Fracture Fridays: Bony complications of repeated shoulder dislocations

The Case

After successfully reducing the shoulder of a young athlete – his fourth, your first. He says the the last 2 times he dislocated it was reduced by his team trainer on the sidelines. You obtain XRays and note the following.

Courtesy of Wikipedia

Courtesy of Wikipedia

The Diagnosis

This is a Bankart lesion. Note the abnormality in the inferior third of the glenoid labrum (in the annotated XRay). With repeated anterior-inferior shoulder dislocations a groove or pocket forms in the front of the glenoid. XRays have sensitivity/specificity in the 60%s with MRI being 96% sensitive and 100% specific according to Cicak et al, J Ultrasound Med, 1998.

Courtesy of Wikipedia

Courtesy of Wikipedia

It is often accompanied by a Hill Sachs lesion, which is a concave cortical depression on the humeral head. The latter is also seen in patients with multiple dislocations, and occurs when the humeral head forcefully impacts against the anteroinferior glenoid rim (seen below).

Courtesy of Wikipedia

Courtesy of Wikipedia

Management

Both of these findings in isolation (or together), and especially in the context of multiple dislocations are basically a signal to send the patient to Ortho. The management of a Hill-Sachs lesion is repair when there is shoulder instability. Bankart lesions are also best managed by a surgeon.

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What I’m reading: Indications for bronchoscopy in inhaled foreign bodies

Once in a while you’ll see a child with a chronic cough. Even in the absence of a compelling history – and let’s face it, the history cupboard is often bare – it is important to consider the possibility of an inhaled foreign body. Thinking about the possibility of a bronchial foreign body got me thinking about the indications for bronchoscopy. Previously I figured that the indications were if a foreign body is present then bronch. Let’s see if good ‘ole intuition was correct.

Cohen et al in J. Peds from 2009 examined a cohort of 142 children with suspected foreign bodies. The authors noted that all of the the patients had a suggestive history; either a witnessed report of an acute episode of choking (n = 106) or an acute persistent cough (n = 36). The median age was 20 months.

Important symptoms n their cohort included cough, dyspnea, labored breathing, drooling, dysphagia, vomiting, and fever. The abnormal physical exam findings were cough, fever, tachypnea, hypoxemia, decreased lung sounds, wheezes, and crackles. Abnormal radiologic findings included air-trapping, atelectasis, infiltration, mediastinal shift, and radioopaque foreign body. All patients underwent bronchoscopy within 24 hours of admission. Overall 43% had a foreign body (61/142). When they were subdivided into 5 groups, the proportion having a foreign body on bronchoscopy was:

  • 42/63 (67%) children with both abnormal exam and XRays
  • 14/22 (64%) children with abnormal exam but normal XRays
  • 3/10 (30%) children with normal exam but abnormal XRays
  • 2/31 (6%) children with a normal exam and XRays – but persistent cough/abnormal symptoms
  • 0/16 (0%)children with normal exam, normal XRays and no symptoms

The children without foreign body were compared to those with one. Note that kids with a FB were more likely to have had a witnessed choking event, have persistent cough, have sats <94%, have localized decreased breath sounds, and localized air trapping or mediastinal shift on Chest XRay.

Bronch comparison

OK, so this wasn’t a randomized controlled trial. But would an IRB approve such an investigation? Anyway, this did help me better understand why a bronchoscopist would be less likely to take an asymptomatic child with a normal exam and normal films to the OR. I’d go so far as to say that such children can probably be discharged home without a consult in the first place.

You can download the pdf right here

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Briefs: ITP

A really well looking preschooler has been referred to the ED because of petechiae and bruising. The mom has consulted Dr. Google and is worried that her son has leukemia. He had a cold last week that he recovered from, and has not had any recent fevers, weight loss, bone pain, pallor or any other complaints for that matter. He is a very active child, and has been known to get bruises on his legs from “diving off of the couch” but nothing like what you see in the ED.

petechiae and purpura ITP purpura

You send off a CBC and note that the white blood cell count is 10.2, the hemoglobin/hematocrit 12.7/38.1 and the platelets 27

Based on the lab results and his reassuring appearance you make the diagnosis of ITP.  Idiopathic thrombocytopenic purpura (ITP) is an IgG-mediated antibody reaction versus platelets leading to their premature destruction. The peak age is 2 to 10 years, with most cases seen in those under 5 years. In more than half of all cases the child has had a recent infection (think cold or sore throat). It generally occurs in children between the ages of 2 and 10 years, with the majority of cases occurring in children under 5 years. In more than half of ITP cases there is a history of a recent infection. Lest you jump to conclusions note that infections don’t cause ITP – nor have they been definitively linked to causing the antibody-mediated reaction.

The presentation is relatively characteristic, beginning with sudden bruises, petechiae or bleeding in an otherwise well appearing child. 9/10 will have mucosal bleeding – often minor and more often in the nasal passages. Other mucosal sites include oral cavity, genitourinary tract and gastrointestinal tract in order of decreasing severity.

ITP mucosal bleed

Intracranial and pulmonary bleeding are very, very rare, even when platelets are under 10,000/microliter. Most patients do not have Hepatomegaly, splenomegaly or lymph node enlargement. If they do, alternative diagnoses should be considered. These include

  • Viral infections (EBV, acute HIV and hepatitis with thrombocytopenia)
  • Drug-induced thrombocytopenia
  • Lupus
  • Leukemia
  • Meningococcemia
  • Aplastic anemia
  • Inherited disorders associated with thrombocytopenia

Though children are well appearing the initial workup should include a complete blood count with differential and a peripheral smear along with a blood type. Coagulation studies may be helpful, especially if you are concerned about a family history of bleeding disorders. In febrile/ill appearing children obtain a blood culture. You’ll likely want  to start antibiotics as well. because, let’s face it – ill appearing + petechiae = sepsis until proven otherwise. In any case, if you think it’s ITP, and the child looks well you’re probably right – and thus you should call a Pediatric Hematologist.  If the diagnosis of ITP is suspected, consult with a hematologist to determine appropriate therapy. Therapy is directed includes intravenous immune globulin (IVIG), systemic corticosteroids, and/or Anti-Rho(D) immune globulin. despite treatment 1/5 children will have a chronic course (>6 months). Interestingly, there also appears to be a slight increase in the month and a half following MMR vaccination.

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No, No Cipro (for uncomplicated UTI)

Uncomplicated urinary tract infections (your garden variety cystitis) is a common ED diagnosis. For most patients there is a wide variety of potentially effective treatment options. The purpose of this post is to caution you against the use of fluoroquinolones (like ciprofloxacin) to treat uncomplicated UTIs in children.

Why is this the case? Well, fluoroquinolones are known to be one of the best options for treating Pseudomonas aeruginosa. But resistance is also an emerging problem. In fact, per Zervos et al, rampant use in adults has increased resistance prevalence. In fact, Fridkin et al noted that resistant P. aeruginosa is #2 only to MRSA in the US. Fluoroquinolone resistant species can also spread from person to person in the community, which is where you will be sending patients with uncomplicated UTI. To make matters worse, cross-resistance to Streptococcus pneumoniae, E. coli, Neisseria, Salmonella and Mycobacterium may develop as well if we keep using Cipro. Additionally, MIC concentrations seem to be increasing significantly – thus requiring more drug to kill the same bacteria. There’s also the issue of tendon rupture. Fortunately (or unfortunately depending on how you look at it) that is more of an issue for our canine friends… So right now approved indications for systemic fluoroquinolone use in kids is limited to Ciprofloxacin for complicated urinary tract infections, pyelonephritis, and inhalational anthrax.

OK, we got it, don’t prescribe Cipro… So now what?

Fortunately, there are a lot of great options out there. Let me highlight four.

Nitrofurantoin

Infants >1 month and Children: 5-7 mg/kg/day divided every 6 hours; maximum dose: 400 mg/day

Children >12 years: 100 mg every 12 hours for 7 days

Great agent, because it really doesn’t concentrate outside of the urinary tract. This does mean however, that it doesn’t concentrate in the blood, and thus can’t penetrate tissues well. It is for that reason that Nitrofurantoin is not a good choice for pyelo. So, in kids with febrile UTIs in which you can’t rule out pyelo – don’t use it.

Trimethoprim/Sulfamethoxazole

Infants and Children 2-24 months: 6-12 mg TMP/kg/day in divided doses every 12 hours for 7-14 days

Children >24 months and Adolescents: 8 mg TMP/kg/day in divided doses every 12 hours for 3 days; longer duration may be required in some patients; maximum single dose: 160 mg TMP

Another good choice – as long as you don’t have a high prevalence of resistance in your area. You must also consider a potential history of sulfa allergies.

Amoxicillin/Clavulante

Infants and Children 2-24 months: 20-40 mg/kg/day in divided doses 3 times daily using the 125 mg/5 mL or 250 mg/5 mL oral suspension; maximum single dose: 500 mg amoxicillin (AAP, 2011)

Again, an example of scaling your drug to the bacteria at hand (on in this case in the bladder)

Cephalexin

Children: 25-50 mg/kg/day divided every 6-8 hours; severe infections: 50-100 mg/kg/day divided every 6-8 hours; maximum dose: 4 g/day

Children >15 years: 500 mg every 12 hours for 7-14 days

Just like Nitorfurantoin, cephalexin can concentrate in high levels in the bladder. It can be a surprisingly good choice.

To learn more about this topic on the adult side I recommend you check out the two-parter over at Academic Life in Emergency Medicine (Part 1 and Part 2) on the treatment of uncomplicated UTI in older adults. Pediatricians need not apply.

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Tech Tuesdays: Go Pro or go home

Recently the Emergency Medicine docs at TamingtheSRU.com and University of Cincinnati Emergency Medicine Residency Program have been sharing some innovate first person videos focused on procedures in the ED. Here is an example of pericardiocentesis.

You may be familiar with the diminutive Go Pro (GoPro.com) as the camera of choice for extreme sports enthusiasts, but it has several advantages for filming medical teaching videos. In the aforementioned case Dr. Hinckley, one of the faculty physicians donned a chest harness to mount the camera. You can see it in the reflection in the video. The camera itself is capable of recording in 1080p (or even 4K for the black edition).

For the image quality to come from such a remarkably small package is amazing. The current Hero 3+ weighs 74g (2.6oz) and is 2.30 x 1.55 x 0.08 inches. There are clamps and mounts for standard tripods as well as other types of equipment (like a surfboard). You can also get waterproof housing – which may be beneficial in medical settings.

Check out a couple more of the first person teaching videos and consider the GoPro as an option if you’re in the market for a compact video camera that will shoot superior footage to your smartphone.

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Briefs: Serum sickness like reaction

You are seeing a child who is well appearing but has a dramatic rash. The rash appeared this morning and seemed to begin on her torso, later spreading to her limbs. The daycare thought that it was an allergy and was going to give her another child’s EpiPen, despite no respiratory symptoms and no history of previous allergy in the patient. Discretion won out, and the EpiPen was not given and the child was referred to the ED. You learn that she has had a fever to 38.9 C for 2 days, and her feet appear to be slightly swollen. This hasn’t limited her ability to walk, run or jump. Mom denies history of vomiting or diarrhea. there are no respiratory symptoms. She has no involvement of her eyes or mouth. Eight days ago she completed a course of cefdinir for otitis media.Let’s say that the rash in question looks like this:

The rash as it appears on the patient's back. 2014, Brad Sobolewski, MD, MEd

The rash as it appears on the patient’s back. 2014, Brad Sobolewski, MD, MEd

The rash as it appears on the patient's leg. 2014, Brad Sobolewski, MD, MEd

The rash as it appears on the patient’s leg. 2014, Brad Sobolewski, MD, MEd

This rash is characteristic of erythema multiforme in the setting of a serum sickness like reaction. Serum sickness is a heterogeneous clinical entity where you will see variable rash, fever  and polyarthlralgias. It begins 1 to 2 weeks following exposure to an offending agent. The offending agent varies, but the most common identifiable agents are antibiotics, including:

  • Penicillins
  • Trimethoprim-sulfamethoxazole
  • Cephalosporins

Resolution generally occurs within 1-2 weeks after stopping the drug. In other cases it may be viral induced, but good luck discontinuing it. This process is immune complex mediated and results in the development a polymorphous, sometimes pruritic rash that starts in the trunk and spreads peripherally. They appear to be urticarial in some patients and like palpable purpura, maculopapular lesions or erythema multiforme-type exanthema in others. There is no involvement of the mucous membranes or eyes. Most patients develop remittent fever without temporal spikes. Two out of three have arthralgias, most commonly seen in the hands, wrists, feet, ankles and shoulders. The differential diagnosis includes:

  • Viral exanthems (roseola)
  • Hypersensitivity vasculitis
  • Scarlet fever
  • Acute rheumatic fever
  • Meningococcemia
  • Disseminated gonococcemia
  • Reactive arthritis
  • Lyme disease
  • Still’s disease
  • Kawasaki syndrome
  • Stevens-Johnson syndrome

You can generally make the diagnosis clinically in most cases. Treatment consists of stopping the offending agent, NSAIDs for pain, and antihistamines for itching. Glucocorticoids may be useful in patients with severe arthritis/arthralgias or extensive rashes but in general do not have an evidence supported role. If you encounter an ill appearing patient, one with eye/mucous membrane involvement, or those in whom you are not certain about the diagnosis you might want to consider a complete blood count with differential, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), urinalysis, blood urea nitrogen, creatinine, serum electrolytes, urinalysis and blood culture obtained to exclude other inflammatory or infectious causes. Again, if you are certain about the diagnosis you don’t need to get any labs. You should list the offending agent as an allergy – and if the patient encounters an offending drug again in the future the symptoms may have a more rapid onset. And finally, mucous membrane and eye involvement does not occur in serum-sickness like reactions. These findings should prompt consideration for Stevens-Johnson syndrome, a potentially fatal hypersensitivity reaction and (in my experience) the one reason for a Dermatologist to come in at night.

 

Fun fact: What was described today is actually serum sickness-like reaction. Classically serum sickness was in response to administration of a non-human species (horse) protein antigen. You may still encounter this today in sheep-derived Fab snake antivenom, heterologous immunomodulators containing murine components (rituximab and infliximab), streptokinase and the human diploid cell rabies vaccine.

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