We have discussed several entities that may lead to a child limping. We have covered osteomyelitis, plantar punctures, and toddler’s fractures. We have also touched upon Osgood Schlatter’s Disease, SCFE, osteosarcoma and even Growing Pains. Now let us review a topic that always crosses our minds when considering the painful extremity: Septic Arthritis.
Septic Arthritis: Basics
- Septic arthritis is an infection in the joint space and synovial fluid.
- Can occur by hematogenous spread of bacteria or direct inoculation.
- High Risk populations = children less than 2 years of age, immunocompromised, and patients without functional spleens
- Capsule damage
- Chronic arthritis
- Growth Arrest
Septic Arthritis: Presentation
- Although no/low fever noted in up to 20% of cases!
- Joint pain, swelling, and erythema
- Pain with passive range of motion!
- Limps or refuses to bear weight on limb.
- 80% of cases in children involve the lower limbs
- Knee involved in 40% of cases
- Hip involved in 20% of cases
Septic Arthritis: The Bugs
- Staph aureus = most common organism across all ages
- MRSA has become more prevalent [Young, 2011]
- Group B Strep is 2nd most common
- Special Population considerations:
- Young Children (<4 years)
- Klingella kingae (notoriously difficult to culture)
- Hemophilus influenza B has become less prevalent since HiB vaccination.
- Klingella kingae
- Streptococcus pneumoniae (especially with HIV infection)
- Sickle Cell Disease:
- Salmonella (although, S. Aureus is still most common)
- Sexually Active:
- N. Gonorrhea – most common cause of polyarticular infections in sexually active patients
Septic Arthritis vs. Toxic Synovitis
- Despite the name, toxic synovitis is the self-limited, benign inflammation of the joint that gets treated symptomatically.
- Unfortunately, the presentation of toxic synovitis can be difficult to differentiate from septic arthritis, particularly when involving the hip joint.
- Acute pain
- Limp / refuses to bear weight
- The treatment strategies and potential outcomes are quite different for the two conditions, so differentiating between them is critical… although challenging. (again, your job isn’t easy)
Septic Arthritis: Kocher’s Criteria
- In 1999, Kocher et al published retrospective data from cases that presented to their facility from 1979-1996 due to “acutely irritable hip.”
- Through a logistic regression analysis of 168 patients, they devised a probability algorithm to help differentiate between septic arthritis and toxic synovitis.
- There was no single lab test that was able to differentiate between the two entities. [Kocher, 1999]
Kocher’s Criteria: [Kocher, 1999]
- Predictors associated with risk of Septic Arthritis
- ESR = 40 or more
- Serum WBC = 12,000 or more
- Probability of Septic Arthritis based on number of Predictors
- 0 Predictors – <0.2 %
- 1 Predictor – 3.0%
- 2 Predictors – 40.0%
- 3 Predictors – 93.1%
- 4 Predictors – 99.6%
- Use this information wisely… not blindly.
- May not apply to your patient.
- Not hip pain?
- Any underlying high-risk factors?
- Clinical Decision Rules typically have diminished performance in different populations other than the derivation group. [Kocher, 2004]
- Must balance the risk of false-positives vs false-negatives.
- At what point does risk of missing septic arthritis outweigh the morbidity of joint aspiration? [Kocher, 1999].
- 0 or 1 Predictors – close follow-up / observation
- 2 Predictors – Aspiration via fluoroscopy/ultrasound
- 3 or 4 Predictors – Aspiration in OR with likely arthrotomy and drainage.
Morals of the Morsel
- Septic Arthritis needs to be higher on your differential than Toxic Synovitis.
- Appreciate the diagnostic challenge inherent in the evaluation.
- NO SINGLE TEST WILL DIAGNOSE OR RULE-OUT SEPTIC ARTHRITIS. [Dodwell, 2013]
- Anticipate what tool (ex, Kocher Criteria) your consultants will likely use, but know their limitations.
- 2 Predictors is more reassuring than 3, but still comes with increased risk.
- Having Fever and being Non-Weight Bearing with normal labs can still be associated with Septic Arthritis!
- Your pretest probability has to be taken into account, like always.
- Don’t forget to give some analgesics!
- The child who is now weight-bearing after NSAIDs just became less concerning and it may be better to arrange close followed-up rather than ordering a bunch of non-specific lab tests.
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Kids love to explore their environment, but sometimes that environment (and their lack of agility and sluggish reflexes) leads to injuries. Fortunately, often these injuries are minor. Unfortunately, those minor injuries can lead to major headaches for you in your ED. One great example of that is the possible nail bed injury. Is that simple subungal hematoma really simple, or does it warrant a big procedures?
Some Number’s to Ponder
- Hand injuries are commonly seen in children. [Shah, 2012]
- In the US, from 1990-2009, ~16.4 MILLION kids were treated in EDs for hand injuries!
- That is equivalent to 2,243 children per day!
- Fingertip and nail bed injuries are some of the more common hand injuries in kids. [Gellman, 2009; Doraiswamy, 1999]
- The middle finger is most commonly injured finger (sometimes it isn’t beneficial to be longer).
The Nail Bed
- Fingertip injuries can be associated with nail bed injuries (in 15-24% of cases).
- A nail bed injury that is not managed correctly can lead to chronic deformity of the nail bed, nail plate, and finger tip. [Patel, 2014; Fairborn, 2012].
- This can also affect the finger’s function.
- Significant nail bed injuries can present in subtle ways initially (i.e., subungal hematoma).
- It is important to evaluate the nail bed for possible injury and repair them as needed.
- Obviously, if there is a laceration through the nail plate involving the nail bed, the nail plate needs to be removed and necessary repairs made, but…
- A “significant” subungal hematoma may indicate nail bed injury also.
- >50% of the nail surface
- >25% with an associated fracture.
- This would equate to needing to remove the nail plate in the setting of significant subungal hematoma.
- Certainly, EM physicians can manage these potential issues and have similar outcomes to other specialists, so there is no need to delay treatment by making consultant phone calls. [Al-Qadhu, 2011]
The Problem with Tradition
- Removing the nail plate is not easy in adults, and can be very challenging in children.
- Tiny digits with delicate structures are more challenging to manipulate.
- The procedure may also require sedation.
- Removing the nail plate may harm the nail bed even more.
- Again, dedicated structures don’t react well to giant instruments.
- Removing the nail plate leads to greater monetary expenses! [Roser, 1999]
Another Approach to Subungal Hematomas
- Based on current literature (as noted by Patel, 2014), in the setting of a Subungal Hematoma, the nail plate DOES NOT need to be removed if:
- If the nail plate is intact and at least partially adherent to the nail bed,
- If there is a fracture, it is not significantly displaced.
- Nail trephination has been shown to produce similar cosmetic and functional outcomes with no increased complications regardless of size of the subungal hematoma. [Roser, 1999; Meek, 1998; Seaberg, 1991]
- Stated another way, an uncomplicated subungal hematoma can be treated with simple trephination.
- Electrocautery device or red-hot paperclip can be used to create hole(s) in the nail plate to decompress the subungal hematoma.
- The procedure is rapid and the heat of the electrocautery/paperclip is dissipated by the hematoma so it does not damage the underlying nail bed. [Patel, 2014]
- A sterile needle can also “drill” through the nail plate, but care needs to be taken to not damage the underlying nail bed.
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We have covered numerous critical topics in the Ped EM Morsels over the past numerous years. Many are quite attention grabbing (ex, Tonsillectomy Hemorrhage, Delayed Sequence Intubation, and Submersion Injuries, and Lawn Mower Injuries), but that does not diminish the importance of other less flashy topics. In fact, the vast majority of what we do in the Emergency Department is not heroic or flashy. We also need to appreciate the opportunity that we have to help prevent injuries by remaining perceptive, receptive and vigilant. One area that deserves special attention is Suicide Risk.
Suicide Risk Deserves Our Attention
- Suicide is the 3rd leading cause of death in the USA for people 10-24 years. [Heron, 2013]
- Suicide is the leading cause of death from intentional injury. [Heron, 2013]
- Suicide affects young people from ALL races and socioeconomic groups. [Shain, 2007]
Suicide Risk Factors
- Fixed Risk Factors
- Family history of suicide or suicide attempts
- Male gender
- Parental mental health problems
- History of physical or sexual abuse
- Previous suicide attempt
- Environmental/Social Risk Factors
- Presence of firearms in the home
- Poor child-parent relationship
- Neither working nor attending school
- Social isolation
- Presence of stressful life event
- Predisposing Mental Health Issues
- Depression, Bipolar, Panic attacks
- Posttraumatic Stress Disorder
- Aggression, Impulsivity, Severe Anger
Suicidal Thoughts Don’t Have to Look Sad
- We are all aware of the need to be concerned about suicidal ideation in those who present with complaints consistent with depression…
- But, patients may also present with somatic complaints: [Shain, 2007]
- One study found ~5% of patients presenting with non-psychiatric complaints had significant suicidal ideation. [Horowitz, 2010]
- So, this requires that we are actively considering the possibility of important non-organic causes… and not just happy to say that “it isn’t appendicitis.”
Suicidal Risk Screening
- Screening patients without psychiatric complaints has been shown to be feasible in the ED. [Horowitz, 2010]
- There are several tools available:
- HEADS-ED [Cappelli, 2012]
- Home, Education, Activities, Drugs, Emotions, Discharge resources
- Risk of Suicide Questionnaire (RSQ) [Horowitz, 2001, Ballard, 2013]
- 4 questions:
- Are you here today because you tried to hurt yourself?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to hurt yourself in the past (other than this time)?
- Has something very stressful happened to you in the past few weeks (a situation very hard to handle?
- Has been validated. [Ballard, 2013]
- A positive response to one or more of the questions constitutes a positive screen and warrants further exploration.
- Remember that while confidentiality is important, safety takes precedence over confidentiality. Be clear about this with the patient. [Shain, 2007]
Moral of the Morsel
- Suicide is a public health problem for which we must remain vigilant.
- Not ever patient who needs your help will present with obvious depressive symptoms – consider somatic complaints also.
- Routinely ask parents/guardians to leave the room while you finish your sensitive questions with your adolescent patients.
- Utilize a screening tool (ex, RSQ).
Horowitz LM1, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, Wharff EA, Ginnis K, Cannon E, Joshi P, Pao M. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department.
Arch Pediatr Adolesc Med. 2012 Dec;166(12):1170-6. PMID: 23027429
. [PubMed] [Read by QxMD]
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Yes, as we’ve mentioned before, kids are often Gravitationally Challenged. Toddlers, toddle and tumble constantly. Often, this leads to simple bumps and bruises and minor injuries. Occasionally, these injuries appear rather dramatically though. One that will always catch parents’ attention is when the fall leads to a Tongue Laceration.
Tongue Laceration: The Bad
- As always, consider worse first…
- Airway Compromise
- The tongue is highly vascular and can bleed substantially.
- This is good, as it will allow the wound to heal rapidly, but…
- This bleeding can cause significant tongue swelling.
- Naturally, oral bleeding can also endanger the airway.
- Retained Foreign Bodies
- Just like any wound, consider that the object that caused the wound may still be lingering within it!
- Fragments of teeth
- Fragments of other objects that were in the mouth during the trauma (ex, Popsicle stick)
Tongue Laceration: The Common
- The most common location is the anterior, dorsal portion of the tongue.
- Next most common is middle of the dorsal portion and the anterior, ventral aspect.
- More posterior locations are less common. [Lamell, 1999]
- When you find one laceration, always look for another… especially on the other side of the tongue.
Tongue Laceration: The Management
- Think worse first…
- Don’t get distracted by the obvious tongue injury.
- It’s a trauma… So assess the Airway.
- Are there other signs of intracranial, facial, or neck trauma?
- Assess other intra-oral structures
- Is there a oral floor hematoma?
- Is there posterior pharyngeal trauma?
- Is the base of the tongue involved (possible hypoglossal nerve injury)? [Mohan Das, 2008]
- Think about possible Foreign Bodies…
- If there is evidence of tooth fracture, worry that that missing piece is in the tongue.
- Ask about other objects that may have been in the mouth.
- Don’t Be Cruel… Treat the pain
- NSAIDs are reasonable.
- Topical Lidocaine applied to the wound (ex, 4% lidocaine soaked gauze for 5 min).
- Regional blocks are possible, but more challenging in toddlers.
- Irrigate the Wound
- Infection is rare… but irrigation will help you evaluate the injury also.
- After care should include continued dental hygiene and oral care with antiseptic mouth wash.
- To Close or Not To Close
- This has not been well researched, but has dogmatic teachings.
- “If a piece of corn fits in it, it needs to be closed.”
- But… what size piece of corn… are we talking about little baby corn, or giant corn kernels?
- “If it crosses the side margin of the tongue, it needs to be closed.”
- But… what about those post-seizure tongue lacs that always seem to involve the margin?… they seem to do well without closure.
- “If it gapes open, it needs to be closed.”
- But… what if it only gapes open when the tongue is protruded?
- There is evidence that even wounds that gape or include tongue margin can be managed without suturing. [Lamell, 1999]
- Some advocate for closing wounds that: [Ud-din, 2007; Mohan Das, 2008]
- Bleed uncontrollably
- Endanger the airway
- Are a “Significant” segment of severed tongue; 2cm or greater
- Wounds that involve the margin or tip still often heal and remodel without closure. [Mohan Das, 2008]
- Patients with Bleeding Disorders?
- Bleeding disorders (ex, Hemophilia) should heighten your concern.
- Have a lower threshold to close these wounds to help control hemorrhage.
- Don’t forget the possibility of intracranial hemorrhage.
- Give Factor replacements!!
Tongue Laceration: Time to Close
- The vast majority do NOT require closure… but some will. When that time comes, be kind.
- Will require some type of sedation.
- Use a bite block to help keep mouth open safely.
- Use towel clamp to grasp tongue and immobilize it.
- Can also use large suture to pull tongue out, but put another hole in the tongue.
- Close with absorbable suture (ex, 5-0 Chromic Gut). [Brown, 2007]
- Or, you may even consider 2-octyl cyanoacrylate (aka, Dermabond) (see case report). [Kazzi, 2013]
The post Tongue Laceration appeared first on Pediatric EM Morsels.
Kids always seem to test gravity… and continually find that it works. While gravity certainly has its advantages, it also tends to lead to a fair amount of injuries for our pediatric patients. We have covered numerous orthopaedic topics previous in the PedEM Morsels (ex, osteomyelitis, patellar dislocation, SCFE, supracondylar fractures, nursemaid’s elbow), but let’s take a moment to look at yet another: Shoulder Dislocation.
Shoulder Dislocations in Kids
- Shoulder dislocations are less common in children than adults.
- ~20% of all glenohumeral dislocations occur in patients <20 years of age.
- <2% occur in kids younger <10 years of age. [Zacchilli, 2010]
- The proximal humerus has 3 primary ossifications centers:
- Humeral Head
- Great Tuberosity
- Lesser Tuberosity
- Ossification centers close between 5-7 years of age.
- The proximal humeral physis then fuses to humeral shaft between 14-17 years.
- Inherently unstable joint:
- The glenoid fossa is shallow.
- Stability of the joint is most dependent upon the ligamentous, muscular, and joint capsule structures.
- The proximal humeral physis is extra-articular in skeletally immature kids.
- Physeal fractures are possible after shoulder dislocation in the skeletally immature. [Xinning, 2013]
- The shoulder capsule, however, is more elastic in the younger children, and may help prevent recurrent dislocations in the future.
Shoulder Dislocation Presentation
- Traumatic shoulder dislocations often have obvious deformity.
- Arm is typically ADDucted and internally rotated (if anteroinferior dislocation).
- Acromion will appear prominent.
- Palpable cavity beneath the acromion, where the humeral once was sitting.
- May also occur without an associated trauma.
- Often due to prior dislocation related joint instability.
- May be more subtle and the patient may describe an apprehension that it will dislocate.
Shoulder Dislocation Evaluation
- Axillary nerve is the most commonly injured nerve during shoulder dislocations.
- As always, assessment of neurologic status is imperative.
- Do you need prereduction films?
- If there is a question as to whether it is dislocated, then yes.
- If there was an associated high-energy mechanism, then yes.
- If clinically apparent and non-concerning mechanism, then no. [Reid, 2013]
- May want a lower threshold for imaging before reduction in the skeletally immature patients (<14 years of age).
Shoulder Dislocation Management
- Don’t be cruel… Manage the pain!
- Consider some intranasal meds to start with.
- Consider an intra-articular injection.
- May use ultrasound guidance to assist with this. [Breslin, 2014]
- May require procedural sedation – especially if it has been out for a prolonged time.
- Be gentle!
- Do not use forceful jerking or attempt to leverage the humeral head over the glenoid.
- Take your time to learn several methods (shoulderdislocation.net).
- Place in sling.
- Conventional therapy is to immobilize for ~3 weeks.
- This will be followed by aggressive physical therapy for most.
- Post-reduction plain films with axillary view.
- Arrange for ortho follow-up as they will need physical therapy to help them recover.
- There is debate about the best management strategy for primary dislocations in children. [Xinning, 2013]
- For active, young, adults, early surgical stabilization may be beneficial.
- Especially true for those with evidence of Bankart lesion on MRI.
- For skeletally immature children (<14 years of age), nonsurgical options are generally favored.
- This age group has a lower rate of recurrent instability of the joint.
- If recurrence occurs, surgical correction will be needed, but often it is delayed until skeletal maturity. [Bishop, 2005]
The post Shoulder Dislocation appeared first on Pediatric EM Morsels.
Obviously diarrheal illness can be quite debilitating and even devastating in children. Often the main concern is Dehydration and that focusing on Oral Rehydration Therapy many of these children will do just fine. While most often the diarrhea is due to a non-specific “virus,” there are a few specific considerations that may cross your mind, like HUS or Salmonella. In addition, one consideration that is often thought of in adults, but perhaps overlooked in children, is C. Diff.
C. Diff Basics
- Clostridium difficile (C. Diff) is a spore-forming, obligate anaerobic, Gram-Positive bacillus.
- It produces toxins (Toxin A and B) that lead to intestinal injury.
- It is the MOST COMMON cause of antibiotic-associated diarrhea.
- C. Diff incidence has been increasing in hospitalized children. [Zilberger, 2010]
- C. Diff infection is associated with longer hospitalizations and increased mortality. [Sammons, 2013]
- Recent evidence also describes the importance of antibiotic stewardship and community-associated cases. [Khanna, 2012; Wendt, 2014]
C. Diff Diagnosis
- The diagnosis of C. Diff disease is based on the presence of diarrhea and C. difficile toxins in a diarrheal stool specimen. [Schutze, 2013]
- Isolation of the organism is not clinically useful.
- Testing for the toxin is preferred.
- Testing by age: [Schutze, 2013]
- < 1 year of age, so avoid routine testing.
- Asymptomatic carriage is common.
- Testing should be limited to those with motility disorders (ex, Hirshsprung’s disease) or during an outbreak.
- 1-3 years of life, search for other alternatives first.
- Interpretation of results is challenging.
- A positive result may indicate C. Diff infection.
- After 3 years of life, a positive result indicates probably infection.
- Still needs to be interpreted within the clinical setting.
- The mere presence of a virulent pathogen does not necessary mean that that pathogen is the cause of the patients current symptoms. [Denno, 2012]
- Pediatric oncology patients can also harbor C. Diff and be asymptomatic. [Dominguez, 2014]
- To recap… C. Diff disease is Difficult to diagnosis accurately.
- Do not “test for cure” as the toxin, the organism, and its genome are present for long periods after resolution of diarrhea. [Schutze, 2013]
C. Diff Therapy
- First stop the offending antimicrobial therapy!
- May be sufficient enough to resolve symptoms.
- Avoid anti-peristaltic medications.
- May worsen condition and lead to toxic megacolon.
- Oral Metronidazole is the drug of choice for initial therapy.
- 30mg/kg/day in 4 divided doses, Max 2 grams/day.
- Metronidazole-resistant C. Diff is rare.
- For severe disease/non-responders to 1st line, oral vancomycin or rectal vancomycin with or without IV metronidazole is used.
- Oral vancomycin 40mg/kg/day in 4 divided doses, Max 2 grams/day.
- Severe disease is more likely in patients with neutropenia, or intestinal stasis (ex, Hirshsprung’s disease).
- Up to 30% will have a recurrence after therapy ends.
Dominguez SR1, Dolan SA2, West K2, Dantes RB3, Epson E4, Friedman D5, Littlehorn CA6, Arms LE6, Walton K5, Servetar E5, Frank DN7, Kotter CV7, Dowell E6, Gould CV8, Hilden JM9, Todd JK1. High colonization rate and prolonged shedding of Clostridium difficile in pediatric oncology patients.
Clin Infect Dis. 2014 Aug;59(3):401-3. PMID: 24785235
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Martinelli M1, Strisciuglio C, Veres G, Paerregaard A, Pavic AM, Aloi M, Martín-de-Carpi J, Levine A, Turner D, Del Pezzo M, Staiano A, Miele E; Porto IBD Working Group of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Clostridium difficile and pediatric inflammatory bowel disease: a prospective, comparative, multicenter, ESPGHAN study.
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Wendt JM1, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Clostridium difficile infection among children across diverse US geographic locations.
Pediatrics. 2014 Apr;133(4):651-8. PMID: 24590748
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Denno DM1, Shaikh N, Stapp JR, Qin X, Hutter CM, Hoffman V, Mooney JC, Wood KM, Stevens HJ, Jones R, Tarr PI, Klein EJ. Diarrhea etiology in a pediatric emergency department: a case control study.
Clin Infect Dis. 2012 Oct;55(7):897-904. PMID: 22700832
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