSI (18-21):

  • persistent neck pain
  • child or parent feeds like the child has an abnormal head position
  • difficulty with neck movement
  • fall >1m or 6 steps of stairs or fall from greater than body height
  • hyperextension injury, acceleration-deceleration injury involving the head or clothes-lining (blunt trauma to the head/neck by a stationary object while the patient is in motion)
  • bicycle collision, pedestrian versus bicycle, accidents involving motorised recreational vehicles, horse riding accidents.
  • current or transient neurological symptoms (motor or sensory): weakness, paraesthesia, lightning or burning sensation down the spine or radiating to an extremity
  • neurological symptoms related to neck movement.
  • torticollis or abnormal head position
  • posterior midline cervical tenderness
  • substantial injury to the chest, abdomen or pelvis (one that is life-threatening, warrants inpatient observation or surgery)
  • physical signs of neck trauma such as ecchymosis, abrasion, deformity, swelling, tenderness
  • limited cervical range of motion
  • significant trauma to head or face
  • inconsolable child

Where the child does not have any concerning features on history or examination, we can look at some low risk factors which offer us some reassurance:

  • simple rear end MVC
  • comfortable in sitting position in ED
  • ambulatory at any time since injury
  • no midline cervical tenderness
  • presenting with delayed onset neck pain

In the awake and alert patient with no neurological signs or symptoms who has neck pain or unspecified neck tenderness, NICE Clinical Guideline 176 permits the search for any one low risk factor from the above list.

If one is found, further clinical assessment of the neck, beyond the initial assessment and palpation is performed. 

This comprises asking the patient to perform 45 degree bilateral active neck rotations. If this is tolerated the cervical spine can be cleared clinically. If not, the patient gets imaged. 

Persistent neck pain/tenderness in the posterior midline with normal clinical examination otherwise and normal conventional radiographs requires further evaluation. The same applies even if the patient presents sub acutely (18). This will vary between institutions but may take the form of a referral to the orthopaedic or spinal service followed by MRI or CT. 

Beware the “trivial” injury, especially in younger children. Correlate history with clinical examination. Remember these patients can be more difficult to assess and there exists limited evidence to guide their management. There are cases in children 9 months to 6 years of falls less than 5ft, out of bed, down steps, running, somersaulting which have led to C1-2 subluxations, rotatory subluxation, C2 pedicle fractures, odontoid fractures and neural arch C2 fractures. Examination findings were torticollis, neck pain, limited range of motion neck, refusal to move neck any one or combination of the above on exam but never just neck pain (22).

Beware also of markings on the child’s body from seatbelts or other age appropriate restraint systems. These may indicate extreme flexion of the cervical spine has occurred especially in head on collision (23). 

As always, consider the potential for non-accidental injury in your differential. 

Involve a senior early in the assessment and management of all suspected cervical spine injury children. 

Interpretation of imaging (where it is necessary) and patient reassessment: 

As we have discussed above, plain films are the main imaging tool used to assess the cervical spine in the ED. These must be interpreted by a senior physician due to the inherent challenges involved. 

If imaging is adequate and shows no abnormality in an alert and cooperative patient (or if imaging was not required in the absence of concerning features), reassess for resolution of neck pain post analgesia. Check 45 degrees of neck rotation either side of the midline. If normal, ask if you are satisfied that there isn’t any persisting clinical concern. If they examine well and there is no residual concern, many institutions and the NICE guidelines declare that the spine is now clear. This final clearance step should always be performed with a senior present.

An 11 year old boy is involved in a single vehicle RTA as a front seat passenger restrained in a booster seat. The vehicle slid at 120kph (75mph) and spun out of control demolishing a fence at the side of the dual carriageway and impacting a treeline before being propelled back onto the road. There is extensive damage to the four door saloon and all airbags deployed. The boy’s father was driving at the time and they self extricated by kicking out a front door which was slightly wedged by the distorted frame. They stood by the side of the road awaiting help to arrive. The father states he is fine apart from a few scrapes from broken glass and declines further assessment by Paramedics. The son complains that he now notices neck pain on moving his head backward and forward. EMS reviewed and decided to treat him with full spinal precautions. He arrives in your ED and is assessed as having no evidence of bruising or deformity of the neck and no midline bony tenderness. He has a normal neurological examination. His neck pain is persistent despite ibuprofen and paracetamol given by EMS en route. He is reluctant to move it much.

Do you want to image this child and if so, what imaging do you want to perform?

The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous (24).

To obtain the optimal sensitivity from plain film we need two or more views. The odontoid view is technically difficult to obtain in children less than 5 years old and may not yield much diagnostic information which can’t be obtained on antero-posterior and lateral. 

Many paediatric radiologists do not routinely obtain odontoid views in children younger than 5 years and many more stop after the first attempt is unsuccessful. The fracture that can only be assessed on the odontoid view is the Jefferson fracture (an eponym for a burst fracture of C1) and this occurs with axial loading mechanisms (uncommon below this age). Usually there is an associated head injury which would require neuroimaging (including upper cervical spine in CT) (25).  

In infants and young children, fractures of the dens tend to involve the subdental synchondrosis (naturally weak area of C2), from flexion mechanisms. The resulting anterior tilt of the dens is normally visible on lateral views. 

Adopting a pragmatic approach based on the child’s age and clinical status allowing them to obey commands and open their mouth is the best course of action (26). Safety is paramount and this view can be dangerous as some movement is required of the patient (10).

It is common practice now to minimize the exposure of children, parents and staff to radiation. The neck is a radiosensitive anatomical area and the thyroid gland receives a 100-200 fold higher radiation dose with CT than with the standard three view plain film series. This extrapolates to a 2x higher mean excess risk of thyroid cancer for patients 0-4years (27). 

To help put that into perspective, in the Republic of Ireland the incidence of thyroid cancer is 3.61/100,000 at baseline (28).

Ionizing radiation imparts a small but real risk of malignancy at the population level. This impact is greater on paediatric patients (29). 

It takes time and a greater degree of patient cooperation to obtain plain films.  As explored above, plain films can have lower sensitivity than CT so require a reliable history and physical examination to back them up as a diagnostic tool. CT has a superior ability to detect critical paediatric cervical spine injury in higher risk trauma patients because it provides more anatomical detail (30, 31). 

Indications for CT imaging (1, 13, 18, 20):

  • peripheral focal neurological signs or symptoms including paraesthesia in upper/lower limb(s)
  • patient is intubated/respiratory failure (severe TBI or C3/4/5 injury damaging phrenic nerve)
  • GCS <13 on initial assessment, pointing to TBI
  • head or multi-system trauma undergoing CT
  • signs of substantial head injury (e.g. signs of base of skull fracture)
  • where an urgent diagnosis is required e.g. for theatre
  • plain films are technically difficult or inadequate
  • strong clinical suspicion persists in spine of normal plain films e.g. symptomatic with head first axial loading as mechanism
  • plain films demonstrate a bony injury

The use of MRI will vary between institutions. 

In patients who have neurological signs on examination, MRI should be the primary modality wherever possible (26). It is often used as a follow on investigation from CT in the intubated sick trauma patient who is unconscious and difficult to assess from a neurological perspective clinically. They are now stabilized enough either via Intensive Care or Surgical input to undergo an MRI.

Younger children with isolated neck injury who are difficult to assess and in whom we are concerned due history and physical examination may also be suitable candidates for MRI (32) post normal plain XR instead of going to CT. Bear in mind that many children will require a general anaesthetic to tolerate this imaging modality as it takes longer than CT or XR to perform.  

A 2 year old girl presents with her father after landing awkwardly post a fall down the last two steps of stairs in her home yesterday evening. She has been starting to walk up and down the stairs and is always supervised. Last night, she complained of some pain which responded to the paracetamol syrup given to her by Dad. She slept well but since this morning, she has been holding her neck strangely and prefers to lie down.

You are the senior registrar on duty and one of your colleagues asks for your review. She is lying in a position of comfort on her left side. When you go to examine her she sits up and clings to her father crying and making it clear that she does not want to be examined, saying bye-bye. She has a torticollis to the left and is moving all limbs. Analgesia was given and plain films were obtained. These looked normal to you and the patient was reviewed and looks more comfortable now, although the torticollis persists.

Should we be concerned? Outline your steps in this patient’s management.

Torticollis in the setting of trauma, even in the absence of neurological signs or symptoms is concerning. 

There is an association between torticollis and cervical spine injury, particularly rotatory subluxation of C1 on C2 (Atlanto axial rotatory subluxation or fixation as it is sometimes termed), however it can also be seen in other patterns of cervical spine injury too (34-38). 

Typically, in trauma, the ipsilateral sternocleidomastoid muscle is in spasm. This differs from torticollis from other causes (benign paroxysmal torticollis, cervical lymphadenitis, cervical spine/cord tumours, posterior fossa tumours) where the contralateral sternocleidomastoid is in spasm (37). 

Despite the fact this little girl’s neurological assessment remained normal, it was decided to proceed to MRI under general anaesthesia. This demonstrated atlanto-axial rotatory subluxation. 

This case emphasises the concerning nature of traumatic torticollis, even in the absence of neurological signs or symptoms.

Injuries sustained by mechanism (33):

Hyper-flexionHyper-extensionAxial Load
Flexion teardropHyperextension dislocationBurst fracture (If occurs to C1 the eponym of Jefferson applies)
Bilateral facet dislocationExtension teardrop
Unilateral facet dislocationHangman’s fracture  (C2 Pedicles)
Anterior subluxation
Wedge fracture
Spinous process fracture

Falls from elevation, MVCs, being struck by motor vehicles while walking or riding and blunt blows to head and neck are more likely to result in axial (C2 and above) CSIs. 

Sports related cervical spine injuries are more likely to result in injuries to the sub-axial (below C2) region or SCIWORA. Children involved in diving and motor sports (All-terrain-vehicles and motorcycles) are more likely to sustain sub-axial cervical spine injuries (8).

What percentage of paediatric spinal injuries are located in the cervical region?

A: 12%

B: 40%

C: 50% or more

D: 2%

C: 50% or more

The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column.

Which of the following mechanisms in history are concerning for a cervical spine injury?

A: Motor Vehicle Collision at a speed of above 30kph (18mph)

B: Diving into a pool

C: Fall from greater than body height

D: Transient neurological symptoms

E: All of the above

E: All of the above

Expert consensus on factors which are suspicious for a CSI include: persistent neck pain, child or parent feeds like the child has an abnormal head position, difficulty with neck movement, fall >1m or 6 steps of stairs or fall from greater than body height, hyperextension injury, acceleration-deceleration injury involving the head or clothes-lining (blunt trauma to the head/neck by a stationary object while the patient is in motion), bicycle collision, pedestrian versus bicycle, accidents involving motorized recreational vehicles, horse riding accidents, current or transient neurological symptoms (motor or sensory): weakness, paraesthesia, lightning or burning sensation down the spine or radiating to an extremity, neurological symptoms related to neck movement.

Plain films are not sensitive enough in children to be our first choice in most circumstances where imaging of the cervical spine is deemed necessary.

A: True

B: False

B: False

The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous.

1. Luehmann NC, Pastewski JM, Cirino JA, Al-Hadidi A, DeMare AM, Riggs TW, et al. Implementation of a pediatric trauma cervical spine clearance pathway. Pediatr Surg Int. 2020;36(1):93-101.

2. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg. 2011;19(10):600-11.

3. Adib O, Berthier E, Loisel D, Aube C. Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol. 2016;45(12):1607-17.

4. Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol. 2016;71(9):844-53.

5. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics and Trauma. 2018;32(5):288-92.

6. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-6.

7. Polk-Williams A, Carr BG, Blinman TA, Masiakos PT, Wiebe DJ, Nance ML. Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg. 2008;43(9):1718-21.

8. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC. Cervical spine injury patterns in children. Pediatrics. 2014;133(5):e1179-88.

9. Patel JC, Tepas JJ, 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-6.

10. Egloff AM, Kadom N, Vezina G, Bulas D. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol. 2009;39(5):447-56.

11. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. 

12. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841–8.

13. Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, et al. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019;144(1).

14. Michelle L. Paucis Verbis: Distracting injuries in c-spine injuries California2011 [Available from: https://www.aliem.com/paucis-verbis-distracting-injuries-in-c-spine-injuries/.

15. Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, et al. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database of Systematic Reviews. 2017(12).

16. Chan M, Al-Buali W, Charyk Stewart T, Singh RN, Kornecki A, Seabrook JA, et al. Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord. 2013;51(5):360-4.

17. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA, Jr., Wales PW, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009;67(3):543-9; discussion 9-50.

18. Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019;101(1):e1.

19. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3):358-62; discussion -62.

20. National Institute for Health and Care Excellence UK. Head injury: assessment and early management, Clinical Guideline 176 2014 [updated September 2019. Available from: https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893.

21. Council P-hEC. Pre-hospital spinal injury management– PHECC position paper: Pre-Hospital Emergency Care Council (PHECC), Republic of Ireland; 2016 [updated June 2016. Available from: https://www.phecit.ie/Custom/BSIDocumentSelector/Pages/DocumentViewer.aspx?id=oGsVrspmiT0dOhDFFXZvIz0q5GYO7igwzB6buxHEgeDKIJ1qe4KMTbg0PR6g5rsqv0UG7SxVNTJNy77oXQjs2j1HSTJmgAW%252fSZveFhrJdevzBefQ%252b6h%252bH%252fxwJoeP22ouJte%252begki%252bcrlDSFj6a%252b%252bRVIqMv2PmiT2JVsY5T2RjJpHZlKxsjlq4%252foSxAKwZlBC%252fbAutc5W5Mhuoptkdh9A4Q%253d%253d.

22. Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.

23. Maxwell MJ, Jardine AD. Paediatric cervical spine injury but NEXUS negative. Emerg Med J. 2007;24(9):676-.

24. Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, et al. ACR Appropriateness Criteria((R)) Suspected Spine Trauma-Child. J Am Coll Radiol. 2019;16(5s):S286-s99.

25. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000;30(3):186-9.

26. The Royal College of Radiologists UK. Paediatric Trauma Protocols 2014 [updated 2017. Available from: https://www.rcr.ac.uk/publication/paediatric-trauma-protocols.

27. Jimenez RR, Deguzman MA, Shiran S, Karrellas A, Lorenzo RL. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol. 2008;38(6):635-44.

28. Lennon P, editor Thyroid cancer in Ireland, a 10 year review of the national cancer registry. 17th European Congress of Endocrinology; 2015; Dublin, Ireland: European Society of Endocrinology.

29. Puchalski AL, Magill C. Imaging Gently. Emerg Med Clin North Am. 2018;36(2):349-68.

30. Brockmeyer DL, Ragel BT, Kestle JR. The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst. 2012;28(5):699-705.

31. Tat ST, Mejia MJ, Freishtat RJ. Imaging, clearance, and controversies in pediatric cervical spine trauma. Pediatr Emerg Care. 2014;30(12):911-5; quiz 6-8.

32. Booth TN. Cervical spine evaluation in pediatric trauma. AJR Am J Roentgenol. 2012;198(5):W417-25.

33. Easter JS, Barkin R, Rosen CL, Ban K. Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging. Journal of Emergency Medicine. 2011;41(2):142-50.

34.      Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.

35.      Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics & Trauma. 2018;32(5):288-92.

36.      Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of emergency medicine. 2011;58(2):145-55.

37.      Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2019;45(5):777-89.

38.      Klimo P, Jr., Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurgery Clinics of North America. 2007;18(4):599-620.

Please download our Facilitator and Learner guides

Non-Traumatic MSK Injuries Module

Cite this article as:
Stephen Gilmartin. Non-Traumatic MSK Injuries Module, Don't Forget the Bubbles, 2020. Available at:
TopicNon-traumatic MSK injuries
AuthorStephen Gilmartin
DurationUp to 2 hours
Equipment requiredAV to project x-ray images
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Expectation is for the learners to have understood the basics before the session.

Anatomy video: https://www.youtube.com/watch?v=kkHRRu6q2_o

Assessment tips: http://pmm-int.boxmodelstaging.co.uk/file.aspx?id=865

If possible or for further resource

Apophysitis, avulsions, Spondolysis: http://pemplaybook.org/podcast/pediatric-sports-injuries/

Rheumatology: https://dontforgetthebubbles.com/podcast/paediatric-rheumatology-jane-munro-dftb19/

  • Differential diagnosis of non-traumatic pain
  • Diagnoses not to miss
  • How to diagnose some of the common causes of non-traumatic MSK pain.
  • How to treat these causes
  • What diagnosis can cause long term morbidity
  • When to seek prompt speciality help.

Non traumatic pain is a common presentation in children and one which has a wide differential.  Lower limbs are most commonly involved. The potential diagnoses range from benign and self-limiting to life and limb threatening. 

There is often a history of an innocuous traumatic event which has prompted the attendance for assessment, but this often has little to do with the underlying diagnosis.

Clinicians should have a standardised approach to history and examination of non-traumatic MSK pain to ensure no diagnoses are missed

The underlying cause varies between age groups as children become susceptible to specific conditions as they progress through childhood.

Common causes

DiagnosisLocationAgeHistoryExamX-ray changes
Apophysitis Any apophysisF 10-14/M12-16Gradual onset
Pain worse on activity
Eases after rest
Point tenderness over apophysis
With or without swelling
Sclerosis and fragmentation
Osteochondrosis Joints: Commonly elbow/hip/foot4-18 dependent on siteGradual onset
Pain worse on activity
Eases after rest
Mild swelling
Stiff and painful joint
Irregular growth of epiphysis
Osteochondritis dissecans Commonly knee and ankle>10Gradual/sudden onset
Pain worse on activity
Associated intermittent swelling
Swollen joint in acute phase
Tender joint line
Lucency about the cortical surface 
May be occult
Osteomyelitis Commonly in areas of high bone turnover such as metaphysis/epiphysisAny ageGradual onset
Point tenderness
Soft tissue swelling
Local osteopenia
Bony lysis or cortical loss
Periosteal reaction
Spondylolysis Lumbar spineAdolescentsGradual onset
History of repetitive activity involving back extension
Pain on extensions and rotation of lumbar spineLimited compared to CT
Scotty dog sign: oblique view, break in pars interarticularis can have appearance of collar on dog
Avulsion fractures Any tendon/ligament attachmentAdolescentsSudden onset
History of pain following sudden muscle contraction
Swelling and bruising if superficial
Pain and weakness with resisted movement 
Widening of open apophysis
With or without displacement and angulation
Patellofemoral pain Anterior kneeAdolescentsGradual onset
Worse on running/jumping and ascending stairs
Commonly in young girls
Weak quadriceps
Altered tracking of patella
Pain on flexion of knee
Slipper upper femoral epiphysis Hip/Knee10-16Gradual/sudden limp
May be non-weight bearing
Reduced ROM of hip
Out toeing
Forced external rotation on hip flexion
Displacement of epiphysis from physis.
Inflammatory arthritis Any jointAny ageGradual onset
May have multiple joints involved
Associated systemic symptoms
Swelling of one or more joints
Systemic features
Soft tissue swelling
Loss of joint space
Joint subluxation
Irregular growth
Malignancy Commonly in areas of high bone turnover such as metaphysis/epiphysisAny ageGradual onset
Systemic symptoms
May have pyrexia
May have swelling and tenderness
Bone destruction
Irregular borders
Wide zone of transition 
Septic arthritis Any jointAny ageGradual onset
Red hot swollen joint
Non weight bearing
Swollen, erythematous painful joint
Normal in early stages

One of the main priorities in patients presenting with atraumatic MSK pain is to seek out red flag symptoms and signs in order to rule out sinister diagnosis.

Red flag symptoms and signs include:

  • Weight loss
  • Night sweats
  • Pyrexia
  • Nocturnal pain
  • Non weightbearing
  • Rash
  • Eye pain

A standardised assessment should be performed depending on the body area/areas involved.  Look for any swelling, bruising, erythema or cellulitis.  Determine if there is any point tenderness which may give indicate a possible fracture.  Assess joint function for range of motion (passive / active / resisted), weight bearing status, additional stiffness and stability.

Always ask yourself, is the story really atraumatic?  Has there been any possibility of non-accidental injury?

Some level of investigation is required for each of the potential diagnoses. You may make the diagnosis of apophysitis based on an accurate history and exam alone but even then, one study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease (apophysitis of the calcaneus).

A low threshold for a baseline x-ray is sensible in all paediatric patients presenting to secondary care with atraumatic MSK pain.  They can be helpful to identify bony lesions, signs of osteomyelitis and unexpected fractures.

Inflammatory markers are useful when the patient’s presentation is concerning an infective or inflammatory process.

Marie is a 12-year-old girl who presents to you complaining of anterior knee pain.  She is an active volleyball player and is trying hard to make her school team.  The pain is getting worse over the past month and is now affecting her ability to train. She denies any trauma.

What are your differential diagnoses?

What factors in the history and exam would you like to elicit in order to narrow the diagnosis?

You feel she has apophysitis of her tibial tuberosity. 

What is the pathophysiology of apophysitis?

Can you name any other common sites affected by apophysitis?

What investigations would you like to perform?

What is your treatment plan?

  • Patello-femoral pain
  • Apophysitis of tibial tuberosity (Osgood Schlatter disease) or inferior pole of patella (Sinding-Larsen-Johansson)
  • Osteochondritis dissecans
  • Arthritis
  • Malignancy
  • Osteomyelitis
  • Hip pathology

Apophysitis has a typical history of gradual onset localised pain in a child from 10-16 years of age.  Pain is exacerbated by activity and initially improves with rest.  The typical patient is highly active and may be overtraining.  Examination will typically reveal point tenderness over the area involved with possibly some mild swelling.

Important factors to exclude are pyrexia, trauma, weight loss and systemic symptoms.

An apophysis is an area of bony growth in children separate to ossification centres.  It is the site of tendon or ligament attachment and fuses with the bone as the body matures. Rapid growth and repetitive movements combined with relative bone weakness, cause increased traction forces at the point of tendon attachment.  This leads to micro-separation and bone fragmentation which is known as apophysitis.  This clinically presents as an insidious onset focal pain, worsened by activity and eased by rest.  There may be point tenderness and swelling on exam. 

Apophysitis commonly affects:

  • Tibial tuberosity: Osgood Schlatter disease
  • Inferior pole of the patella: Sinding-Larsen-Johansson disease
  • Calcaneal tuberosity: Sever’s disease
  • Medial vondyle of elbow: Little leaguers’ elbow

Apophysitis is described as a clinical diagnosis and as such patients do not require any investigations.

Despite this, it is reasonable with the above differentials in mind to perform a baseline x-ray in all patients presenting with possible apophysitis.  This is especially important if the patient presentation or clinical course is atypical.

One study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease.

Knee x-ray of a 12-year-old female volleyball player.  She is presenting with progressive pain over her tibial tuberosity.  Her pain is exacerbated by jumping.  The x-ray shows fragmentation of apophysis with overlying soft tissue swelling.  Some isolated fragmentation can be normal at the tibial tuberosity.

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 9740


Plain ankle radiograph of an 11-year-old male basketball player complaining of heel pain. There is increased density of the calcaneal apophysis, typical for ages between 7 and 14 years. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation. This may be seen in the context of the clinical diagnosis of Sever’s disease.


Case courtesy of Dr Dinesh Brand, Radiopaedia.org, rID: 60324

  • There is sparse evidence looking at appropriate type and length of treatment for apophysitis. This has led to guidance on treatment being expert opinion only.
  • Traditional treatment plans have involved activity cessation until symptoms free with a gradual return.
  • Most of the research that is available focuses on Osgood Schlatter and Severs disease. 
  • One RCT looking at management of Osgood Schlatter disease looked at the effectiveness of dextrose injections vs steroids injection vs normal therapy.  This study showed small benefits of dextrose injections.  But this is unlikely to be a sensible treatment plan due to possible adverse effects in a self-limiting condition
  • There have been recent developments looking at active treatment pathways.  These are moving away from total rest and sport cessation. Instead the aim is to move towards active and monitored treatment plans. Rathleff et al (2020) have a good infographic describing different treatment options for Osgood Schlatter’s.
  • There is some weak evidence that treatment of Sever’s disease with heel raises can improve symptoms when compared to physiotherapy or doing nothing.
  • The type of heel raise does not need to be customised, but whatever is comfortable and available to the patient.
  • Principles can be adopted to all forms of apophysitis with the main aims of treatment being
    1. Altering current activity to prevent worsening symptoms
    2. Stretching and strengthening programmes as appropriate
    3. Cross training
    4. Graduated return to sporting activity
    5. Prevention of recurrence
  • Although apophysitis is self-limiting.  One study found that up to 40% of patients will continue to suffer from intermittent pain even 2 years after diagnosis.  This pain might not necessarily prevent a return to sporting activities.

Exercise programmes https://bjsm.bmj.com/pages/wp-content/uploads/sites/17/2019/06/OSD-table.pdf

Good podcast for extended learning https://soundcloud.com/bmjpodcasts/osgood-schlatter-not-the-self-limiting-condition-we-once-thought-episode-384

Katie is a 9-year-old complaining of left foot pain.  The pain has been getting worse over the past month and she is now beginning to develop some stiffness.  She is a keen athlete and trains five times per week.  She denies any trauma and is systemically well.

What are some of the differential diagnosis?

What changes do you see on the x-ray?

What is the diagnosis?

What is the pathophysiology?

What other sites can be affected?

What is your treatment plan for this patient?

  • Stress fracture
  • Arthritis
  • Osteochondrosis
  • Apophysitis
  • Arthritis
  • Osteomyelitis
  • Malignancy
  • Retained foreign body

Flattening and sclerosis of the navicular bone. Mild soft tissue swelling. No fracture seen.

Kohler disease: osteochondrosis of the navicular bone.

Typical x-ray Findings of osteochondrosis:

Early: Potentially normal

Initial radiological findings

  • Irregular epiphyseal growth
  • Flattening of the epiphysis
  • Soft tissue swelling

Radiological findings as disease progresses

  • Sclerosis
  • Fragmentation
  • Joint destruction
  • Osteochondrosis is often described as idiopathic osteonecrosis.
  • It is a disorder of bone growth primarily involving the ossification centres at the epiphysis.
  • It leads to altered bone and cartilage formation beyond the growth plate.
  • There are some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis.
  • You should always ensure the osteonecrosis is not from a secondary cause such as sickle cell disease or leukaemia.
Common Location   Eponymous nameAge of onset
Femoral headLegg-Calve-Perthes (Perthes)4-8
Head of metatarsals (2nd most commonly) Freiberg13-18

Treatment in this case will involve activity modification.  This will entail reduced overall activity but and specifically avoiding activity which stresses the foot.  Immobilisation in a walking boot may be beneficial if there is significant pain or inability to weight bear comfortably.

  • Osteochondrosis is self-limiting and the bone will eventually revascularise. 
  • The goal of therapy is to facilitate maximal revascularisation while minimising long term affects.

Three broad treatment strategies exist for osteochondrosis

Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physio programme can help to strengthen the area and improve joint function.  This approach is suitable for patients with minimal symptoms and early changes of disease progression on x-ray.

Immobilisation:  Immobilisation can be beneficial for patients with significant pain or more advanced changes on x-ray.  This may be in the form of a cast, walking boot or splint depending on the area involved.  This needs to be weighed up against the risk of worsening joint stiffness.

Surgery:  It is very rare, if ever, that patients will require surgery.  When used it is only in advanced stages of disease and when appropriate conservative management has proved ineffective. Surgical options include osteotomy, arthroplasty and physeal drilling.

A 15-year-old girl attends with intermittent pain and swelling to her left knee for the past two months.  She is a keen soccer player but pain on the medial aspect of her knee is affecting her ability to run. She complains that after every game her knee swells and is now taking increasingly longer to subside. On exam she is walking with a limp, her knee is swollen and she has pain to the medial joint line.  Her knee feels stable with all ligaments intact on testing.

 You decide to do an x-ray:

Describe the x-ray findings.

Are you aware of any grading system used for Osteochondritis dissecans?

What investigations should you consider?

Largely normal knee x-ray. Subtle lucency to chondral surface of medial femoral condyle. Findings consistent with osteochondritis dissecans. 

  • Osteochondritis Dissecans is a focal injury disruption of articular cartilage and subchondral bone.
  • It is largely idiopathic, but some theoretical causes are genetics, trauma or vascular phenomenon.
  • There is a juvenile and adult form.  The juvenile version is most common and present in patients between 10 and 16 with open physis.
  • The knee is the most common joint involved with >70% of knee lesions being in the posterolateral aspect of the medial femoral condyle.  The ankle and elbow are other joints that are regularly affected.

Presentation depends on the stage of lesion.  Initially nonspecific pain with or without swelling.  As the process progresses, patients can develop mechanical symptoms such as reduced range of movement (ROM) and locking of joints.

Osteochondritis dessicans grading system:

Clanton Classification of Osteochondritis (Clanton and DeLee)

Type IDepressed osteochondral fracture
Type IIFragment attached by osseous bridge
Type IIIDetached non-displaced fragment
Type IVDisplaced fragment

  • Bilateral x-rays should be obtained as up to 30% of patients can have bilateral lesions.
  • An additional notch view x-ray can help to get a better image of the femoral intercondylar spaces.  This is taken with the patient supine and knee flexed to 40 degrees.
  • MRI is widely used in patients with high suspicion for osteochondritis dissecans or to assess stability of a lesion diagnosed on x-ray. 
  • MRI has superior capabilities for assessing stability of cartilage and subchondral bone when compared to standard radiographs.
  • Arthroscopy is the gold standard for assessing stability and may be used if questions marks remain following MRI

There is a lack of consensus on appropriate type and length of treatment.

The latest American Academy of Orthopaedic surgeons’ guidelines were unable to recommend any conservative treatment regime.

Masquijo and Kothari (2019) illustrate their preferred treatment algorithm in a flowchart 

Modern protocols recommend patients should have a three to 6 months trial of conservative management. 

Conservative management involves

  • Immobilisation phase with minimal weight bearing followed by
  • A phase of partial weightbearing and
  • Lastly a gradual supervised return to activity.

Favourable prognostic factors are:

  • Younger age
  • Open distal femoral physis

Poor prognostic factors include

  • Lesions involving the patella
  • Sclerosis on x-ray

Approximately 50-75% of lesions will heal in 6-12 months following conservative management.

Conservative management is not suitable for displaced or loose fragments.

Surgical treatment

Surgical treatment is preserved for large or unstable lesions, displaced fragments and those not responding to conservative therapy

Three broad surgical options

  • Stimulate growth by retroarticular drilling,
  • Reducing and fixing displaced fragments
  • Osteochondral grafts

Drilling and fixation are usually successful surgical options with minimal complications.  Up to 90% of patients can expect radiographic resolution of lesions.  Unfortunately, grafts are usually seen as salvaging surgeries and outcomes can be variable.

Judith is a 10-year-old girl who is attending with pain and stiffness to bilateral wrists with intermittent swelling to fingers.  She has no history of trauma. You think she may have arthritis.

What will you want to decipher during your history and exam?

Our patient has bilateral wrist, metacarpophalangeal and proximal inter phalangeal joints involvement.  She complains of some morning stiffness but denies any previous medical problems.  She cannot remember any trauma and has not had any temperatures or rashes.

What are your differentials?

You think this patient has Juvenile Idiopathic Arthritis. What is JIA?

What investigations will help with this diagnosis?

What is your chosen treatment for JIA?

Apart from rheumatology who else should see this patient with JIA?

Length of symptoms: This is important as JIA can only be diagnosed once the patient has had symptoms for over 6 weeks without any other cause found.

Effect on activities: Has the patient stopped playing a sport they previously enjoyed.  Is the patient regressing at physical activity or schoolwork such as handwriting?

Pattern of symptoms: Important to elicit if any stiffness or worsening of symptoms in the morning.  Ask about symptoms associated with malignancy such as leukaemia.

Illicit any associated symptoms which may help discover a cause such as multisystem condition (Lupus/Vasculitis/psoriasis) or a reactive arthritis from a satellite infection (UTI/STI)

You should also enquire about symptoms which may indicate complications such as eye pain caused by uveitis or tendon pain caused by enthesitis.

Pattern of joint involvement.

Monoarthropathy: Single joint. Can still be JIA but infection, trauma and malignancy would be higher on your list and need to be consciously out ruled.

Oligoarthritis: Four or fewer joints involved

Polyarthritis: Over four joints involved.

Typical patterns include:

  • Asymmetric, small and large joints and distal interphalangeal joint involvement is typical of psoriatic arthritis.
  • Symmetric, small and large joints is typical of polyarticular JIA.
  • Hip involvement and enthesitis is typical of Enthesitis-Related Arthritis. 
  • Large joint and intermittent / flitting involvement is typical of acute rheumatic fever. 
  • Fever, rash and serositis and later symmetrical involvement of small and large joints (including distal small joints of the hands, ankle or wrist involvement) are typical of systemic JIA.


  • Trauma: Bruising, wound, bleeding, deformity.
  • Infection: Guarding joint and refusing to move/weight bear.  Hot red and swollen.  Temperature
  • Malignancy: Secondary signs of anaemia, thrombocytopenia.  Cachexia in advanced stages.  Unusual swelling i.e. not involving a joint and not in an area typically injured.
  • Rashes: look for signs of psoriasis, vasculitis rashes, rheumatological rashes as seen in lupus, skin changes produced by Kawasaki.
  • Joints: As previously mentioned look for patterns of swelling, record joints involved, assess range of motion and function of joints.
  • Review of systems: Assess for any other signs of systemic disease, distant infection or complications which may give you a clue to the aetiology of the arthropathy.

The most likely diagnosis is JIA but there are also some other reasonable differentials.

  • Psoriatic arthritis
  • Post viral arthritis
  • Rheumatic fever
  • Malignancy
  • Metabolic disease (rickets/osteomalacia)

JIA comprises a group of inflammatory disorders that begins before the 18th birthday and persists for at least 6 weeks and other known conditions are excluded.

There are six main disorders of JIA with their own individual diagnostic criteria

  • Systemic JIA
  • RF-Positive JIA
  • Enthesitis/Spondylitis-related JIA
  • Early onset ANA positive JIA
  • Other JIA: does not meet

For further background on the individual criteria. http://www.jrheum.org/content/46/2/190

No blood or radiological test can definitively make a diagnosis of JIA.  The diagnosis is based on careful clinical assessment, exclusion of other possible causes and aided by blood and radiology.

pGALS screen has the benefit of quickly assessing all joints. pGALS is a standardised musculoskeletal (MSK) basic examination. Free educational resources to demonstrate pGALS are available online. (www.pmmonline.org).

  • CRP and ESR give an indication of total body inflammation.  But you cannot rule out the diagnosis if inflammatory markers are normal.  These markers are more useful in disease monitoring.
  • Antinuclear antibodies (ANA) are positive in roughly 50% of oligoarticular JIA, however positive ANA can be seen in healthy children also.  A positive ANA can indicate a higher risk of uveitis once JIA is diagnosed.
  • HLA-B27 is positive in 27% of patients with JIA and up to 80% of patients with enthesitis related arthropathy.
  • Rheumatoid factor can help with diagnosis of RF-positive JIA.  It also provides a worse prognosis if positive.
  • Radiographs are useful for investigating alternative causes.  They rarely show any changes in the early stages of arthropathy but are important to get a baseline condition of the joints.

Refer early. Treatment should be initiated by a specialist. If you have concerns about JIA, you should discuss with rheumatology.  The dawn of biologic treatment has ensured reduced symptoms, chronic complications and minimised need for systemic steroids.

Ophthalmology.  JIA patients are at risk of losing their eyesight from chronic uveitis and may be asymptomatic despite having eye changes.

Which of these conditions and age of onset do not match?

A: Apophysitis 10-14 F 12-16 M

B: Osteochondrosis 12-18

C: SUFE 10-16

D: Osteochondritis dissecans >10

E: Septic arthritis Any age

B: Osteochondrosis, the usual age of onset is anywhere between 4 and 18.  There have even been some Kohler diseases documented as young as 3.

Which of these anatomical areas do you not commonly see apophysitis?

A: Capitellum

B: Inferior pole of patella

C: Tibial tuberosity

D: Medial condyle of elbow

E: Calcaneal tuberosity

A: Capitellum.  Apophysitis only occurs at sight of apophysis formation.

Which of these statements about osteochondritis dissecans is not true?

A: Osteochondritis is a focal disruption of articular cartilage and subchondral bone

B: Most commonly seen on the medial femoral condyle

C: The aetiology is largely unknown

D: Recovery can take 6-12 months

E: A closed physis is a good prognostic factor

E: An open physis is seen as a good prognostic factor

Which of these is not a radiological finding of osteochondrosis?

A: Sclerosis

B: Fragmentation

C: Flattening of epiphysis 

D: Lytic lesion

E: Irregular epiphyseal growth

D: Lytic lesions.  There may be no radiographic changes in the initial stages of osteochondrosis.  You will then begin to see epiphyseal changes, soft tissue swelling, fragmentation and sclerosis. 

Lytic lesions would help point you towards another possible differential diagnosis depending on its location and characteristics.  Lesions can be caused by infections, malignancy or simple cysts.


Brenner, J. S. (2007). Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics, 119(6), 1242 LP – 1245

Rathleff, M. S., Winiarski, L., Krommes, K., Graven-Nielsen, T., Hölmich, P., Olesen, J. L., … Thorborg, K. (2020). Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine.

James, A. M., Williams, C. M., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review.” Journal of Foot and Ankle Research, 6(1), 16.


Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common

Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–


Chan, J. Y., & Young, J. L. (2019). K&#xf6;hler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.

Osteochondritis dissecans

Masquijo, J., & Kothari, A. (2019). Juvenile osteochondritis dissecans (JOCD) of the knee: current

concepts review. EFORT Open Reviews, 4(5), 201–212.

American Academy of Orthopedic Surgeons. Clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont, IL: American Academy of Orthopedic Surgeons, 2010.


Alberto Martini et al, for the Pediatric Rheumatology International Trials Organization (PRINTO) Toward New Classification Criteria for Juvenile Idiopathic Arthritis: First Steps, Pediatric Rheumatology International Trials Organization International Consensus, The Journal of Rheumatology Feb 2019, 46 (2) 190-197

Jason Palman, Stephanie Shoop-Worrall, Kimme Hyrich, Janet E. McDonagh, Update on the epidemiology, risk factors and disease outcomes of Juvenile idiopathic arthritis, Best Practice & Research Clinical Rheumatology, Volume 32, Issue 2, 2018, Pages 206-222,

Please download our Facilitator and Learner guides

Rapid Sequence Induction and the Difficult Airway Module

Cite this article as:
Robyn Goodier. Rapid Sequence Induction and the Difficult Airway Module, Don't Forget the Bubbles, 2020. Available at:
TopicRSI and the difficult airway
AuthorRobyn Goodier
DurationUp to 2 hrs
Equipment requiredCan be done without equipment, however for interactivity it would be useful to have different laryngoscopes/ETT/bougie/stylet etc for demonstration purposes.
  • Basics – including airway plans and assessment (30 mins)
  • Main session: (2 x 15 minute) case discussions 
  • Advanced session: (2 x 20 minutes) case discussions covering more controversial settings
  • Sim scenario – optional (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Paediatric airway compromise requiring emergency management by rapid sequence induction (RSI) is a rare event in the Emergency Department. However, despite it being rare, it is associated with high mortality and morbidity with an overall death rate of 3.8%, the highest for a critically unwell child. 

Airway securement is a procedure that every critical care physician should be competent in performing. 

RSI is an airway management technique that produces unconsciousness and muscular relaxation for the purposes of intubating and taking control of the emergency airway. The airway is usually intubated and controlled within 3 minutes of paralysis. 

Don’t forget ABC…

A – Airway protection, this can be due to numerous reasons such as burns, penetrating neck injury 

B – Respiratory failure – hypoventilation, severe asthma, hypercarbia 

C- Circulatory collapse – severe sepsis

D – Neurological problems – termination of seizures, need for neuroprotection, GCS <8, C Spine trauma, diaphragmatic paralysis

E-  Everything else! Transportation or facilitation of procedure, for patient safety (e.g. combative patient)

Once you have decided that you need to intubate the child, you should prepare to intubate the child using a local cognitive aid. The Twelve P’s of RSI are a useful way to intubate the child safely and successfully, however please refer to your local guidance. 

To ensure you are correctly prepared, we would advocate the use of an airway checklist. This is a checklist to ensure that all aspects of the RSI have been thought about to mitigate any omissions during the procedure. This is an example airway checklist from Liverpool Hospital, Sydney (Airway Checklist) recommended by the Emergency Care Institute in Australia. 

Please check your hospital for your airway checklist – if you don’t have one, then check the ECI website for a blank version to create your own! They are a great aide memoire for a safe intubation. 

Preparation includes:

Roles allocated
Team Leader
Airway Doctor
Airway Nurse
Procedure Nurse x2 for drug checking
Procedure doctor – usually the drug giver

This is the minimum set up – you may have more but ensure your roles are clearly allocated

Labels on the front of scrubs can help the team know who is responsible for each role. 

Have you considered calling for help? The definition of help will depend on your setting but could include Emergency Consultant, Anaesthetics or ICU. 

Equipment required – remember the mnemonic SOAP ME

Suction – large bore suction (x2 if soiled airway) under the pillow and turned on 

Oxygen (mask and BVM ventilation)

Airway equipment:

  • Bag valve mask with PEEP valve, oxygen on. (Neopuff for infants <10kg may be more effective than BVM)
  • Nasal prongs for apnoeic oxygenation
  • Adjuncts available – specifically Oropharyngeal and nasopharyngeal airway devices (x2). A correctly sized LMA (Laryngeal mask airway) should also be available.
  • Laryngoscope – direct and video -(direct – light checked, video – plugged in and tested)
  • ETT – size up and down also available, cuff tested and lubricated
  • 10ml syringe
  • Tube tie or tape avaliable
  • Ventilator (checked) with a paediatric circuit 
  • Bougie/stylet – (size selected)

Patent IV line with fluids available – from bag or flushes drawn up 

Specific RSI medications: Correct doses drawn up, labelled correctly as per local guidelines, order of medications to be given decided before administration 

Monitoring Equipment:
NIBP on 2 minutely cycles (or arterial line if already inserted)
SpO2 probe with good trace
ETCO2 – attached to the circuit, if ETCO2 is unavailable alternative capnography such as colour capnography should be used.

How do I size my equipment?

ETT = age / 4 + 4 (for uncuffed tube)
Age / 4 + 3.5 (for cuffed tube)

Depth of insertion
<1 year insert to 10cm
>1 year age/2 + 12cm 

Miller blades are straight blades which are designed to directly lift the epiglottis

MAC blades are curved to sit in the vallecula to lift the epiglottis indirectly but putting pressure on the glossoepiglottic ligament. 

Miller blades are better for neonates and young infants – up to 1 year then MAC blades are better. Miller are used in this age group due to their large floppy epiglottis and laxity of the ligament. 

< 1 year Miller 00, 0 and 1 

>1 year MAC size 2 and 3 (size 3 usually 5 years upwards)

Please see your local policy for what is available in the area in which you work.

Royal Children’s Hospital Melbourne Airway Recommendations

Remember – you can intubate with a larger blade, but not a smaller one! If in doubt go for the bigger one!

Anatomical differences in paediatric vs adult airways

  1. The airways are smaller! This might sound very obvious, however, this means that there is a lot less room for other things such as secretions, oedema and foreign bodies. Also, external compression can lead to rapid increase in airway resistance 
  2. Larger tongue and adenoids – increases the difficulty in advancing the laryngoscope and visualizing the cords on laryngoscopy. Think of Macroglossia seen in conditions such as Trisomy 21 and Beckwith-Wiedemann syndrome 
  3. Large, floppy epiglottis 
  4. Short trachea (high risk of endobronchial intubation)
  5. Soft structures are at higher risk of airway trauma with repeated attempts causing oedema and further airway narrowing 
  6. Large occiputs – neck flexed causes obstruction
  7. Young children have higher and more anterior tracheal openings than adults (C1 in infants, C7 in adults), therefore visualisation of the glottis is difficult
  8. There is a small cricothyroid membrane so landmarks for surgical airways are more difficult to locate

Positioning in an RSI

  • Infant should be a neutral position
  • Younger child consider a shoulder roll 
  • Older child use an occipital pad 

What are the differences in physiology in intubating children?

The two most important things to consider are:

  1. Oxygen consumption – this is much greater than in an adult counterpart especially when unwell. There is a lower functional reserve capacity and it can cause rapid desaturation during laryngoscopy and intubation despite adequate preoxygenation. 
  2. Horizontal ribs limit the ability to increase tidal volume and ventilation is predominantly diaphragmatic, any air in the stomach may splint the diaphragm and make ventilation difficult. Prompt decompression of the stomach post intubation via NGT or OGT will reduce this splinting and improve ventilation.
    In the <12 month old the NGT can be inserted during the preoxygenation phase of intubation.

Pre-oxygenation should be done for all patients requiring an RSI. The aim is to wash out all of the nitrogen from the lungs and replace it with oxygen, thereby creating a reservoir of oxygen within the lungs. This is especially critical in children due to their propensity to desaturate quickly. 

Pre-oxygenation can be done in a number of ways and will largely depend on the patient’s physiology. All patients (except trauma with suspected base of skull fracture) should have nasal prong oxygen delivering 15L min on in addition to preoxygenation aids.

  • If the patient is awake and spontaneously ventilating well consider 15L oxygen via non- rebreathe mask that it fitted well. Otherwise bag-valve-mask with PEEP valve at 15L oxygen 
  • In the obtunded patient use bag-valve-mask with PEEP valve at 15L oxygen with assisted ventilations for 5 minutes prior to induction. 

Use a LEMON!

 L – Look Externally

  • Body habitus
  • Head and neck anatomy
  • Small mouth 
  • Teeth – overcrowding? Loose? 
  • Jaw abnormalities- micrognathia?
  • Tongue – Macroglossia?

E – Evaluate

  • Mouth opening
  • Thyromental distance

M – Mallampati 

  • Ability to view may be easier in older children who are cooperative 
  • Difficult to do in an emergency situation
  • The higher the number the more difficult the airway is predicted to be

NB This should be done ideally in an upright patient without vocalisation.


O- Obstruction

  • Head and neck abnormalities i.e. cancer, surgeries, laryngectomy 
  • Foreign body
  • Burns
  • Epiglottitis

N – Neck mobility

  • Remember in children to have a more neutral neck position 
  • May have immobilised due to trauma (C Spine collar)


  • This goes with what we had predicted earlier that desaturation occurs quickly in children
  • Those with underlying respiratory disease, or acutely unwell with respiratory distress will desaturate quickly
  • Ensure preoxygenation is given well and that apnoeic oxygenation is maintained 
  • Ensure laryngoscopy time is limited


  • Children are sensitive to changes in circulatory volume, they can compensate up to a point by increasing their heart rate but not their stroke volume. They decompensate very quickly
  • Ensure they are adequately fluid resuscitated prior to intubation. Consider concurrent inotropes if there are concerns over pre induction haemodynamic instability.


  • This is a metabolically stressful situation and children are prone to hypoglycaemia due to their lower glycogen stores in the liver. Ensure BSL checks are done regularly, hypoglycaemia is promptly corrected and that maintenance fluids contain 5% dextrose. 

So, you have everything ready and the team leader asks you for your airway plan, “what is an airway plan?” you ask….

As the airway doctor you should have an airway plan which is verbalised to the entire team so everyone is aware of the expected sequence of events. 

This is an example of an airway plan from Life In the Fast Lane. 

At each plan everyone is aware of the expected outcome and the triggers for moving on to each section. Although this is written for adults, the same is true of paediatrics.


Difficult airways will be covered in more detail later – however signposting the Vortex website to learners now is helpful. Vortex approach is an approach where there are set triggers meaning you move further down the vortex mental model to prepare for front of neck access. The website has invaluable information regarding CICO packs and an instructional video of paediatric front of neck access.  

Consider atropine – this will be discussed in detail later.

Induction agent of choice – i.e. ketamine, propofol, thiopentone

This will differ with institutions, clinical picture, availability and personal preference

The majority of emergency environments will now prefer ketamine as the induction agent of choice, except for status epilepticus where thiopentone is preferred, however this is site specific. 

In a neonate an induction agent is often not required and it is an opiate based induction using either fentanyl or morphine, remembering that morphine has a longer time of onset. 

Muscle relaxant
Depolarising – e.g. suxamethonium
Non- depolarising e.g Rocuronium, Atracurium etc 

Other medications indicated by presentation e.g. mannitol, adrenaline, midazolam etc 

Post intubation sedation – usually morphine and midazolam, check with the team leader

Perform laryngoscopy

Insert ETT past the vocal cords 

Inflate cuff

  • Attach capnography, end tidal CO2 is gold standard (colourimetry can also be used) 
  • Check for misting of the tube
  • Check for equal air entry and movement of the chest (to ensure not Right main  bronchus intubation)
  • Secure the airway with tape in children, or tie in older children
  • Confirmatory post intubation chest x-ray 

Post intubation care is a large topic on its own and beyond the scope of this session. 

The main considerations post RSI are:

  1. Ensure tube is secured correctly 
  2. NG or OG tube inserted for decompression of the stomach 
  3. Ensure IDC is inserted for drainage of the bladder
  4. Ensure nutrition is addressed (usually ongoing IV fluids in the acute phase) 
  5. Post intubation sedation is running 
  6. Further investigations/procedures/treatments are coordinated with as little disruption to the patient as possible 
  7. Disposition is decided upon

Again, transportation of the critically unwell child is beyond the scope of this teaching session. There are numerous specialist retrieval services that facilitate  interhospital transfers. For any staff member doing transfers within the hospital they should have specialist training.

Robert is a 7 year old boy seen in ED with a cough for 5 days, increasing shortness of breath and fevers. Mum brought him to ED as he was lethargic and breathing quickly. On examination he is lethargic with dry mucous membranes, in respiratory distress with a rate of 45, saturations of 92% on 15L oxygen. He is persistently hypotensive despite 40ml/kg fluids. He is becoming bradycardic and his GCS is now 9. You are worried he is in septic shock with impending respiratory failure and circulatory collapse. You decide to proceed to an emergent RSI.

How can he be optimized physiologically before RSI?

Would you start inotropes?

What is your induction agent of choice for RSI in these haemodynamically compromised children? 

First thing’s first here, this is a very, very sick child – have you called for help? Depending on your setting you will require help from ICU, senior Emergency and Paediatric staff and if not in a tertiary centre from specialist paediatric retrieval services. 

In this setting this child has a high risk of mortality associated with the RSI. Ensure you have optimised and resuscitated as much as possible before the RSI.

Hypotension before intubation is associated with a higher mortality. This child has been fluid resuscitated, therefore you will need pressors to maintain the blood pressure prior to intubation.
In this situation you need to optimize the blood pressure prior to intubation, therefore an adrenaline infusion is the treatment of choice to support the blood pressure during the induction process.

Ketamine is the drug of choice. It exhibits a stimulatory effect on the cardiovascular system and is the least cardiac depressive induction drug available, therefore has the least chance of inducing hypotension. That being said, it is not only the drug that is important but the dose. Smaller amounts of induction agent will be required than a “typical” RSI.

Dosing is usually 1-2 mg/kg, doses of 0.5mg – 1mg/kg would be more appropriate in this setting.

Intubation, Hypotension and Shock • LITFL • CCC Airway
Additional reading – please look at the powerpoint from Dr Chris Nickson 

Jeremy is a 10 year old boy brought in by ambulance after falling off his BMX at a skate park doing a jump without a helmet on. He had a fall from approximately 2 metres onto his head. He had an initial LOC for 2 minutes then was ok, but since then he has had multiple vomits and become drowsy. The ambulance have issued a pre arrival phone call as they are concerned he has a reduced GCS of 8 but no evidence of raised ICP at this stage. The ambulance crew have immobilised his C Spine.

You decide to prepare for an RSI before the child arrives as it seems he will need a secure airway.

How do you do an RSI with a C spine collar on?

His friend tells you they went to McDonalds 2 hours prior to this happening. Would you alter your approach knowing this information? Would you ask for cricoid pressure? 

What is your choice of induction agent and why?

The reason the C Spine collar is on is because of suspected cervical spine trauma, therefore the cervical spine must be protected and avoid hyperextension of the neck during laryngoscopy and intubation. The C Spine collar in children has been contested, with the latest APLS update stating that C spine manual in line stabilisation (MILS) is the preferred option in the conscious patient and that C spine collars can potentially be very distressing for children, fit poorly and therefore a risk/benefit discussion should take place before routinely applying them in children. 

In this case the child has a reduced GCS and a properly fitted, well tolerated collar. Prior to intubation the C spine collar should be removed, however immobilisation should remain in place at all times via MILS. 

The current recommendations of when MILS should be used in general (when C Spine should be thought of) are: 

  • Neck pain or neurological symptoms
  • Altered level of consciousness
  • Blunt injury above the level of the clavicles (significant)

This is aimed to keep the head in a neutral alignment whilst laryngoscopy occurs, to avoid hyperextending the neck. MILS involves a secondary person being tasked with holding the head in neutral alignment, this can either be done facing the intubator and having the hands placed over the side of the head from below, or can be done by crouching beside and underneath the intubator and holding still from above.

Once the airway is intubated the C Spine should be protected with a Philadelphia Collar and sandbags/rolls to ensure ongoing stability is maintained. 

He is likely to have a full stomach or at least food in his stomach which would make him more likely to aspirate, however in an Emergency Situation, not protecting the airway is a larger risk than aspiration. RSI is designed to be a quick induction and reduce the chance of emesis. 

Cricoid pressure was initially thought to help reduce aspiration by blocking the oesophagus, however in children it has been widely contested and not thought to be of benefit. The force required to do cricoid pressure in children is a lot less than in adults; a less trained assistant may cause damage by improperly applied cricoid pressure. It can worsen the view at laryngoscopy and studies have shown that it may only displace the oesophagus laterally and not help with passive aspiration. It can also cause full occlusion of the trachea making intubation impossible.

The short answer is no, you would not change your approach and you would not have routine cricoid pressure. 

Ketamine was previously contraindicated for use in isolated head injury due to the concerns that it raises ICP, however now it is the drug of choice for the head injured child (with the exception of globe injury as ketamine can raise intraocular pressure).

Evidence that it raises ICP was weak. It is advocated for this use now due to its maintenance of haemodynamic stability. 

Haemodynamic stability is very important in traumatic brain injury as hypotension is a major predictor of poor outcomes in TBI, even a single hypotensive event can have deleterious consequences in terms of secondary brain injury. This is a situation where an opiate adjunct would be helpful in ensuring that haemodynamic stability is maintained but so that laryngoscopy does not provoke a hypertensive response. Ketamine activates the sympathetic nervous system, therefore it can result in maintaining cerebral perfusion pressure. Doses should be titrated according to the haemodynamic parameters of the child in front of you; the dosing range is 1 – 2 mg/kg.

Ashleigh is a 2 year old female brought in to you on New Year’s Eve after her sister accidentally let off a firework that exploded in her face.

Ashleigh has obvious burns to her face/neck/chest/upper limbs. When you perform an airway assessment you can hear soft stridor and see burns inside her mouth.

You decide that she has a threatened airway and decide to intubate her. 

Your consultant decides to use suxamethonium as the muscle relaxant of choice. You ask why because you heard it was contraindicated in burns. What is the evidence surrounding use of suxamethonium in burns?

You find yourself in a CICO situation after failed intubation and LMA placement. What is your difficult airway plan for this 2 year old? 

Why is expectant airway management in burns so important?

This is an area that is easy to get confused about. The evidence regarding suxamethonium and burns is that it is safe within the first 24 hours of injury (some evidence states 48 hours) but not for use after 24 hours of injury. After this time it is contraindicated, due to hyperkalaemia (thought to be due to release of potassium from extrajunctional acetylcholine receptors). This potassium release can cause severe hyperkalaemia and lead to cardiac arrest. The important thing to remember is it is contraindicated for 1 year after a burn injury. 

NB The ideal situation for this child is that they are intubated in theatre by an experienced anaesthetist with ENT on standby where there is an option of fibreoptic intubation. This is not available in all institutions. 

Can’t intubate, can’t oxygenate is the worst thing an airway team can hear – but they MUST hear it. The first thing to do is ensure you have said loudly to the team that they are in can’t intubate, can’t oxygenate situation. 

  1. If anaesthetics were not involved earlier, they need to be involved and called now
  2. Consider waking the child up – in this case with airway burns it is prudent to establish access otherwise the airway will be lost later
  3. Front of neck access – the question here is how to puncture the neck – needle or knife?

DAS UK guidelines suggest that children over 8 should have a “scalpel, finger, bougie” technique. Under 8 the cricothyroid membrane is so small that needle jet insufflation should be utilised. Early involvement of ENT and anaesthetics is a must. 

The technique for this as described by DFTB:

  • Extend the neck (making the target as big as possible)
  • Stabilize the larynx with the non-dominant hand
  • Access the cricothyroid membrane with a dedicate 14/16g cannula
  • Aim in a caudal direction
  • Confirm position with aspiration of air into a syringe containing saline
  • Connect to oxygen source
  • Adjustable, pressure limiting device – some departments will have a specific jet insufflation device, other institutions may have to create their own. This can be done by attaching IV tubing to a 3 way tap directly onto the cannula and occluding the 3 way tap to be the breath, proximal end of the tubing can be attached to the oxygen source. Please check your department to see what is available. 
  • 4bar O2 source (hospital oxygen wall meter delivering 10-15L) – matching l/min with age
  • Slowly increase inflation pressure/flow rate to achieve maximal chest rise
  • Maintain upper airway patency to aid expiration

Front of neck access is rarely done, however it is a lifesaving skill that all critical care physicians looking after both adults and children should be able to do. Practice on mannequins and watch videos so that you are able to call upon your knowledge should you ever have to use it!

Airway swelling rapidly increases after the burn and is at risk of airway closure and difficulty intubating the airway later.
Signs of airway burns:

  • History of burn in enclosed space
  • Upper airway oedema (swollen tongue and lips)
  • Sooty sputum (may not be able to assess in a young child that cannot expectorate)
  • Facial burns, singed nasal hair, soot in the mouth
  • Respiratory distress (dyspnoea, stridor, wheeze, hoarse voice)

If any of those are present the airway is at risk and consider intubation of the airway earlier rather than later.

Lily is a 2 month old infant being brought into ED by her mum as she is not feeding well and she has noticed her breathing is abnormal. She has an unremarkable birth history, born at term via NVD, GBS negative, Apgars 9 +9.

She has an older brother Isaac who attends daycare and has a runny nose recently. 

Lily is in respiratory distress with grunting, nasal flaring, recession and head bobbing. You have tried HFNP and CPAP to little avail over the past 3 hours. She is now tiring and is becoming bradypnoeic and bradycardic. To prevent cardiac arrest you decide to intubate this child so proceed to an RSI. 

Does this child need atropine preloading? Do all children need atropine?

Would you use a cuffed or uncuffed ETT?

Would you use a bougie?

There is much debate regarding premedication with atropine prior to RSI. The idea behind atropine as a pre RSI agent is that it increases the heart rate prior to induction to reduce the chance of bradycardia on induction. 

There have been multiple studies which have suggested that atropine is not routinely required for premedication for an RSI and that uncontrolled hypoxia is the largest determinant in bradycardia when compared to the use or not of atropine. 

In this case you could consider atropine given that the patient already has a bradycardia secondary to her respiratory failure, however you could also argue that adrenaline would be a better choice to reverse her bradycardia and improved general perfusion prior to induction. 

This decision would be made with senior decision makers as an RSI in this situation would be high risk due to her already deranged physiological parameters. 

Atropine is not a drug to be given “just in case”, careful consideration needs to be given as it is not without important side effects such as increased temperature with a risk of malignant hyperthermia: at too high a dose it can induce ventricular arrhythmias, at too low a dose it can cause bradycardia. It lowers seizure threshold and increases risk of aspiration by relaxing the lower oesophageal sphincter.

The general rule is no, it is not needed for every RSI, however it should be drawn up and available in the event of a bradycardia. However if you start out bradycardic prior to induction then this needs treatment otherwise there is significant risk of clinical deterioration or cardiac arrest during induction. 

First of all why are we asking this question? In an adult circumstance the answer is always a cuffed ETT, so why is there a choice in paediatrics?

The issue comes from neonates. Cuffed ETTs are thought to cause cuff-related trauma and subglottic stenosis, despite the benefits of a cuffed ETT (better aspiration protection, more accurate ETCO2 detection and lung recruitment). These rates however are much lower than previously thought and the evidence suggests that cuffed tubes are more advantageous. The current APLS guidance is that cuffed ET tubes are advantageous however it requires meticulous attention to size, cuff pressure, and to exact placement to ensure it is in the correct position. 

This will be determined by what is available in the correct size in your department, the correct size is more important than cuffed vs uncuffed. Remember, if you are not in a tertiary centre the tube can always be exchanged if there is an issue. Please check in your department what is the accepted practice and be aware of the availability of these tubes.

A  bougie is a plastic stick which is used to help instrument the airway; it acts as a rigid placeholder for the ETT to be railroaded over the top. In many emergency airways the bougie is the first thing to be called for, however, be aware that it is not small enough for paediatric airways especially neonatal ones. Check and see what your department has – most may have an adult and paediatric bougie with the paediatric bougie being compatible until approximately a size 5 ETT. You do not want to intubate the airway with a bougie and then realise your ETT does not fit!

With the smaller airway especially the neonatal airway then you use a stylet which is small enough for the ETT to fit over the top.

Difficult airway leading to cricothyroidotomy Paediatric Difficult Airway Simulation

More airway learning material Optimus Bonus

The airway assessment mnemonic is named after which fruit? 

A: MANGO – Mallampati/Airway Diameter/Neck/Gnashers/Obstruction

B: APPLE – Airway diameter/Positioning/Palate/Look/Evaluate

C: LEMON – Look/Evaluate/Mallampati/Obstruction/Neck

D: LIME – Look/Incisor distance/Mallampati/Evaluate


Don’t forget it is a LEMON! Look first, then evaluate, check the mallampati, check for obstructions and lastly look at the neck!

What can you use to help optimise airway anatomy when intubating a small child? 

A: Philly collar

B: Neck/shoulder roll

C: Head of the bed sloping downwards

D: Put the child in the recovery position

B: Neck/shoulder roll

Neck/shoulder roll should be used to due to the large occiput in a child to ensure appropriate position for laryngoscopy.

Which of these is an indication for an RSI in the Emergency Department?

A: Elective surgery for inguinal hernia repair 

B: Suspected airway burns

C: Child with GCS 14 

D: Trauma – isolated leg injury but going to theatre in a few hours

B: Suspected airway burns

Airway burns need to be managed promptly. If possible this should be done in theatre by anaesthetics, but not all centres have this availability therefore it may have to be done in an Emergency Department setting.

Please download our Facilitator and Learner guides

Pneumonia Module

Cite this article as:
Ellis Collins and Michelle Alisio. Pneumonia Module, Don't Forget the Bubbles, 2020. Available at:
AuthorEllis Collins & Michelle Alisio
Duration1- 2 hrs
Equipment requiredNone

  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Khan Academy: What is pneumonia? (9 mins) OR

Khan Academy: Classification of lung diseases. (restrictive, obstructive, ventilation and perfusion lung problems 11mins)

GPpaedstips: Diagnosing a lower respiratory tract infection (LRTI)

LITFL: Pneumonia in the ED

Paediatric clinical examinations- The respiratory system (7mins)

DFTB: Respiratory infections

RCH: Community Acquired Pneumonia

DFTB: The Mire of Mycoplasma

DFTB: POCUS and Pneumonia

ALiEM: Lung Ultrasound for diagnosing pneumonia

Substituting POCUS for CXR Podcast on using lung USS (11 mins)

Pathophysiology and background

According to the WHO pneumonia kills more children than any other illness – more than AIDS, malaria and measles combined. In 2017 pneumonia accounted for 15% of all deaths of children under 5 years old, killing 808 694 children and it accounts for nearly one in five child deaths globally. It should also be noted that pneumonia is one of the leading causes of deaths for children under the age of 5.

Pneumonia is an invasion of the lower respiratory tract, below the larynx by pathogens either by inhalation, aspiration, respiratory epithelium invasion, or hematogenous spread. There are barriers to infection that include anatomical structures (nasal hairs, turbinates, epiglottis, cilia), and humoral and cellular immunity. Once these barriers are breached, infection, either by fomite/droplet spread (mostly viruses) or nasopharyngeal colonization (mostly bacterial), results in inflammation and injury or death of surrounding epithelium and alveoli. This is ultimately accompanied by a migration of inflammatory cells to the site of infection, causing an exudative process, which in turn impairs oxygenation. In the majority of cases, the microbe is not identified, and the most common cause is of viral aetiology.

There are four stages of lobar pneumonia. The first stage occurs within 24 hours and is characterized by alveolar oedema and vascular congestion. Both bacteria and neutrophils are present.

Red hepatization is the second stage, and it has the consistency of the liver. The stage is characterized by neutrophils, red blood cells, and desquamated epithelial cells. Fibrin deposits in the alveoli are common.

The third of the grey hepatization stage occurs 2-3 days later, and the lung appears dark brown. There is an accumulation of hemosiderin and haemolysis of red cells.

The fourth stage is the resolution stage, where the cellular infiltrates are resorbed, and the pulmonary architecture is restored. If the healing is not ideal, then it may lead to parapneumonic effusions and pleural adhesions.

In bronchopneumonia, there is often patch consolidation of one or more lobes. The neutrophilic infiltrate is chiefly around the centre of the bronchi.

The WHO reclassified pneumonia in children into two categories; pneumonia with fast breathing and/or chest in-drawing, which requires home therapy with oral amoxicillin, and severe pneumonia, which is pneumonia with any general danger sign (i.e. hypoxaemia), which requires referral and injectable therapy.

The presentation of children with pneumonia can be very varied and may include cough, fever, tachypnea, and difficulty breathing. Young children may even present with abdominal pain only.

Features from the history and what they might mean

Prolonged duration of coughSecondary infection, abscess or empyema formation Longer admission, tertiary referral
ChokingAspiration of FB or foodBronchiole/lower airway obstruction, pneumonitis 
Birth complications- e.g. meconium or prematurityChronic lung disease for the newbornMore susceptible to infections/severe infections
ImmunisationIncomplete immunization/ no immunisationAt risk of acquiring bacterial infections, severe infections or viral complications from measles, chickenpox
Travel and exposureContact with unwell relative, contact with other childrenExposure to different pathogens with travel Contact with older/unwell children, or adults may be exposed to pathogens not yet immunized against, or atypical ones 

Mary is 3 years old and was referred to hospital from the GP with a 2 day history of coryzal symptoms, cough, fever and saturations of 91%. She is not eating but still drinking fluids well. On assessment in triage she is crying; her respiratory rate is 45, saturations are 96% and temperature is 37.8°.

The play therapist distracts her while you examine her chest on mum’s lap. You don’t see any use of accessory muscles or intercostal recessions at rest; you think you heard crackles but it could also be transmitted sounds.

What is the probability that Mary has pneumonia?

Should you do a chest x-ray?

Mary’s mother says the GP frightened her by referring her to hospital. She asks you whether Mary needs antibiotics. Should you prescribe antibiotics?

Mary is a well grown, fully immunised and a previously well child who now displays mild signs and symptoms of pneumonia. She does not need a CXR nor does she need antibiotics. The family requires reassurance that the child is safe, can be managed at home as well as be provided with illness specific information and when to return.


Children with pneumonia may present with fever, tachypnoea, breathlessness or difficulty in breathing, cough, wheeze or chest pain. They may also present with abdominal pain and/or vomiting and may have headache. Cough and fever are non-specific symptoms and are not grounds for diagnosing LRTI on their own. 

Tachypnoea is also a non-specific sign in children. It may present in fever, when a child cries or is in pain and in many non-respiratory cases. 

Hearing crepitations on auscultation is also a common finding that should not be given too much weight. The infant or child with an upper respiratory tract infection (URTI) will often have crepitations that can be heard in one or more places in the chest.  These may be transmitted sounds or due to secretions. Often, these noises go away or move around if re-examined, especially after a cough. In the absence of abnormal breathing, these crackles are not good evidence for LRTI. Also, auscultation and percussion in infants and small children is difficult. Chests are small and there is always the possibility that the area of abnormality will be missed.

What clinical findings are of value in diagnosing pneumonia?

The Rational Clinical Examination Systematic Review concludes that more important than tachypnoea and auscultatory findings are

Hypoxia (saturations ≤ 96%) and 

Increased work of breathing/abnormal breathing

There are no absolute rules about when to x-ray but we shouldn’t rely on CXRs to make the decision for us. The sensitivity and specificity of a CXR as a way to diagnose pneumonia in children is too poor to justify using radiation when the diagnosis should be made clinically. The BTS guidelines for community acquired pneumonia in children and the Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America both recommend that CXR is routinely avoided.

Special circumstances where a CXR should be considered include:

Small infants and babies

This age group tend to have a higher probability of serious bacterial infection whenever they present.

The child with complex medical problems

They may not demonstrate abnormal breathing or unwellness in the way that normal children do.

Chronic symptoms in a child that does not appear unwell, red flags (such as weight loss), known exposure to tuberculosis

Daily cough for several weeks should be taken seriously. Underlying causes including bronchiectasis and simply unresolved LRTI may need to be ruled out in which case referral will be necessary. Unilateral findings to evaluate for a foreign body.

Chest radiography should also be done when a child fails to improve clinically after 48-72 hours of appropriate antibiotic therapy, in patients with severe or unexplained respiratory distress, and those who require hospitalisation. 

Severity assessment to direct treatment

A clinical examination cannot distinguish between a viral or bacterial pneumonia, neither can a CXR. More important than distinguishing whether a pneumonia is viral or bacterial is to adopt a severity-based approach to guide your treatment. Even if mild to moderate disease is caused by bacteria, these infections still resolve on their own and antibiotics make little to no difference anyway.There is no single validated severity scoring system to identify children at risk from a severe infection. A global assessment of clinical severity and risk factors is crucial in identifying the child likely to require hospital admission. One key indication for admission to hospital is hypoxaemia. British Thoracic Society Guidelines’ features of severe disease in an infant and older child include oxygen saturations < 92% together with other features of abnormal breathing listed below.

Bringing all these things together shows that there are two key features.  The first of these is abnormal breathing in the context of an unwell child with cough.  The presence of abnormal breathing almost immediately makes it likely that the problem is LRTI, bronchiolitis or viral wheeze.  If there is a wheeze, this largely rules out LRTI. It’s almost that simple.

Safety-netting advice is key.

For the majority of encounters, parents bring their child to medical attention because they are uncertain as to the severity of their child’s illness, and they are frightened. Not because they seek antibiotics. DFTB lists reassurance steps to take in your discussion:

  • Acknowledge their child feels poorly.
  • Acknowledge this is difficult for their child, and for them as parents.
  • Reassure them their child is safe, and there are no ‘red flags’ – remember what we consider severe (physiological derangement) is not the same as parents (behavioural impact).
  • Explain that medical treatment is supportive and offer symptom management.
  • If you need to, confirm antibiotics are neither necessary nor helpful, as it will not speed up recovery and only expose the child to unnecessary risk.
  • Most importantly – provide illness specific information and safety net advice (ideally written information/leaflet).

Life in the Fast Lane – Paediatric CXR (some of the CXR start with CT images)

Martin is an 8 year old fit and healthy young boy who was brought in by his dad with three days of fever, a dry cough, shortness of breath, and abdominal pain, initially seen by the GP and started on amoxicillin. Today he was sent home from school because of breathing difficulties.

On assessment Martin is lying in bed, alert with a tracheal tug, use of accessory muscles, a respiratory rate of 37 breaths per minute, and oxygen saturations of 89% in room air. You also note that Martin has a rash on his lower legs.

Why is Martin not improving on appropriate antibiotics?

How should Martin be investigated and managed?

Perhaps it’s a viral pneumonia

One could consider whether antibiotics were appropriate in the first place. Martin could be dealing with a viral infection, which could explain why there is no change in symptoms. Inappropriate antibiotic prescribing drives antibiotic resistance and drives future medicalised health behaviour.

Perhaps it’s the wrong antibiotics

NICE recommends amoxicillin as the first choice of oral antibiotic for a low severity pneumonia in children and adults less than 18 years of age and high dose oral amoxicillin (30mg/kg TDS) is as effective as IV benzylpenicillin. 

Is Martin allergic to penicillin? Perhaps the amoxicillin has caused the rash and worsening respiratory symptoms, so amoxicillin should be discontinued immediately and replaced with a macrolide. NICE recommends doxycycline or clarithromycin in penicillin allergy.

Perhaps it is the wrong diagnosis

Here we come to the crux of any child that fails to respond to initial treatment: always go back to the drawing board. Retake a detailed history and do a thorough examination. Draw out any red flags, allergies, previous medical history, a significant family history. On examination it is clear that Martin has a severe pneumonia – he is hypoxic with obvious work of breathing and will require oxygen therapy, further work up and admission.

What other differentials would one think about?

Pneumonia can occur at any age but tends to occur in younger children and become less common as they get older.

In neonates respiratory distress can be a sign of underlying pathology and such things as congenital abnormalities, laryngeal injury, pulmonary haemorrhage/birth trauma and these must be considered in the differential.

In older children respiratory distress can be present in asthma, bronchiolitis, chronic anaemia, cystic fibrosis, heart disease, haematological malignancies and even foreign body inhalation.

Also important to consider whether this is a complicated pneumonia (pneumothorax, effusion, empyema) or sepsis.

Some differentials are demonstrated below

Sudden onset or precipitating trigger of dust/hay/animalAllergy or anaphylaxis
Acute exacerbation of asthma
Trigger/sudden onset more likely asthma/anaphylaxis than pneumonia
If anaphylaxis then IgE levelsPeak flow in Asthma pre and post bronchodilators, response and improvement- more likely asthma over pneumonia
Nocturnal cough or sx of cough and SOB when well (interval symptoms)Undiagnosed or under treated asthmaPeak flow
Fatigue, easy bruising, pallorAnaemia, leukemiaFull blood count with film – low Hb, high WBC or pancytopenia
Failure to thrive in neonate/infantCystic fibrosisSweat test and specialist referral
Feeding difficulties, cyanosis on feedingCongenital cardiac defectECG, CXR, echocardiogram and specialist referral
Hx of sickle cell diseaseAcute chest crisisSevere chest pain and bilateral CXR changes, pain in regions outside of chest, or previous presentations
History of choking, unilateral chest signsForeign body inhalationCXR, bronchoscopy and specialist referral
Previous streptococcal infection, fever, erythema marginatum, carditisRheumatic feverESR, WCC, blood culture, ECG, echocardiogram, antibiotics
Immunocompromised (primary immunodeficiency, HIV)Fungal pneumonia, tuberculosis (if exposure to known contact)Antifungals and anti-tuberculous therapy and specialist referral to Infectious Diseases.

Pneumonias have a variety of classifications, such as community acquired pneumonia (CAP), aspiration pneumonia, hospital acquired pneumonia, and pneumonia classified by age group or causative pathogen. Atypical pneumonia refers predominantly to an uncommon pathogen causing pneumonia. Below is a classification of pneumonia typical for certain age groups of children.

Respiratory tract problems, cough and fever, are the most common presentations to the Paediatric Emergency Department (PED). Most of these children do not have pneumonia, and most who do have pneumonia can be discharged from the PED with oral antibiotics and careful safety netting. 

Refer children under the age of 1 year, if they have comorbidities (i.e. immunodeficiency, cardiac disease), poor oral intake or urine output and most certainly if there is laboured breathing, hypoxaemia and signs of sepsis. RCEMLearning has a simplified (and useful) summary of how to differentiate the common respiratory problems in PED.

There is also fungal pneumonia which in addition to common bacterial and viral pathogens are considered uncommon and opportunistic microorganisms in a ‘poly-microbial mix’ seen mainly in immunocompromised children such as in HIV-exposed or infected children. Pneumocystis jiroveci (PJP) is a common fungal infection of the lung in immunocompromised infants from 2-6 months of age. They present with an acute onset of respiratory distress, minimal/absent chest signs in a child who is HIV exposed or infected. Hypoxaemia and cyanosis are common features in severe disease and CXR shows a range of abnormalities including bilateral perihilar interstitial changes.

Perinatally acquired cytomegalovirus associated pneumonia in HIV infected infants presents as an interstitial pneumonitis with acute hypoxic respiratory failure and tuberculosis in HIV infected children occurs at all ages. The diagnosis is difficult to confirm, one needs to have a high index of suspicion if exposure to a contact has been elicited from the history and a Mantoux test of ≥ 5mm induration is indicative of tuberculosis disease.

Those children with chronic lung diseases such as in immunocompromised children or whose with cystic fibrosis (CF) are typically colonised with uncommon organisms such as Pseudomonas aeroginosa and Klebsiella pneumoniae.

Mycoplasmas are distinguished from other bacteria by their lack of a cell wall, which has implications for its treatment – as most antibiotic classes, which act on the cell wall, will be ineffective in treating Mycoplasma species. While LRTI decreases with age, the prevalence of atypical infections increases, with a median age of about 7. They most commonly present with respiratory symptoms such as pneumonia, however they also have a range of extrapulmonary symptoms. CXR manifestations in this group are also wide and varied as are laboratory findings. Some CXR features can involve reticulonodular patterns confined to one lobe, segmental and lobar consolidations, or diffuse interstitial and bilateral perihilar peribronchial patterns. Below is an example of left lower lobe consolidation complicated by a pleural effusion in a patient with confirmed mycoplasma pneumonia.

Atypical pneumonias, such as those caused my mycoplasma, are generally treated with oral macrolides, fluoroquinolones or tetracycline. There is no need to target extrapulmonary symptoms such as in this case, as it is likely immune mediated but supportive therapy maybe considered. Skin manifestations are the most common of the extra-pulmonary manifestations and range from erythema nodusum (as depicted in the diagram) to Stevens-Johnson Syndrome. These are raised and tender nodules. Part of Martin’s management should include adequate analgesia not only for erythema nodosum but also for his referred abdominal pain.

When considering admission there is no one clinical factor for admission, it is based on a combination of clinical signs, but most importantly on severity of pneumonia. Compliance with medication and parental anxiety can be a valid reason.

Admission does not necessarily need to mean further investigation and can be trial of PO antibiotics in hospital, switching to IV/ambulatory IV if a trial of oral is not tolerated, and importantly supporting the parents.

EmDocs: Paediatric Pneumonia Management Algorithm

Individual risk factors for the child e.g prematurity, immunocompromise, congenital abnormalities or previous complications from CAP must also be considered.

Children who are ex-premature may have chronic lung disease of the newborn and are likely to be more susceptible to severe pneumonias and infections.

The same applies for children with congenital abnormalities and immunocompromised.

It can also be secondary to chemotherapy or as a result of HIV. 

Being immunocompromised may mean they are more likely to require IV antibiotics or a longer period of observation.

Martin has severe mycoplasma pneumonia and requires humidified high flow nasal cannula oxygen (HHNC) therapy to start. He also needs a CXR, so we can make sure we are not dealing with a complicated pneumonia. It’s probably advisable to get intravenous access in case of further deterioration and a set of baseline bloods (FBC, CEU) and a baseline blood gas to determine how well (or poorly) Martin is oxygenating (Pa02). Septic markers are controversial here as they would probably not change the initial management in the paediatric emergency department but seeing that Martin is unwell and needing admission, it would be reasonable in this situation to do a CRP and/or procalcitonin (PCT). If tolerating oral medication, he would continue on oral Azithromycin. Mycoplasma pneumonia’s are usually diagnosed retrospectively so depending on local guidelines a viral pharyngeal polymerase chain reaction (PCR) swab or sputum and/or antibody test to Mycoplasma pneumonia can be done. Martin is admitted to the Paediatric high care isolation ward and PICU is also made aware of Martin’s condition.

Mimi is well known to the department. She has Trisomy 21 and had her VSD repaired at 3 months of age. She is now 10 months old and is brought in with a 2 day history of coryzal symptoms, cough and fever. Today her parents have noticed fast breathing, she is much more lethargic and off food. She is normally a very bright bubbly child.

On examination Mimi is tiring, she is cyanosed with oxygen saturations of 82%.

Which patients are at increased risk of a severe pneumonia?

Should we CPAP ‘trial’ or immediately intubate?

As previously discussed children with other comorbidities or congenital abnormalities are at increased risk of lower respiratory tract infection and complications.

Those with underlying or previous cardiac abnormalities can deteriorate more rapidly with fewer precipitating symptoms.

Similarly, ex-premature infants are at increased risk of severe pneumonia’s (typically RSV pneumonia) and remember the child with complex medical problems may not demonstrate severe clinical signs as would a normal child. One should always have a low threshold for investigating further.

Recognising the child at risk and the deteriorating child early means appropriate early intervention and escalation of care, but sometimes there isn’t the time and a child may need an emergent intubation

It is important to recognise when a child is deteriorating by looking at response to treatments given, work of breathing, RR, SPo2 and general appearance.

In the hypoxic child the simple administration of oxygen may not always be sufficient

This is where continuous positive airway pressure (CPAP) which delivers constant positive end expiratory pressure (PEEP). Normally a mask or nasal prongs are sealed against the nostrils and are connected to a pressure generator and an airflow source. Options are where the mask is connected to a mechanical ventilator, which provides airflow and PEEP. Alternatively an oxygen concentrator or cylinder provides airflow, and the depth of expiratory tubing within a fluid reservoir generates PEEP and this is referred to as bubble CPAP (bCPAP).

There are several studies looking at CPAP particularly in low resource settings and if it reduces mortality in childhood pneumonia. The difficulty in low resource settings (or indeed a small DGH) is access to equipment and a balance of providing highly concentrated/pressurised O2 to a small number of children vs being able to provide low flow to several. Hopefully this is a highly unlikely scenario but was what was recognised in some of the studies conducted to very rural areas.

Generally the studies suggested that CPAP reduced respiratory distress and improved oxygenation, but rate of mortality was unchanged particularly with associated comorbidities.


CPAP is useful particularly for respiratory distress regardless of SPO2 and is often better tolerated than a face mask as the nasal prongs are less intrusive and the humidified oxygen less distressing. It can eliminate the need for intubation and along with distraction technique calm a child down. However some models you cannot transfer on easily and this need to be taken into consideration when setting it up (e.g if they are in ED and not a ward)

If a child does not respond to CPAP then the next definitive step is to perform an emergency intubation, or a rapid sequence induction. 

If the child is in respiratory failure then it may be that intubation is the first step.

CPAP is only indicated as a method of pre oxygenation if pre oxygenation is not possible via normal face-mask (but this will take time to set up and may delay intubation)

This podcast discusses some different situations and nuances around RSI

Any child who you are considering CPAP/RSI should have a PICU involvement as this is the area they will need to be transferred to after the interventions.

Ideally PICU should be present at the time of intubation or a paediatric anaesthetist as these will be the best placed clinician to intubate and with a child in respiratory distress the goal is to secure the airway and provide adequate oxygenation as quickly and safely as possible.

A 4 year old child, Hannah, was diagnosed with pneumonia and admitted to the children wards on oxygen and commenced on IV antibiotics. After 48hr of initial therapy her oxygen requirements have increased, and she is still spiking fevers.

You have been called to review Hannah as the nursing staff are concerned that she is febrile again despite paracetamol. Her initial CXR showed a dense left lower lobe consolidation.

Would you repeat a chest x-ray?

Or are their alternative investigations?

Hannah has developed an empyema. Discuss your approach to inserting a chest drain.

Point of care ultrasound is becoming an increasingly utilised tool for clinicians in the emergency field, by specialist and emergency physicians. Several studies have started looking to lung ultrasound for diagnosing pneumonia and this has been expanded into the paediatric cohort.

Several studies have now shown that lung ultrasound (LUS) is as sensitive in diagnosing pneumonia as CXR. However it is noted that this may be user and locality dependent, e.g. clinicians on shift being able to perform and interpret USS, or having access to this modality out of hours.

One meta analysis comparing LUS vs CXR showed that LUS had a sensitivity of 95.5% and specificity of 95.3% whereas CXR had a sensitivity of 86.8% and specificity of 98.2%. We know that CXR is currently the gold standard

Yet some studies have demonstrated LUS may pick up even smaller areas of consolidation that can be missed on CXR. Ultrasound is something that is being used more and more and can be readily taught to physicians to achieve basic competence. Utilising US provides rapid insight into the pathology of the lungs and can identify, monitor and assess changes at regular intervals without the need for repeated CXR. It may be easier to have access to an USS rather than a CXR especially in a critical emergency.

However if LUS is not immediately available then CXR should not be delayed if indicated.

If a child has not responded to antibiotics after 48hr then the clinician must think why and assess what has changed. The incidence of parapneumonic effusion and empyema in children is 3.3 per 100 000 children. If effusion is suspected on CXR then an US must be used to confirm the presence of fluid. All children with effusion/empyema must be admitted for IV antibiotics.

If confirmed on LUS then a CT scan with contrast enhancement can be used as a definitive investigation. Effusions that are enlarging or causing respiratory embarrassment should be considered for invasive intervention. Conservative management alone can be appropriate but can prolong the overall hospital admission. As per the British Thoratic Society (BTS) guidelines for the management of pleural infection in children a chest drain should be considered and placed by an appropriately trained member of staff and with the aid of LUS.

Repeated aspirations are not recommended as they are less efficacious, and more likely to cause distress and involve repeated invasion into the pleural cavity.

Whereas an appropriately placed drain (and not necessarily the biggest!) when inserted under appropriate procedural sedation (or GA) can shorten the illness and resolve the effusion faster. Different types of chest drain are available; one small study compared pigtail with large bore surgical drains and found no significant difference in outcome, but did find that the smaller pigtail drains were better tolerated. If a child has a complicating fibrinopurulent empyema then the drain can also be used to administer intrapleural fibrinolytics e.g. urokinase. This can also allow continued drainage with reduced risk of purulent blockage, and help re-establish normal pleural flow.

Read the DFTB rule of 4s

Then when to remove/ when to clamp?

Clamp the drain for 1 hour once 10 ml/kg are initially removed.

Remove the drain when they no longer swing/bubble and LUS shows resolution of effusion/empyema and importantly the child is clinically improving.

However if the drain stops swinging- check why, has the effusion been drained or has the tube become kinked or blocked, attempts at repositioning or flushing the drain should be undertaken and assessment of the clinical picture.

If the effusion has not drained or the child has not improved then it would be appropriate to refer to the paediatric surgeons for consideration of a replacement drain or potentially a VATS procedure if a particular viscous or loculated effusion remains.

Removal of drains should be based on resolution of effusions and clinical improvement. Antibiotics should be continued for 1-4 weeks after removal, all children should have routine follow up and underlying comorbidities should be considered e.g undiagnosed CF, immunocompromise, malignancy.

Even with effusion/empyema most children should recover without any long-term complications of adverse reduction in lung function.

Optimus Bonus Simulation Package – Paediatric sepsis

This simulation focuses on management of sepsis so would follow on from recognising complications or deteriorations in children with LRTI, recognising shock and when to escalate care.

A 5 year old is brought in with 3 day history of fever, lethargy and complaints of left sided abdominal pain. Normally fit and well, immunisations are up to date and they attend school.

In triage he is noted to have subcostal and intercostal recession, with SpO2 of 90% in air, the triage nurse moves him to a bay and asks for your urgent review.

What on examination/initial investigation would make the diagnosis of pneumonia more likely?

A: Fever and cough

B: Low sats and fever

C: Focal crackles on chest auscultation

D: Hypoxaemia and increased work of breathing

E: Coryzal and increased work of breathing

Answer D

Hypoxaemia and increased work of breathing were most clinically significant in diagnosis of pneumonia. Chest signs can be misleading and it is often difficult to tell upper airway noises from focal signs. Even viral pneumonias can lead to focal signs on auscultation and on chest x-ray. Upper airway noises can be distinguished as they tend to change on positioning/after coughing as upper airway secretions move and are expelled whereas focal signs will be less affected by this. A viral pneumonia may have a history of coryzal symptoms and would be similar to that of bronchiolitis.

On examination the child has consistently reduced air entry at the right, persistently low sats of 91%. CXR shows a right lower lobe pneumonia.

What is the most likely causative pathogen?

A: Streptococcus pneumoniae

B: Staphylococcus aureus

C: Haemophilus influenza (type B)

D: Mycoplasma pneumonia

E: Respiratory Syncytial Virus (RSV)

Answer A

The infective agents that commonly cause pneumonia will vary by age.

Pathogens will vary from neonates, to infants to preschool to school age children, think of the vaccination schedule, maternal swabs in pregnancy and maternal fever in labour and atypical pathogens in immunocompromised children.

Remember atypical e.g. mycoplasma’s become more common in the older child.

Haemophilus influenza B – rates overall are reduced due to vaccinations

You insert an IV cannula and take bloods. Results show a white cell count of 24.3 × 109/L (with neutrophils 92%), a CRP 283 mg/L and a sodium (Na) 126 mmol/L. The rest of his full blood count and renal function are normal.

Which of the following is the most likely cause for his hyponatraemia?

A: Low sodium intake

B: Increased renal excretion

C: Hyponatraemic dehydration

D: Increased sodium dilution

E: High sweat sodium concentrations

Answer D

Hyponatremia has frequently been ascribed to the syndrome of inappropriate antidiuretic hormone (SIADH) in the past, but the existence of this entity in children with pneumonia is now being questioned. SIADH leads to hyponatremia by increasing the total body water causing a dilutional effect.

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A New Way To Teach

Cite this article as:
Team DFTB. A New Way To Teach, Don't Forget the Bubbles, 2020. Available at:

At DFTB we are very excited to be able to present the DFTB Modules – a set of free, open access teaching modules which are mapped to the UK and Australasian Paediatric Emergency curriculum that you can pick up and run in your own organisation.

This is a project that has been developed by our DFTB Fellows at the Royal London Hospital – Rebecca Paxton, Helena Winstanley, Chris Odedun, and Michelle Alisio. The DFTB Modules would not have been possible without our wonderful community of writers and contributors from around the world who have spent time crafting and reviewing the modules over the past year.

We’ve prioritized flexibility in creating the modules with cases and discussions with both basic and advanced trainees in mind. This way you can adapt them to your learners and existing resources. The first 15 modules have been released and we have another 30 in the pipeline. These will be published over the next few months. We would love to get your feedback or comments at fellows@dontforgetthebubbles.com

Why did we create the project?

The DFTB mission is about taking a “World recognized leadership role in making meaning of information in paediatric medicine, for clinicians“. Our principles are structured around being collaborative, pioneering, community-focused, and evidence-based.

Opportunities for teaching and learning across the curriculum in paediatrics, particularly in paediatric emergency, are variable between hospitals often due to access to useful resources. Whilst there are many fantastic educators in hospitals, many fill clinical roles. This means that their time to prepare for teaching is limited. For trainees, who often rotate from hospital to hospital, having access to structured resources and an opportunity for case-based discussion of a wide range of topics will help strengthen their learning.

By collaborating, as a group of medical professionals across the world, in writing these modules – we are working together as an international community to support thoughtful, evidence-based sessions.

Access the DFTB Modules here