Mandible Fracture

Mandible FractureUnfortunately, children are at significant risk for traumatic injuries, whether they be young or old. Injury prevention strategies is, obviously, the best way to avoid these events, but “accidents” do happen, so we need to be facile with managing all aspects of pediatric traumatic injuries (ex, Splenic Injury, Abdominal Trauma, Thoracic Trauma, Aortic Injury, Pelvic Trauma). Recently a colleague of ours @BurnsidePatrick inquired about Mandible Fractures in children. Well, Dr. Burnside, that is a great question (if you have a clinical question, don’t hesitate to email the question to… so let us take a moment to digest a Morsel on Mandible Fracture.


Mandible Fracture: Basics

  • The mandible is the most commonly fractured facial bone (>30%) in children. [Allred, 2015; Imahara, 2008]
  • Facial fractures, overall, in children are more rare than in adults.
    • The proportion of cranium to face is greater in young children compared to adults.
      • 8 : 1 (cranium : face) at birth
      • 2.5 : 1 (cranium : face) in adults
    • As children age, risk for facial injury increases. [Imahara, 2008]
  • Age Matters  [Owusu, 2016]
    • Mean age for mandible fracture = 14 years 
    • For children <12 years of age
      • Fall is most common cause
      • Condyle most frequent fracture site
    • Teenagers are different (>12 years of age)
      • Assault is most common cause (~40% of cases) [Hoppe, 2015]
      • Angle of mandible is the most frequent fracture site in teenagers
  • Motor Vehicle Collisions, Falls, Violence, Bicycles and Sports are the major causes. [Owusu, 2016; Smith, 2013; Imahara, 2008]


Mandible Fracture: Evaluation

  • Scrutinize for other traumatic injuries. [Owusu, 2016; Allred, 2015]
    • Associated intracranial injuries found in 8.5% [Owusu, 2016]
    • Associated cervical spine fractures found in 4.4% [Owusu, 2016]
    • So, don’t need to reflexively order head and neck CT, but do need to carefully assess.
  • Look for lacerations
    • External lacerations of the chin may be sign of force directed posteriorly, leading to crush injury to the condyles. [Wolfswinkel, 2013]
    • Intra-oral lacerations may change management (i.e., open fractures).
    • Any fracture through a tooth-bearing region is considered an “open” fracture and requires prophylactic antibiotic therapy. [Wolfswinkel, 2013]
  • Assess for numbness
    • Fracture of the body of the mandible can lead to inferior alveolar nerve injury.
    • Check for numbness of chin or teeth.
  • Assess for malocclusion
    • Asking the patient about the bite occlusion is useful.
    • Bimanual palpation (intra-orally and extra-orally) can help find asymmetry too. [Wolfswinkel, 2013]
    • Palpate the TMJ also.
  • Look for loose teeth or lost teeth! (see Dental Trauma)
  • TONGUE BLADE BITE TEST! [Neiner, 2016]
    • In small group of pediatric patients, this was found to be 100% sensitive and 88.9% specific.
    • Negative predictive value = 100%
    • (yes, small study… so it is worth repeating)
    • If the kid is able to break the tongue blade with her/his bite, then no mandible fracture!


Mandible Fracture: Imaging

  • Panorex
    • Historically considered study of choice
    • Requires patient cooperation (tough for acutely injured children)
    • Requires specialized equipment
    • Can’t be performed on patient with possible C-Spine injury
    • Inferior to CT when looking specifically for condylar fracture. [Gelesko, 2013]
  • Plain Films
    • Can provide timely information
    • Need to obtain “mandible series” = PA, Townes, Bilateral Obliques, Lateral and Subment0vertex views
  • CT
    • Most versatile and useful modality
    • Particularly useful for detecting subtle or questionable fractures.
    • If Panorex shows midline mandible fracture, CT recommended to evaluate for genial tubercle fracture. [Gelesko, 2013]


Mandible Fracture: Management

  • The future growth of the mandible has to be carefully considered when considering operative management.
    • The posterior borders of the condyle and ramus actively remodel for normal growth.
    • The body and symphysis undergo minimal changes normally.
  • Operative vs non-operative strategies can be successfully employed.
    • “Best” strategy still debated.
    • Open reduction more likely to be needed for:
      • Multiple fractures – less stable fracture patterns
      • Certain fracture locations – ex., isolated body fracture
      • Older patients – younger patients more likely to have greenstick fractures
    • Non-surgical stabilization is also option for some injuries:
      • Condylar fractures
      • Non-displaced fractures are most often managed conservatively. [Wolfswinkel, 2013]
    • Resorbable fixation devices are also employed.
      • Strength for 4-6 weeks.
      • Degrade over course of 1-2 years.
  • Soft Diet and Pain Meds!
    • Unless going to the OR, a soft diet can be initiated.
    • Patient may require period of hospitalization to ensure adequate pain control to assist with oral intake.


Moral of the Morsel

  • Thoroughly evaluate the child for concomitant injuries.
  • Perform Tongue Blade Bite Test! If able to break the blade, awesome! Save the kid from the CT scan.
  • If clinically apparent fracture, then consider lower sensitivity tests (Panorex).
  • If concern for subtle fracture, CT is the best means to truly evaluate the entire mandible.
  • Do not forget the social considerations and impact of interpersonal violence! – consult your social worker and help this child avoid another ED visit due to violence.




Neiner J1, Free R1, Caldito G1, Moore-Medlin T1, Nathan CA1. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016 Jun;9(2):121-4. PMID: 27162567. [PubMed] [Read by QxMD]

Owusu JA1, Bellile E2, Moyer JS2, Sidman JD3. Patterns of Pediatric Mandible Fractures in the United States. JAMA Facial Plast Surg. 2016 Jan-Feb;18(1):37-41. PMID: 26470008. [PubMed] [Read by QxMD]

Hoppe IC1, Kordahi AM, Lee ES, Granick MS. Pediatric Facial Fractures: Interpersonal Violence as a Mechanism of Injury. J Craniofac Surg. 2015 Jul;26(5):1446-9. PMID: 26106996. [PubMed] [Read by QxMD]

Allred LJ1, Crantford JC, Reynolds MF, David LR. Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes. J Craniofac Surg. 2015 Nov;26(8):2368-74. PMID: 26517461. [PubMed] [Read by QxMD]

Swanson EW1, Susarla SM1, Ghasemzadeh A2, Mundinger GS1, Redett RJ3, Tufaro AP3, Manson PN4, Dorafshar AH5. Application of the Mandible Injury Severity Score to Pediatric Mandibular Fractures. J Oral Maxillofac Surg. 2015 Jul;73(7):1341-9. PMID: 25936782. [PubMed] [Read by QxMD]

Morrow BT1, Samson TD, Schubert W, Mackay DR. Evidence-based medicine: Mandible fractures. Plast Reconstr Surg. 2014 Dec;134(6):1381-90. PMID: 25415101. [PubMed] [Read by QxMD]

Smith DM1, Bykowski MR, Cray JJ, Naran S, Rottgers SA, Shakir S, Vecchione L, Schuster L, Losee JE. 215 mandible fractures in 120 children: demographics, treatment, outcomes, and early growth data. Plast Reconstr Surg. 2013 Jun;131(6):1348-58. PMID: 23714795. [PubMed] [Read by QxMD]

Wolfswinkel EM1, Weathers WM, Wirthlin JO, Monson LA, Hollier LH Jr, Khechoyan DY. Management of pediatric mandible fractures. Otolaryngol Clin North Am. 2013 Oct;46(5):791-806. PMID: 24138738. [PubMed] [Read by QxMD]

Gelesko S1, Markiewicz MR, Bell RB. Responsible and prudent imaging in the diagnosis and management of facial fractures. Oral Maxillofac Surg Clin North Am. 2013 Nov;25(4):545-60. PMID: 24183372. [PubMed] [Read by QxMD]

Imahara SD1, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008 Nov;207(5):710-6. PMID: 18954784. [PubMed] [Read by QxMD]

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Can’t Intubate Can’t Ventilate

Can't Intubate Can't Ventilate“Can’t Intubate Can’t Ventilate” is one of the frightening statements that causes massive surges of adrenaline in everyone. Unfortunately, most neural synapses don’t function well with that large surge of adrenaline, and it is, therefore, imperative to contemplate how to manage this scenario before it arises.  We have previously discussed Transtracheal Ventilation and have several videos to view, but let us review this important topic briefly once more. Can’t Intubate Can’t Ventilate: How Do I Oxygenate?


Can’t Intubate Can’t Ventilate: Anatomy Matters!

  • With larger children and adults, the can’t intubate can’t ventilate scenario often leads to the Cricothyrotomy.
  • In younger children and infants, the differences in anatomy make a traditional cricothyrotomy challenging.
  • In infants and young children:
    • Generous proportions of subcutaneous adipose tissue (chunky little babies are cute…) obscures landmarks.
    • The Hyoid bone is more prominent than the thyroid cartilage.
    • The Thyroid notch is often not palpable.
    • The Cricothyroid membrane is:
      • More horizontally positioned vs its typical vertical position
      • Small!
        • Around 8 years of age it is 1/2 the height and width of an adult’s
        • In neonates, the size is not sufficient enough to insert any commonly used rescue device. [Navsa, 2005]
  • The altered anatomy makes location of the cricothyroid membrane more difficult (if at all possible) and the small size may make it impossible to pass a large cric-tube through.


Can’t Intubate Can’t Ventilate: Go Transtracheal

  • Transtracheal ventilation has been used successfully in children as well as adults. [Frerk, 2015; Cote, 2009]
  • It may not “secure” an airway, but it will provide the patient with oxygen while you sort out the problem (and change your pants).
  • It is also easier than placing an IV in a child!
    • Locate the trachea!
      • If you are able to locate the cricothyroid membrane and it is large enough you can use it
      • Potential to use this catheter later to convert to a guidewire-assisted percutaneous cricothyrotomy. [Boccio, 2015]
    • Load a large gauge needle/catheter (14 gauge), ideally one that is reinforced (as simple peripheral IV catheters are prone to kink and become obstructed) onto a fluid-filled syringe.
    • Aspirate as you enter the skin at a 30-45 degree angle aimed caudally.
    • When you aspirate bubbles, you are in the airway! Advance the catheter and retract the needle.
    • Boom… done. High-Fives all around! {oh wait… we need oxygen!}


Can’t Intubate Can’t Ventilate: The Hard Part

  • The most difficult aspect of the procedure is not waiting too long to do it and leading to hypoxic insult.
  • The next most difficult aspect is figuring out how to connect oxygen to the tiny catheter you just placed in the neck.
  • This is where contemplation of how to do this before you need to do it is important, because most of us are not going to successfully “MacGyver it” on the fly.
  • Oxygen Connection Options

    1. Commercial products
      • Have flow regulators that are easy to use. [Cote, 2009]
      • Connect easily via Lure-lock to the catheter.
      • Many have pressure regulators as well.
      • Con = Expensive.
    2. Oxygen Tubing and High Flow O2 from Wall 
      • Not as optimal as commercial products, but may be best you have available.
      • Turn flow up all of the way. [Bould, 2008]
      • Need to “MacGyver” a flow regulator and a connector
        • Flow Regulator
          • Cut large holes (several) in side of oxygen tubing.
          • Need large/multiple holes to allow air flow to egress easily and not add to PEEP. [Sasano, 2014]
          • May also use Y-connector to another oxygen tube.
        • Connector
          • 3-way stop cock can be used to fit into distal end of oxygen tubing and Lure-lock onto the catheter.
          • Need to ensure 3 way valve is open to flow!
    3. Self-Inflating Ventilation Bag [Sasano, 2014]
      • Not as optimal as commercial products, but may be best you have available.
      • 3.0 ETT bag connector
        • Remove from ETT
        • Insert distal end into catheter
      • 7.5 ETT bag connector
        • Remove from ETT
        • Insert into proximal end of 3 mL syringe (after removing the plunger).
        • Use Lure-lock on syringe to connect to catheter
      • Will need to disengage the bag’s pop-off valve.
  • Oxygenate!
    • Occluding the flow regulator will lead to airflow into the trachea (inspiration).
    • Uncovering the flow regulator will allow air flow from oxygen source and patient to escape (expiration).
    • Inspiration : Expiration = 1 second :  4 seconds
    • Use longer expiration phases for completely occluded upper airway (ex, 1:9)
      • Patient will tolerate hypercapnia better than barotrauma/pneumothorax.


Moral of the Morsel

  • Do not let the first time you think about transtracheal ventilation be when you realize you need to do it.
  • Know what equipment you have available.
    • If you have a commercial product, know how to use it and where it is.
    • If you don’t have a commercial product, make your MacGyver survival bag and keep it handy with the tools you need, so you don’t need to recall how to do it in the time of need.



Boccio E1, Gujral R2, Cassara M3, Amato T4, Wie B5, Ward MF6, D’Amore J7. Combining transtracheal catheter oxygenation and needle-based Seldinger cricothyrotomy into a single, sequential procedure. Am J Emerg Med. 2015 May;33(5):708-12. PMID: 25791154. [PubMed] [Read by QxMD]

Frerk C1, Mitchell VS2, McNarry AF3, Mendonca C4, Bhagrath R5, Patel A6, O’Sullivan EP7, Woodall NM8, Ahmad I9; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48. PMID: 26556848. [PubMed] [Read by QxMD]

Sasano N1, Tanaka A, Muramatsu A, Fujita Y, Ito S, Sasano H, Sobue K. Tidal volume and airway pressure under percutaneous transtracheal ventilation without a jet ventilator: comparison of high-flow oxygen ventilation and manual ventilation in complete and incomplete upper airway obstruction models. J Anesth. 2014 Jun;28(3):341-6. PMID: 24212332. [PubMed] [Read by QxMD]

Coté CJ1, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatr Anaesth. 2009 Jul;19 Suppl 1:66-76. PMID: 19572846. [PubMed] [Read by QxMD]

Bould MD1, Bearfield P. Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia. 2008 May;63(5):535-9. PMID: 18412654. [PubMed] [Read by QxMD]

Navsa N1, Tossel G, Boon JM. Dimensions of the neonatal cricothyroid membrane – how feasible is a surgical cricothyroidotomy? Paediatr Anaesth. 2005 May;15(5):402-6. PMID: 15828992. [PubMed] [Read by QxMD]

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Little League Shoulder

Shoulder InjurySummertime is rapidly approaching (at least for us in the Northern Hemisphere).  While this is often met with great excitement as we ponder vacations, it also means that we need to prepare for the consequences of all of that leisure time.  We have previously discussed the importance of injury prevention, particularly with respect to submersion injuries and lawn mower injuries, but not all of the leisure activities will lead to such significant risk of mortality.  The majority of the injuries that we will manage are the more common orthopedic varieties (ex, Patellar Dislocation, Shoulder Dislocation, Supracondylar Fracture). Unfortunately, while we all want/need our children to be active, this activity may lead to some injuries, even some from the repetitive nature of an activity like Osgood Schlatter Disease or Little League Shoulder.


The Child Athlete is at Risk

  • Over the past decades there has been greater participation in youth sports.
    • 60 million children (6-18 yrs) participate in athletics. (National Council of Youths Sports)
    • ~37 pediatric sport/recreational injuries are treated HOURLY in the US. [Schwebel, 2014]
  • Level of competitiveness has increased as well.
    • Leads to more training, practicing, and competition
    • Leads to more physical stressors
  • Immature skeletal structures are at distinct risk for injury. [Lomasney, 2013]
    • Growth plates are weaker than surrounding tendons and ligaments
    • Particularly vulnerable to fracture during growth spurts
  • At risk for high velocity injuries.
  • Also at risk for overuse injuries:
    • Both Females and Males are at risk, although with different patterns of injuries. [Stracciolini, 2015]
    • All sports can lead to overuse injuries, but greatest percentages are seen with: [Stracciolini, 2015]
      • Tennis
      • Swimming
      • Track/Field
      • Dance
      • Running
      • Gymnastics
      • Cheerleading


“Little League Shoulder”


  • “Little League Shoulder” = Proximal humeral epiphysiolysis
  • Overuse condition that affects the proximal humeral physis
    • Distinctly different that adult shoulder injury from same mechanism.
      • Once growth plates are closed, more commonly injure rotator cuff or shoulder joint itself.
    • Proximal humeral physis is weakest point in shoulder girdle of younger patients.
    • Exact pathophysiology is not completely understood. [Heyworth, 2016]
    • Thought to result from repetitive microtrauma from the rotational torques involved during throwing.
  • Often described in children who play baseball, but has also been seen in other sports.
    • Diagnosis of has increased annually over past decade. [Heyworth, 2016]
    • Any sport involving forceful overhand throwing motion. [Lomasney, 2013]
      • Softball
      • Tennis
      • Cricket [Drescher, 2004]
      • Football


  • Diffuse pain in shoulder or upper arm [Heyworth, 2016]
    • Initially, occurs only during throwing activity.
    • With more severe injury, pain can occur with all activities or even at rest.
  • Elbow pain (13%) [Heyworth, 2016]
  • Shoulder fatigue / weakness (10%) [Heyworth, 2016]
  • May have history of accelerated intensity of activity recently. [Lomasney, 2013]


  • Examination
    • 30 % have glenohumeral internal rotation deficit – decreased rotational ROM of the shoulder [Heyworth, 2016]
    • Tenderness over the region of the proximal humeral physis. [May, 2013]
  • Radiographs
    • Physeal widening can be seen
      • Represents a Salter-Harris I fracture of the proximal humeral physis
      • May be better seen with external rotation view
      • Compare to contralateral
    • Increased sclerosis
    • Lucency
    • Metaphysical calcification
    • Fragmentation adjacent to physis


  • Most often resolves with rest
    • Convincing the patient to avoid the sport that lead to this injury is the hardest part!
    • May still be able to play sport, but change positions (ex, moving from pitcher to 1st base).
    • Continued activity can lead to acute fracture completion. [Lomasney, 2013]
  • Physical therapy
  • Particular training to improve throwing mechanics


Moral of the Morsel

  • Think twice before labeling a child’s joint pain as a “sprain or strain.” (See Ankle Injury)
  • Consider obtaining comparative films if thinking of overuse injuries.
  • While the therapy for Little League Shoulder is primarily rest, it does require good education to help the family understand why that rest is important!




Heyworth BE1, Kramer DE2, Martin DJ2, Micheli LJ2, Kocher MS2, Bae DS2. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med. 2016 Mar 16. PMID: 26983458. [PubMed] [Read by QxMD]

Stracciolini A1, Casciano R, Friedman HL, Meehan WP 3rd, Micheli LJ. A closer look at overuse injuries in the pediatric athlete. Clin J Sport Med. 2015 Jan;25(1):30-5. PMID: 24926911. [PubMed] [Read by QxMD]

Schwebel DC1, Brezausek CM. Child development and pediatric sport and recreational injuries by age. J Athl Train. 2014 Nov-Dec;49(6):780-5. PMID: 25162780. [PubMed] [Read by QxMD]

Pengel KB. Common overuse injuries in the young athlete. Pediatr Ann. 2014 Dec;43(12):e297-308. PMID: 25486038. [PubMed] [Read by QxMD]

Lomasney LM1, Lim-Dunham JE, Cappello T, Annes J. Imaging of the pediatric athlete: use and overuse. Radiol Clin North Am. 2013 Mar;51(2):215-26. PMID: 23472587. [PubMed] [Read by QxMD]

May MM1, Bishop JY. Shoulder injuries in young athletes. Pediatr Radiol. 2013 Mar;43 Suppl 1:S135-40. PMID: 23478929. [PubMed] [Read by QxMD]

Osbahr DC1, Kim HJ, Dugas JR. Little league shoulder. Curr Opin Pediatr. 2010 Feb;22(1):35-40. PMID: 19926993. [PubMed] [Read by QxMD]

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Legg Calve Perthes Disease

Avascular NecrosisThe limping child often grabs our attention and makes us ponder many conditions, like Toddler’s Fracture, Septic Arthritis, SCFE, Osteomyelitis, and Growing Pains. One additional condition that shouldn’t be overlooked is one with an interesting name: Legg Calve Perthes Disease.


Legg Calve Perthes Disease: Basics

  • Legg Calve Perthes Disease is a Juvenile form of Idiopathic Osteonecrosis of the Femoral Head. [Kim, 2012]
  • Incidence = 0.4 – 29 per 100,000 children (<15 years of age) [Loder, 2011]
    • Large range due to discrepancy in definitions and variability between populations.
    • Male:Female = 4:1
  • Described in 1909-1910 by Legg (in US), Calve (in France), and Perthes (in Germany).
    • Each postulated a different etiology, but described the same findings. [Wenger, 2011]
    • Today ideas continue to range from traumatic to abnormal osteogenesis to inflammatory to hypercoagulable states to genetic.
    • Some have found associations with high impact sports also. [Georgiadis, 2015]
    • The exact etiology, pathogenesis, and epidemiology is still debated. [Cook, 2014; Kim, 2012]
  • While the exact cause is debated, studies do show that the immature femoral head is mechanically weakened following ischemic necrosis. [Kim, 2012]
    • There is an imbalance of bone resorption and new bone formation.
    • The relationship between the femoral head and acetabulum becomes distorted leading to the acetabular rim impinging on the femoral head. [Wenger, 2011]
    • Mechanical weight bearing on the hip leads to further:
      • Deformity
      • Hinge abduction
      • Incongruent joint
      • Premature arthritis
  • There are several classification systems – which also points toward persistent controversies. [Kim, 2012; Kuo, 2011; Wenger, 2011]


Legg Calve Perthes Disease: Presentation

  • Age at presentation: [Cook, 2015; Loder, 2011]
    • Ranges from 3 – 10 years.
    • Average age = 6.5 years.
    • Children from Indian subcontinent present at average age of 9.5 years.
  • Unlike septic arthritis, it is more common in older children.
  • Presentation can be similar to other hip pathology and is often on a spectrum of disease.
    • Hip pain
      • Don’t forget about “Knee” or “Thigh” pain as being referred pain from the hip!
    • Limp and antalgic gait
    • Limited range of motion of hip
  • Findings that favor Legg Calve Perthes over others (i.e., septic arthritis or synovitis): [Cook, 2015]
    • Onset: weeks – months and may have intermittent episodes reported
      • “Recurrent transient synovitis” should raise your concern.
    • Lack of fever
    • Able to bear weight and may even have normal gait
      • May have a “lurch” or “stiff hip gait”
      • Helps patient avoid using hip flexors while walking.
    • Mild to moderate pain
      • May not even have pain during your exam.
      • NSAIDs often help with pain.
      • “Hip strain” in child? Keep high index of suspicion for other pathology!
    • Pain on flexion and internal rotation.
      • Transient synovitis often has pain at end of range of motion arc.
      • Septic arthritis has severe pain throughout the range of motion arc.


Legg Calve Perthes Disease: Evaluation

  • Generally, the best initial testing is with plain radiographs.
  • Obtain:
    • AP Pelvis
      • Better than isolated hip film
      • Provides information about sacroiliac joints and pelvis
      • Allows comparison to other hip as well
    • Bilateral frog-leg laterals (AP pelvis with the hips flexed and abducted)
  • May have normal film on initial presentation.
  • Look for subtle findings:
    • Mild flattening of femoral head compared to other side
    • Loss of epiphyseal height
    • Sclerosis
    • Crescent sign – lucency just under the joint line of the femoral head


Legg Calve Perthes Disease: Management

  • Objectives are to: [Kim, 2012]
    • Maintain containment of the femoral head in the acetabulum
    • Maintain good hip range of motion
  • Current treatment strategies yield only modest results.
    • Non-operative strategies (ex, bracing, casting) – challenging for patients to use
    • Operative strategies is generally successful, but do have cases of failure. [Nguyen, 2012; Wenger, 2011]
  • Not clear that the objectives actually yield improvement in outcomes.


Moral of the Morsel

  • There are a number of conditions on the Differential of Limp or Hip/Knee pain.
  • Don’t overlook Legg Calve Perthes Disease just because the patient is able to walk.
  • Think twice before diagnosing “Recurrent Transient Synovitis” or “Hip Strain.”
  • Consider it highly if there is prolonged history of pain or episodic history of pain.
  • Most will be managed as outpatient, but early diagnosis and consultation may help maintain hip functionality.



Divi SN, Bielski RJ. Legg-Calvé-Perthes Disease. Pediatr Ann. 2016 Apr 1;45(4):e144-9. PMID: 27064472. [PubMed] [Read by QxMD]

Georgiadis AG1, Seeley MA, Yellin JL, Sankar WN. The presentation of Legg-Calvé-Perthes disease in females. J Child Orthop. 2015 Aug;9(4):243-7. PMID: 26210773. [PubMed] [Read by QxMD]

Hyman JE1, Trupia EP1, Wright ML1, Matsumoto H1, Jo CH2, Mulpuri K3, Joseph B4, Kim HK2; International Perthes Study Group Members. Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2015 Apr 15;97(8):643-50. PMID: 25878308. [PubMed] [Read by QxMD]

Hailer YD1, Haag AC, Nilsson O. Legg-Calvé-perthes disease: quality of life, physical activity, and behavior pattern. J Pediatr Orthop. 2014 Jul-Aug;34(5):514-21. PMID: 24787306. [PubMed] [Read by QxMD]

Larson AN1, Sucato DJ, Herring JA, Adolfsen SE, Kelly DM, Martus JE, Lovejoy JF, Browne R, Delarocha A. A prospective multicenter study of Legg-Calvé-Perthes disease: functional and radiographic outcomes of nonoperative treatment at a mean follow-up of twenty years. J Bone Joint Surg Am. 2012 Apr 4;94(7):584-92. PMID: 22488614. [PubMed] [Read by QxMD]

Nguyen NA1, Klein G, Dogbey G, McCourt JB, Mehlman CT. Operative versus nonoperative treatments for Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop. 2012 Oct-Nov;32(7):697-705. PMID: 22955534. [PubMed] [Read by QxMD]

Kim HK1. Pathophysiology and new strategies for the treatment of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2012 Apr 4;94(7):659-69. PMID: 22488623. [PubMed] [Read by QxMD]

Loder RT1, Skopelja EN2. The epidemiology and demographics of legg-calvé-perthes’ disease. ISRN Orthop. 2011 Sep 5;2011:504393. PMID: 24977062. [PubMed] [Read by QxMD]

Wenger DR1, Pandya NK. A brief history of Legg-Calvé-Perthes disease. J Pediatr Orthop. 2011 Sep;31(2 Suppl):S130-6. PMID: 21857426. [PubMed] [Read by QxMD]

Kuo KN1, Wu KW, Smith PA, Shih SF, Altiok H. Classification of Legg-Calvé-Perthes disease. J Pediatr Orthop. 2011 Sep;31(2 Suppl):S168-73. PMID: 21857433. [PubMed] [Read by QxMD]

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Thyroid Storm

Thyroid StormThyroid disease is a common consideration for the ill adult patient, but not as commonly considered in children.  That being stated, we have mentioned several conditions which may be related to thyroid disease in children (ex, Bulging Fontanelle, Fever of Unknown Origin, Bradycardia, Down’s Syndrome, Hypothermia in Neonate, and Hypertensive Crisis).  So, it obviously can be a significant issue, but rather challenging to diagnosis if we don’t consider it.  This is particularly true when managing the critically ill child.  Let us now consider Thyroid Storm.


Thyroid Storm: Basics

  • Thyroid hormone influences almost every tissue. [Bahn, 2011]
  • Cellular actions of thyroid hormone are mediated by T3, the active form of the hormone.
  • Thyrotoxicosis / Hyperthyroidism 
    • Thyrotoxicosis – clinical state resulting from high thyroid hormone action due to inappropriately high tissue hormone level. [Bahn, 2011]
    • Hyperthyroidism – a form of thyrotoxicosis due to high synthesis and secretion of thyroid hormone(s) by the thyroid gland. [Bahn, 2011]
    • Hyperthyroidism prevalence in USA – ~1% [Bahn, 2011]
    • Median age of onset of hyperthyroidism = ~11 years
    • CNS symptoms often prevalent in children with hyperthyroidism (adults often with more Cardiac symptoms).
      • Tremor, hyperreflexia
      • Anxiety and fragile emotional states
      • Frequent bowel movements
  • Thyroid Storm is a severe form of thyrotoxicosis.
    • Life-threatening crisis that requires rapid assessment and management.
    • Can lead to overt hemodynamic instability.
    • Since it’s symptoms can be similar to other critical illnesses (ex, sepsis, toxic ingestion), it take vigilance and active consideration to diagnosis it promptly.
    • ~1-2% of patients with hyperthyroidism will experience a thyroid storm event.


Thyroid Storm: Presentation

  • Individual symptoms are not often specific.
    • Fever, diaphoresis, weakness
    • Nausea, vomiting, abdominal pain
    • Tachycardia, hypertension
    • Extreme anxiety, confusion, altered mental status, seizures, coma
    • High-out congestive heart failurearrhythmias 
    • Hypotension may develop late
  • Characterized by MULTIsystem involvement! (remember the thyroid hormone influences nearly every organ system)
  • High index of suspicion is needed – keep it high on Ddx of patient with thyrotoxicosis and decompensation. [Bahn, 2011, Ureta-Raroque, 1997]
  • There is a Point Scale for the Diagnosis – see [Bahn, 2011]


Thyroid Storm: Precipitants

  • Often the precipitating cause of the Thyroid Storm can, itself, produce symptoms similar to the Thyroid Storm, making it challenging to consider.
  • Infection, Trauma and Surgery are commonly associated with Thyroid Storm.
  • Other physical or emotional stressors can lead to Thyroid Storm.
    • Anesthesia
    • Uncontrolled diabetes
    • Pre-eclampsia/eclampsia 
    • Medical reaction / side-effect (ex, taking over the counter cold-preparation medications) [Ureta-Raroque, 1997]
    • Abrupt cessation of antithyroid Rxs
    • Exogenous thyroid hormone ingestion [Majlesi, 2010]
    • Rarely following radioactive iodine therapy [Rohrs, 2014; Bahn, 2011]
    • Exposure to iodine-containing contrast (decompensation after CT??)


Thyroid Storm: Therapy

  • Multimodality approach is recommended. [Bahn, 2011]
  • Beta-Adrenergic Blockade
    • Propanolol – thought to also block peripheral conversion of T4 to T3.
    • Esmolol is an alternative
  • Antithyroid Drug Therapy
    • Proplthiouracil (PTU)
      • Blocks new hormone synthesis AND peripheral conversion of T4 to T3
      • In patients with Graves Disease, use has been associated with Hepatotoxicity and, therefore, not recommended. [Glinoer, 2012]
    • Methimazole – Blocks new hormone synthesis. Do NOT use in pregnancy.
  • Inorganic Iodine
    • Potassium iodine (ex, SSKI) – Blocks synthesis and release of hormone.
    • May use Lithium if patient has allergy to iodine.
    • Start 1 hour AFTER giving Antithyroid Rx [Bahn, 2011]
  • Corticosteroids
    • Stress dose Hydrocortisone or Dexamethasone.
    • May block peripheral conversion of T4 to T3
    • Used to empirically treat possible adrenal suppression.
  • Supportive Measures
    • Aggressive Cooling Measures
      • Acetaminophen
      • Cooling blankets and ice packs!
    • Volume Resuscitation
    • Respiratory Support
    • Treat heart failure and/or arrhythmia
  • Treat Precipitating Events
    • Don’t overlook the issue that caused the decompensation.
    • Consider empiric antibiotics if unclear inciting event.


Moral of the Morsel

  • While the critically ill child will appropriately generate concern for the usual suspects (ex, Sepsis, Hypovolemia, Mechanical Obstruction, Cardiogenic, Adrenal Crisis, Intussusception/Bowel injury), don’t overlook the potential for other offenders!
  • History of conditions related to thyrotoxicosis should raise your concern!
  • Feel the anterior neck too… maybe you’ll just find the answer when you palpate an enlarge thyroid gland. (see case described by Ureta-Raroque, 1997)
  • As always… be Vigilant!



Rohrs HJ 3rd1, Silverstein JH1, Weinstein DA1, Amdur RJ2, Haller MJ1. Thyroid storm following radioactive iodine (RAI) therapy for pediatric graves disease. Am J Case Rep. 2014 May 14;15:212-5. PMID: 24847412. [PubMed] [Read by QxMD]

Glinoer D1, Cooper DS. The propylthiouracil dilemma. Curr Opin Endocrinol Diabetes Obes. 2012 Oct;19(5):402-7. PMID: 22820213. [PubMed] [Read by QxMD]

Bahn Chair RS1, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011 Jun;21(6):593-646. PMID: 21510801. [PubMed] [Read by QxMD]

Majlesi N1, Greller HA, McGuigan MA, Caraccio T, Su MK, Chan GM. Thyroid storm after pediatric levothyroxine ingestion. Pediatrics. 2010 Aug;126(2):e470-3. PMID: 20643722. [PubMed] [Read by QxMD]

Ureta-Raroque SS1, Abramo TJ. Adolescent female patient with shock unresponsive to usual resuscitative therapy. Pediatr Emerg Care. 1997 Aug;13(4):274-6. PMID: 9291518. [PubMed] [Read by QxMD]

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