Osgood Schlatter’s Disease

Osgood Schaltters


Musculoskeletal complaints are common in the pediatric Emergency Department. As I sit here watching March Madness Basketball (for those not in the US, that is our college basketball tournament, during which my wife consistently humiliates me by picking the winner), I was inspired to write this Morsel. We have covered several Orthopaedic topics in the past (ex, Toddler’s Fracture, Plantar Puncture Wounds, Supracondylar Fracture, Clavicular Head Dislocation), but one of the most commonly encountered is Osgood Schlatter’s Disease.


Osgood Schlatter’s Disease: Basics

  • Common cause of knee pain in children
    • 20% of children who participate in sports are affected
  • Believed to be an overuse injury
    • Tension at the insertion site of the patellar tendon on the anterior tibial tubercle
    • Repetitive use before the closure of the epiphysis can lead to traction injury and microavulsion of the tubercle
  • Occurs most often during rapid growth phase
    • Boys: 13-15 years of age
      • Boys more commonly affected (Hanada, 2012)
    • Girls: 11-13 years of age
      • Amongst basketball players, females had more overall knee injuries than males, but had lower rates of Osgood Schlatter’s Disease. (Ito, 2015)
      • Patellofemoral Dysfunction is more common than Osgood Schlatter’s Disease in females. (Foss, 2014)
    • Body Mass found to be associated with severity
      • Lower weight and lower BMI had lower severity on radiographs (Hanada, 2012)
    • Self-limited condition
      • On rare occasions can lead to persistent pain
      • Extremely rare to require surgical intervention
    • Can develop associated bursitis


Osgood Schlatter’s Disease: Presentation

  • Pain at the anterior tibial tubercle
  • Pain worse with running, jumping, climbing stairs
  • Often associated with basketball, soccer, football, ballet, figure skating, gymnastics
  • Pain improves with rest
  • Has normal range of motion and gait
  • Tenderness over tibial tubercle
  • Ocassional warmth and erythema of this area as well (it is an inflammatory process)


Osgood Shlatter’s Disease: Evaluation

  • The diagnosis does not require any specific testing
  • Radiographs are often obtained to rule-out other conditions (ex, malignancy)
  • Lateral x-ray may show:
    • Thickening of the patellar tendon
    • Thin, anterior ossicles / fragment separating from the tibial tubercle


Osgood Schlatter’s Disease: Treatment

  • Basic management is conservative.
    • Conservative management does not mean that you “do nothing.”
  • Decreased Activity
    • Not, NO ACTIVITY!
      • Do not recommend just sitting on couch, watching TV (unless it’s during March Madness and there are multiple games to watch).
    • Recommend that they decrease their activities to the point where pain is improved and then begin adding back in activity as it is tolerated.
    • Cross training may help (ex, swimming)
  • Ice
    • I usually tell them to pretend like they are Michael Jordan and need to ice down their knees.
    • Good trick is to fill small paper cups with water and freeze them. Then they can peel the paper and then use that to apply directly over the tibial tubercle.
  • NSAIDs
  • Physical Therapy



Launay F1. Sports-related overuse injuries in children. Orthop Traumatol Surg Res. 2015 Feb;101(1S):S139-S147. PMID: 25555804. [PubMed] [Read by QxMD]

Ito E1, Iwamoto J1, Azuma K1, Matsumoto H1. Sex-specific differences in injury types among basketball players. Open Access J Sports Med. 2014 Dec 29;6:1-6. PMID: 25565908. [PubMed] [Read by QxMD]

Yen YM1. Assessment and treatment of knee pain in the child and adolescent athlete. Pediatr Clin North Am. 2014 Dec;61(6):1155-73. PMID: 25439017. [PubMed] [Read by QxMD]

Foss KD1, Myer GD2, Magnussen RA3, Hewett TE4. Diagnostic Differences for Anterior Knee Pain between Sexes in Adolescent Basketball Players. J Athl Enhanc. 2014 Jan 10;3(1). PMID: 25362859. [PubMed] [Read by QxMD]

Maher PJ1, Ilgen JS. Osgood-Schlatter disease. BMJ Case Rep. 2013 Feb 27;2013. PMID: 23446046. [PubMed] [Read by QxMD]
Whitmore A1. Osgood-Schlatter disease. JAAPA. 2013 Oct;26(10):51-2. PMID: 24201924. [PubMed] [Read by QxMD]
Hanada M1, Koyama H, Takahashi M, Matsuyama Y. Relationship between the clinical findings and radiographic severity in Osgood-Schlatter disease. Open Access J Sports Med. 2012 Mar 9;3:17-20. PMID: 24198582. [PubMed] [Read by QxMD]

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Hair Tourniquet

Hair Tourniquet


Simple answers are always better than complicated ones. Often we get caught focusing on the complex and can forget that Basics are the Best (ex, Pediatric Shock Index, Optimize Chest Compressions, and Penicillin for Pneumonia)! Often, I have found myself knee deep in complicated decisions only to be recued by a straightforward answer. One such scenario is the “Hair Tourniquet Syndrome” case… is there a simple answer or do I have to perform surgery?


Hair Tourniquet Syndrome

  • Caused by more than just Hair.
    • We have discussed the unique situation of Metal Band Tourniquet.
    • Hair – one study did show that 95% of cases were due to hair. [Claudet, 2010]
    • Fine thread
    • Thin rubber bands
    • Many advocate for this condition to be termed “constricting tourniquet” or “hair-thread tourniquet.” [Plesa, 2015]
  • Circumferential constriction can lead to substantial injury.
    • Lymphatic drainage is initial obstructed, leading to edema.
    • Increasing edema eventually impedes venous flow.
    • Venous obstruction further increases swelling and can eventually obstruct arterial blood flow… that leads to badness.
      • Tissue necrosis
      • Infection
      • Non-healing ulcer
      • Osteomyelitis
      • Amputation
    • Process can take hours, days, weeks, or even months.
      • May go undetected, especially in the very young (who’s discomfort is often difficult to decipher – consider this in the fussy/crying infant).
      • The swollen tissue can obscure the etiology!
        • As the process continues, the hair/thread cuts into the skin.
        • The skin can scar, cover over the thread, and obscure the etiology.
      • Often involves distal appendages in the young. [Barton, 1988]
        • Toes – 43%
        • External Genitalia – 33%
        • Fingers – 24%


Hair Tourniquet Syndrome – Management Options

  • Need to remove the constricting band as soon as possible.
  • Unwind the Thread
    • Certainly, if caught early enough, you may be able to simple unwind the thread.
    • Occasionally, using a curved needle to get under the thread can assist in this.
    • Need to ensure that the entire amount is removed and that no residual constrictive portion remains.
  • Depilatory Cream [O’Gorman, 2011; Plesa, 2015]
    • Cream with thioglycolate and calcium hydroxide or sodium hydroxide (Brand Name = NAIR)
      • The thioglycolate will break down the disulfide bonds of keratin, dissolving the hair.
      • The alkaline component assists with penetration into the hair.
    • Found to dissolve hair within 2.5 minutes and 8 minutes (depending on hair thickness). [Plesa, 2015]
    • The manufacturer does not recommend application on open skin… so a deep laceration may not be the best place to apply it.
    • Can cause skin irritation and even minor burns (it is an alkali).
    • DOES NOT dissolve cotton, polyester, or rayon threads. [Plesa, 2015].
  •  Incise the Thread
    • Toe/Finger
      • A DORSAL incision, along the long axis, down to the bone of the digit is recommended. [Barton, 1988; Serour, 2003]
      • Lateral incisions may injury nerve or blood vessel.
      • Incision along long axis may incise extensor tendon, but should not affect the tendon’s function.
      • Incision down to the bone should ensure transection of the constrictive thread.
    • Penis
      • Low threshold for surgical exploration
      • Incision needs to avoid the urethra in the corpus spongiosum.
      • Incise on one of the lateral, inferior aspects between the corpus cavernosum and the corpus spongiosum. [Barton, 1988]

Hair Tourniquet Syndrome – Management Plan

This is submitted as a reasonable option…

  1. Treat pain! (remember even neonates feel pain!)
    • Topical anesthetic may help initially.
      • This will also help if an incision is needed.
    • Could also consider a digital block.
  2. Can you grasp the thread?
    • If able, carefully remove it and ensure no residual material remains.
    • This can be challenging with small digits and swollen tissues.
  3. Is there a deep laceration?
    • Applying topical depilatory cream may cause more pain, so may want to proceed directly to incision.
  4. Unable to grasp/unwind, but no deep laceration, then apply Depilatory Cream.
    • Since the majority of the threads will be hair, application of depilatory cream is reasonable.
    • The cream should work within 10 minutes.
    • After 10 minutes, rub the area and rinse with water.  If no improvement, proceed to incision.
  5. Incise
    • Consider surrounding structures!
    • Consultation for surgical exploration is required if there is any concern that there is continued constriction.
  6. Topical antibiotic cream if there is evidence of skin breakdown.
  7. Close Follow-up is appropriate.
    • If evidence of vascular compromise, consider emergent Consultation.
    • If good cap refill and improvement after management, close follow-up as outpatient is reasonable.



Plesa JA1, Shoup K2, Manole MD3, Hickey RW3. Effect of a depilatory agent on cotton, polyester, and rayon versus human hair in a laboratory setting. Ann Emerg Med. 2015 Mar;65(3):256-9. PMID: 25240921. [PubMed] [Read by QxMD]

Bannier MA1, Miedema CJ. Hair tourniquet syndrome. Eur J Pediatr. 2013 Feb;172(2):277. PMID: 23117472. [PubMed] [Read by QxMD]

Alvarez-Pérez A1, Mateo S, Fernández-Redondo V, Toribio J. Hair-thread tourniquet syndrome: a hidden hazard. Pediatr Dermatol. 2013 Jul-Aug;30(4):e61-2. PMID: 22938208. [PubMed] [Read by QxMD]

O’Gorman A1, Ratnapalan S. Hair tourniquet management. Pediatr Emerg Care. 2011 Mar;27(3):203-4. PMID: 21378520. [PubMed] [Read by QxMD]

Arch Pediatr. 2010 May;17(5):474-9. PMID: 20338735. [PubMed] [Read by QxMD]

Serour F1, Gorenstein A. Treatment of the toe tourniquet syndrome in infants. Pediatr Surg Int. 2003 Oct;19(8):598-600. PMID: 14551712. [PubMed] [Read by QxMD]

Barton DJ1, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome . Pediatrics. 1988 Dec;82(6):925-8. PMID: 3186385. [PubMed] [Read by QxMD]

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Pediatric SHOCK Index

SHOCK Basics

Fortunately, the critically ill child is not as common in the Emergency Department as the critically ill adult. Unfortunately, when the critically ill child does arrive, it can be challenging to recognize him/her initially. This can lead to delays in resuscitation care. Even at the extreme point of being pulseless, children can be tricky (See Palpation of Pulse). Then there is always the challenge that having to account for the effect that age has on normal vital signs (See Blood Pressures).  Often, though, by focusing on the Basics, we can met the challenge of detecting Pediatric Shock and act aggressively to treat it!


Pediatric Shock

  • Broadly speaking, shock is the state in which there is a failure to meet the metabolic demands of the body leading to anaerobic metabolism. (Mtaweh, 2013)
  • Often categorized as:
    1. Hypovolemic
    2. Cardiogenic
    3. Distributive
      • Toxin mediated – Septic
      • Hypersensitivity reaction – Anaphylaxis
      • Loss of sympathetic tone – Neurogenic


Pediatric Shock: A Challenge

  • The diagnosis is initially suspected based upon clinical exam.
  • There is no lab value or “test” that defines shock. (See Lactate)
  • Clinical Findings:
    • Tachycardia
      • Must account for age-adjusted values!
      • Often children present with elevated heart rates without overt illness.
    • Poor Capillary Refill
      • Normal capillary refill can vary with age and is influenced by the environment. (Schriger, 1988)
      • The initial cap refill in the ED, may artificially affected by the pre-hospital environment.
    • Peripheral Pulse Quality
    • Altered Mental Status
    • Cold/Mottled Extremities
    • Poor Urine Output
      • Not likely useful in the initial assessment in the ED.
      • If the patient is “hanging out” in your ED for some time, monitor this!
  • Of these clinical findings, only Altered Mental Status and Poor Peripheral Pulse Quality was associated with development of Organ Dysfunction. (Scott, 2014)
  • No single finding defines shock, but the absence of all of them is reassuring.


Pediatric Shock: The Shock Index

  • The Shock Index (Heart Rate / Systolic BP) has been shown to be useful in detecting adult patients with shock.
  • There is evidence that the Shock Index can be useful in pediatric patients also. (Yasaka, 2013; Rousseaux, 2013)
  • Since, pediatric vital signs alter with age, it would make sense to have a “adjusted” tool. (Acker, 2015)
    • Using standard heart rate and systolic BP values for age ranges, Maximum Normal Shock Index values were calculated.
    • Shock Index, Pediatric Adjusted (SIPA)
      • 4-6 years = 1.2
      • 6-12 years = 1
      • > 12 years = 0.9
    • Comparing the patient’s actual HR / Systolic BP to the SIPA was shown to perform better and identify those most severely injured following blunt trauma. (Acker, 2015)
  • Obviously, this may not apply to all pediatric patients presenting with shock, but I do like the concept of utilizing Basic information that is age adjusted.
  • Consider utilizing this tool as another method to help find those subtle presentations of shockRemain Vigilant!



Acker SN1, Ross JT2, Partrick DA3, Tong S4, Bensard DD5. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015 Feb;50(2):331-4. PMID: 25638631. [PubMed] [Read by QxMD]

Scott HF1, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. Effectiveness of physical exam signs for early detection of critical illness in pediatric systemic inflammatory response syndrome. BMC Emerg Med. 2014 Nov 19;14:24. PMID: 25407007. [PubMed] [Read by QxMD]

Dellinger RP1, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013 Feb;39(2):165-228. PMID: 23361625. [PubMed] [Read by QxMD]

Mtaweh H1, Trakas EV, Su E, Carcillo JA, Aneja RK. Advances in monitoring and management of shock. Pediatr Clin North Am. 2013 Jun;60(3):641-54. PMID: 23639660. [PubMed] [Read by QxMD]

Yasaka Y1, Khemani RG, Markovitz BP. Is shock index associated with outcome in children with sepsis/septic shock?*. Pediatr Crit Care Med. 2013 Oct;14(8):e372-9. PMID: 23962830. [PubMed] [Read by QxMD]

Rousseaux J1, Grandbastien B, Dorkenoo A, Lampin ME, Leteurtre S, Leclerc F. Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013 Oct;29(10):1055-9. PMID: 24076606. [PubMed] [Read by QxMD]

Schriger DL1, Baraff L. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med. 1988 Sep;17(9):932-5. PMID: 3415066. [PubMed] [Read by QxMD]

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Laundry Detergent Pod Toxicity

Detergent Pods


We have discussed previously how poisonings (Childhood Injury) is one of the top leading causes of death in children.  Obviously, knowing your friendly, neighborhood toxicologist or the number to the local Poison Control Center is very helpful when working in the Pediatric ED, but it is also helpful to know some of the basics and what items should raise your concern level.  Some of the most colorful and fun-looking household items can induce substantial injury and illness in children.  Let us look at an interesting one: Laundry Detergent Pod Toxicity.


Childhood Poisonings

  • In the US, > 300 children / DAY require treatment for poisonings. (CDC)
  • Over 50% of all ED visits for poisoning were for children <4 years of age. (Nalliah, 2014)
  • The majority of poisonings are unintentional in young children.
  • Over 90% of exposures occur in homes.
    • Bleach is the most common exposure.
    • Primary mechanism of exposure is ingestion.


Laundry Detergent Pod

  • Single load capsules that contain concentrated liquid detergent within a water-soluble membrane. (MMWR, 2012)
  • The water-soluble membrane dissolves once contacted by moisture (like a toddler’s mouth).
  • In 2012, 48% of the detergent exposures involved the pod variety.
  • 22% of pod exposures were associated with inappropriate storage! (Valdez, 2014)
  • The laundry detergent pod causes slightly different presentations than non-pod exposures.
    • Pod exposure occurs in younger children (5 years of age and younger).
    • Pod exposure has a higher likelihood of leading to symptoms.


Laundry Detergent Pod Toxicity: Route

  • Ingestion – most common
    • Laundry detergent pods are more likely to be ingested than other non-pod varieties. (MMWR, 2012)
    • Accounted for at least one of the exposure routes in 90% of the laundry detergent pod toxicity cases.
  • Eye exposure – 17%
    • Causes an alkaline injury! (Whitney, 2015)
    • Irrigate with copious isotonic saline until pH has become neutral.
  • Skin exposure – 11%
    • ~2% has noted 2nd and 3rd degree dermal burns (Russell, 2014)
    • Remember to expose children and remove contaminated clothing.
    • Rinse thoroughly!
  • Inhalation – 1%


Laundry Detergent Pod Toxicity: Symptoms

  • Pod exposure and non-pod exposure lead to many of the same symptoms: (MMWR, 2012)
    • Eye irritation and pain
    • Nausea
  • Pod exposure does lead to some symptoms more commonly than non-pod exposure: (MMWR, 2012)
    • Vomiting
    • Coughing/Choking
    • Drowsiness/CNS Depression
      • Unclear what the cause of the CNS depression is due to from the pods.
      • Seen in ~1 – ~8% of cases. (Stromberg, 2014)
      • Combination of altered mental status and possible pulmonary injury has lead intubation, although infrequently.


Moral of the Morsel

  • Laundry Detergent Pod Toxicity can cause CNS depression!
  • It is important to ask specifically if the exposure was to one of these pods.
  • It is important to do some injury prevention
    • Remind parents to keep colorful and candy-appearing items locked up and/or out of the sight and reach of children!!



Whitney RE1, Baum CR, Aronson PL. Diffuse corneal abrasion after ocular exposure to laundry detergent pod. Pediatr Emerg Care. 2015 Feb;31(2):127-8. PMID: 25422858. [PubMed] [Read by QxMD]

Stromberg PE1, Burt MH2, Rose SR1, Cumpston KL1, Emswiler MP1, Wills BK3. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. Am J Emerg Med. 2014 Dec 3. PMID: 25592250. [PubMed] [Read by QxMD]

Sidhu N1, Jaeger MW. Concentrated liquid detergent pod ingestion in children. Pediatr Emerg Care. 2014 Dec;30(12):892-3. PMID: 25469600. [PubMed] [Read by QxMD]

Valdez AL1, Casavant MJ2, Spiller HA2, Chounthirath T3, Xiang H4, Smith GA5. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Dec;134(6):1127-35. PMID: 25384489. [PubMed] [Read by QxMD]

Russell JL1, Wiles DA, Kenney B, Spiller HA. Significant chemical burns associated with dermal exposure to laundry pod detergent. J Med Toxicol. 2014 Sep;10(3):292-4. PMID: 24526400. [PubMed] [Read by QxMD]

Nalliah RP1, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Children in the United States make close to 200,000 emergency department visits due to poisoning each year. Pediatr Emerg Care. 2014 Jul;30(7):453-7. PMID: 24977994. [PubMed] [Read by QxMD]

Beuhler MC1, Gala PK, Wolfe HA, Meaney PA, Henretig FM. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013 Jun;29(6):743-7. PMID: 23736069. [PubMed] [Read by QxMD]

Centers for Disease Control and Prevention (CDC). Health hazards associated with laundry detergent pods – United States, May-June 2012. MMWR Morb Mortal Wkly Rep. 2012 Oct 19;61(41):825-9. PMID: 23076090. [PubMed] [Read by QxMD]

McKenzie LB1, Ahir N, Stolz U, Nelson NG. Household cleaning product-related injuries treated in US emergency departments in 1990-2006. Pediatrics. 2010 Sep;126(3):509-16. PMID: 20679298. [PubMed] [Read by QxMD]

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Gun Safety

Injury Prevention Guns


Judging for the fact that the Post-Tonsillectomy Hemorrhage morsel gets more views than any other, I know that most of you are interested in critical care and “exciting” topics. Certainly, your heroic efforts are occasionally necessary to help positively affect a patient’s future; however, don’t underestimate the power of some of your subtle actions.  Injury Prevention fits nicely within the arena of emergency medicine and we have discussed several topics already (ex, Submersion Prevention, Heat-Related Illness, Childhood Injuries).  There is another that we should consider when contemplating injury prevention: Gun Safety.

Now, this is not a political Morsel.  It is meant to highlight some simple points that you can use to help educate families so that their loved ones don’t come back to you as trauma patients. What follows is based on AAPs Policy Statement and other educational literature (Dowd, 2012; Crossen, 2015)

Gun-Related Deaths

  • In the US, from 2008-2010, 2,829 children (0-19 years of age) died due to gun-related injuries.
  • In 2009, 28.7% of the teenagers (15-19 yrs) that had an injury-related death, died due to a firearm-related injury.
  • Unintentional Deaths

    • Each year, an average of 134 children (0-19 years) die due to an unintentional gun-related injury.
    • Unintentional deaths occur within all age groups at almost similar incidence levels.
    • Many deaths are due to friends or siblings mishandling firearms.
    • A significant number of deaths are due to unintentional self-inflicted wounds.
  • Intentional Deaths

    • Guns are the leading mechanism for intentional death for children older than 5 years of age.
    • Suicide is the 4th leading cause of death for children 10-14 years of age.
    • Suicide is the 2nd leading cause of death for children 15-19 years of age.


What Can We Do?

Recognize the potential influential power you and your team possess in the Emergency Department.

When a patient presents with history of asthma and is wheezing, we quickly ask about smoking in the house as a means to help educate the family about the risk of continued exacerbations due to the smoke exposure.  When a patient has been involved in a minor MVC, we ask about seat belts to reinforce their utility and help prevent a future devastating injury. When a patient presents for a forearm fracture sustained after falling off a bike, we ask about whether a helmet was being worn.  These questions are asked without judgement and are useful in helping to reinforce safe behaviors to help prevent future injury.  Similarly, there are questions that we can ask to help reinforce gun safety to help prevent a child returning with a GSW.

NOTE: There are currently some states, like Florida, that have pending laws that would make it illegal for a healthcare providers to ask about firearms. While these are not currently enacted, it is always best to know your local laws.

I think that it is reasonable to ask about the presence of firearms when dealing with patients who are presenting to your Emergency Department for:

  • Injury suffered from a violent act / assault
  • Psychiatric complaint (ex, depressive symptoms, suicidal ideation)

Discussing Gun Safety

  • Counsel parents, not the kids.
    • Strategies to educate children have not demonstrated alterations in behaviors (which are often impulsive).
  • If guns cannot be removed from the home (for whatever reason), then safe storage practices are vital.
    • Use of trigger locks or cable locks
    • Use of lock boxes and gun safes
    • Storing firearms locked and unloaded
    • Storage of ammunition locked and in separate location from firearm


It is known that brief health promotional messages delivered by care providers can influence patients and their families.  It does not have to take long. It might not change the world immediately, but it might be just what that family needed to hear to help protect their child.



Crossen EJ1, Lewis B1, Hoffman BD1. Preventing gun injuries in children. Pediatr Rev. 2015 Feb;36(2):43-51. PMID: 25646308. [PubMed] [Read by QxMD]

Dowd MD, Sege RD; Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012 Nov;130(5):e1416-23. PMID: 23080412. [PubMed] [Read by QxMD]

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Koplik Spots

Koplik Spot


We all know that our diagnosis is built upon the foundation of the history and physical exam. One of the challenges in caring for children in the ED is that the physical exam can be, at times, difficult to do… particularly the oral exam.  While it may be challenging, it is incredibly important to do a thorough exam to make a timely and accurate diagnosis. The common wrestling match (you vs child) is seen during assessment for strep pharyngitis, but let us not forget that the oral exam may be very helpful in assessing the febrile child.  Is this a simple viral illness or is this measles?  Are there Koplik Spots present??


Koplik Spots: Their Appearance

  • Millimetric, erythematous, blue-white or grey speck on the buccal mucosa. (Steichen, 2009)
    • Typically appear opposite to the upper molars.
    • Can extend to include the entire buccal mucosa.
  • Seen before the external rash – about 24 hours prior.
  • Persist for 2-3 days.


Koplik Spots: Their Importance

  • With the low incidence of measles, the importance of Koplik spots may have faded from our collective memories. (Lefebvre, 2010)
    • Unfortunately, measles has not been erased from existence… so, we should still be aware and vigilant!
  • Regarded as pathognomonic of measles.
    • Seen in 50-70% of patients with measles, if examined early on in the course.
    • Koplik spots are highly predictive of confirmed measles. (Tenner, 2012)
  • Detecting Koplik spots may enable prompt measles management and control measures. (Tenner, 2012)


Early Detection is Imperative!

  • Measles is a leading cause of preventable childhood morbidity and mortality worldwide.
  • Measles is one of the most contagious disease known!
    • It is spread through aerosol exposure or contact.
    • It has a 90% transmission rate!
  • Initially, it presents similar to every other febrile, viral illness (cough, coryza, and conjunctivitis).
  • The patient is contagious for ~5 days after the onset of symptoms (yup, when that simple fever started).
  • Early detection is key to limit its spread.
    • Unfortunately, since it may look just like every other viral URI at first… combined with the fact that measles is not encountered that commonly in the US (until, recently)… it may be difficult to detect it early.
    • Koplik Spots may be the key to help you make the diagnosis… but you have to look for them!


The Oral Exam: Some Tips

For whatever reason, most kids don’t like strangers looking into their mouths.  This seems to be even more true when they don’t feel well.  Given the fact that finding Koplik spots would dramatically change your management plan, it is imperative that you examine the mouth well.  You probably shouldn’t just give ketamine to everyone who has a fever though… so what can you do?

  1. Don’t be scary.
    • No one wants a stranger prying open their mouth… so don’t be a stranger.
    • Play with the child before jumping to the mouth exam.
    • Or, at least start with areas of the exam that are less intimidating (ex, feet).
  2. Make your first attempt your best attempt.
    • This applies to all procedures… from intubation to lumbar puncture.
    • Rate of success decreases proportionally with each successive attempt
      • This is not scientific, but true…
      • Ok, it might actually be an exponential relationship.
    • Have your tools handy, but hidden…
      • Using ungloved fingers isn’t wise and realizing you need a tongue blade after starting isn’t encouraging for the family.
      • Lighting is imperative!
        • Headlamps are awesome… but a little scary… unless you are super cool and can convince them that you are a quirky Cyclops (part of the fun of being a Ped EM doc… you get to play a lot).
        • The small Mac Blade laryngoscope is ideal.  Consider it a lighted tongue blade.
    • Teach the family how you want them to hold the child before you start.
      • Learning while the child is kicking them in the face is difficult.
      • The traditional method is having the child sitting facing you with parent restraining legs, arms, and head.
  3. Have a Plan C
    • Another option for restraining, that works well, but is a bit odd:
      • Have the child sit facing parent, with his/her legs wrapped around parent’s waist.
      • The child then is reclined onto the parent’s legs with his/her neck slightly extended as it reaches past the parent’s knees.
      • The parent restrains arms and legs.
      • Typically the child’s mouth opens as they are slightly upside down.
      • Be ready with your light and quick hands… and some other assistants if needed!




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