EMERGENCY TOPICS
From The 18th Annual Las Vegas Postgraduate Meeting, Advances in Pediatrics, presented May 17-20, 2007, by the
American Academy of Pediatrics, California Chapter 2
Douglas Nelson, MD, Professor of Pediatrics, University of Utah School of Medicine, and Medical Director, Emergency
Department, Primary Children’s Medical Center, Salt Lake City
| Seriousness determined by: location, size, shape, and composition of foreign body (FB); patient age (determines degree
of cooperation); longer FB in place, more difficult to detect and remove
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Otic Foreign Bodies
| Signs and symptoms: often, history of FB placement in ear; 90% of affected patients have ear pain (30%, decreased
hearing; 9%, bleeding); many previously treated for otitis media (OM), especially if wax blocks view of tympanic membrane
(TM; irrigation may be necessary)
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 | Common mistaken assumptions: that only 1 FB in canal; FB only in 1 ear; back of object shaped like front; child will
hold still
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| Factors affecting removal technique: FB characteristics—beans absorb moisture and swell; soft or irregular, round or
hard; ability to sedate or anesthetize—antipyrine and benzocaine (Auralgan Otic) helpful, but makes surfaces slippery
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| Tools: alligator forceps (jaws 3-4 mm long); ear cleaning loop (plastic not as good as metal); suction
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| Irrigation: do not push FB further back (squirt water behind it); consider angiocatheter or clave adaptor to direct stream of
water down side of ear canal (usually, crack present between FB and surface of canal)
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| Refer to otolaryngologist if: deep sedation needed; physician worried about perforating TM, or FB has already done so
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Nasal Foreign Bodies
| Diagnosis: most cases occur in 2- to 3-yr-old children; less common than FBs of ear; classic presentation—persistent
unilateral nasal discharge; foul odor; nonclassic presentations—discharge only or odor only; nosebleed
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| Removal: need adequate restraint; sedation (if needed); vasoconstrictor sprays (eg, oxymetazoline [Neo-Synephrine]), especially
if mucosal swelling or bleeding present; nasal speculum widens narrowest part of exit; bent calcium alginate swab (Calgiswab);
small Foley catheter (push past FB, inflate balloon, and pull; have child lie on side); pneumatic technique—in
young child, physician blows through mouth using bag-valve-mask device (occlude unaffected nostril); for older child, patient
occludes unaffected nostril and blows; refer to otolaryngologist if—excessive bleeding present; patient cooperation insufficient
(consider ketamine); FB too far superior in nasal cavity (unlike ear, nose has no back wall)
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Oropharynx and Upper Airway
| Diagnosis: symptoms depend on size, shape, and location; condition can be life-threatening; FB sensation may persist after
FB gone; common culprits include fish bones, toys, hot dogs, candy, nuts, grapes, and meat (all radiolucent); lateral neck radiography
may reveal radiolucent FB if object turned right way; problem of delayed diagnosis—in recent study by Bloom
et al, mean time to diagnosis 11 days; suspect FB in pharynx or esophagus of well-appearing child who will not eat or drink;
have low threshold for laryngoscopy or bronchoscopy
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Lower Airway Foreign Bodies
| Diagnosis: early presentation—choking, gagging, turning blue; asymmetric breath sounds; unilateral wheezing; late
presentation—once FB far enough down lung, patient able to breath reasonably well; unexplained fever; nonresolving
pneumonia; long-standing wheezing (especially unilateral; often misdiagnosed as asthma); most lower airway FBs found
in children 1 to 3 yr of age; bronchial FBs—peanuts and other nuts most common; symptoms at diagnosis—cough; decreased
breath sounds; wheezing; respiratory distress; fever; stridor; only one-third of patients present with classic clinical
triad of unilateral wheeze, cough, decreased breath sounds; in recent study, rate of diagnosis delayed >1 mo almost
20%; longer FB present, less respiratory distress; history—choking or gagging spell within last few weeks; consider respiratory
FB in any child with respiratory complaint
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| Initial work-up: starting point usually chest x-ray; inspiratory and expiratory (I and E) views helpful (look for air trapping
[lung with FB does not deflate]); if patient too young to cooperate for I and E films, obtain lateral decubitus films
(weight of mediastinum pushes against lung); bronchoscopy—gold standard (perform based on clinical suspicion, even
if imaging studies normal)
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| Esophageal foreign bodies
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| Diagnosis: never believe “there was nothing around for the child to swallow”; type of FB—coins most common;
complications—pain with swallowing; refusal to eat; drooling; vomiting, retching; stridor; FB sensation (presents in
younger children as crying); radiography—usually start with FB series (lateral head and neck; anterioposterior (AP)
chest and abdomen) even if not sure FB radiopaque; coin ingestions—does every child need radiography? (generally,
yes); symptoms poor predictor of location; large percentage of children with esophageal coins asymptomatic; consider
metal detector to localize coin; barium esophagraphy—outlines radiolucent FB; usual level of lodgment—thoracic inlet
(most common); aortic arch; gastroesophageal (GE) junction
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| Removal: choices—bougienage; esophagoscopy; endoscopy; observation; Foley catheter technique (Schunk et al,
1994)—if FB present <3 days, success rate almost 100%
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| Disc (button) batteries: children have died because button battery misdiagnosed as coin; battery can erode through
esophagus and cause mediastinitis; case (battery wore hole through aorta); mechanisms of injury—pressure necrosis;
leakage of contents or electrical discharge, causing burning and scarring; remove emergently; coin vs battery—button
batteries have step-offs, and edges have different density from center
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| PEDIATRIC ORTHOPEDIC EMERGENCIES
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| Why children’s bones are different: bones more flexible, porous, and deformable; frequently, bones weaker than
tendons and ligaments; periosteum thicker and stronger (holds fragments in place); growth plates—weak points in immature
skeleton that may resemble fractures on x-ray; fracture in growth plate can cause growth problems; healing—
better potential for remodeling (nonunion more rare in children than adults); fragments immobile sooner (periosteum
more biologically active; narrower window to correct malposition)
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| History and physical examination: frequently, history vague (“child out playing”); chief complaint—child will not
use arm, or crying more than usual; uncooperative preverbal patient—difficult to diagnose compartment syndrome in
crying child with cast on; medicolegal liability increased; maximize—information obtained before physical examination
and x-rays; child will not walk—leave room and keep door open; child may walk for parents; take child from parent and
let patient “flee in terror”; crawling uses hip, femur, and bit of knee (not tibia or fibula); children who refuse to walk, but
crawl, usually do not have hip or femur pathology
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| Avoiding mistakes: if child limping, check for FB in foot or shoe; if fever present, worry about osteomyelitis and discitis;
hip pain may be referred to knee; listen carefully to parents—if baby cries when picked up, suspect clavicle fracture
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| Radiography tips: include joint above and below injury; immobilize suspected fracture to reduce pain before sending
patient to radiology department; administer pain medications; in recent study, 2 µg/kg intranasal fentanyl at triage works
well; if AP or lateral view ambiguous, consider oblique or additional views
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| Describing fracture for orthopedic surgeon: location; path (transverse or spiral); amount of displacement; angulation;
shortening; whether comminution (>2 fragments) present; whether fracture open
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Growth Plate (Physeal) Injuries
| Epidemiology: growth plate fractures account for 20% to 30% of pediatric fractures; more common in adolescents; radius
and ulna most common bones involved
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| Anatomy review: physis (growth plate)—composed of cartilage; has no blood supply; weak area of bone;
metaphysis—bone shaft next to physis newly formed portion of bone; epiphysis—secondary ossification center; separated
from metaphysis by physis; contains germinal layer of cartilage; capital epiphyses located at ends of long bones
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| Salter-Harris fractures: type I—fracture confined to growth plate; difficult to see on radiography; may need comparison
views; if focal pain at growth plate strongly suspected, even if fracture not seen, assume type I fracture and splint;
type II—fracture goes through physis and metaphysis; better prognosis than types III, IV, and V; type III—frequently,
extends into joint; requires referral to orthopedic surgeon to reestablish and maintain normal anatomic position; goes
through physis and epiphysis (not metaphysis); type IV —involves physis, metaphysis and epiphysis; surgical intervention
usually required; perfusion to bone often interrupted (bone at higher risk for growth problems); type V—crush injury
to physis; bone at highest risk for growth arrest; may be difficult to see on radiography; diagnosis often made in hindsight
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Upper Extremity Pediatric Orthopedics
| Radial head subluxation (nursemaid’s elbow): annular ligament slips into radiohumeral joint and becomes
trapped; classic history—arm pulled during play; one-third of patients have nonclassic history of falling on arm; chief
complaint that patient will not use arm; presentation—arm limp at side, elbow flexed, hand pronated; child often presents
holding wrist (immobilizes elbow); unlike supracondylar fracture, point tenderness or swelling not present;
radiography—not necessary if physician comfortable with diagnosis based on clinical findings; treatment—traditional
method to extend arm, place thumb on radial head, supinate, and flex (physician can feel “thunk” in arm); if not effective,
hyperpronate and extend
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| Mechanism: usually fall on outstretched hand (FOOSH); most often, fracture in distal radius; often, subtle buckle or
torus fracture produces small change in contour of metaphysis; incidence increased 40% in last 30 yr
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| When is reduction needed? arm looks bent on examination; degree of angulation—younger children can tolerate more
angulation than older ones (longer time until bones mature and locked in place); other factors—distance between fracture
and physis; amount of rotation (bowing fractures do not remodel as well as buckle fractures)
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| Avoid these mistakes: obtaining wrist films only (omits fractures near head of radius); not recognizing Salter-Harris I
fractures at distal radius (point tenderness strongly suggests it); not splinting wrist sprain (in study of prolonged “wrist
sprain” in children, almost 90% had Salter-Harris I fractures); not evaluating and documenting neurovascular status of any
fracture
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| Supracondylar fracture: most common elbow fracture in childhood (second most common fracture overall); fracture usually
displaced posteriorly; higher rate of neurovascular injury than with distal forearm fractures (document presence or
absence)
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| Pediatric elbow films: difficult to read, especially in infant, due to lack of calcification; as patient matures skeletally, different
epiphyses appear on films because cartilage becoming calcified; order of appearance—mnemonic CRITOE
(capitellum, radial head, internal [medial] epicondyle; trochlea; olecranon; external [lateral] epicondyle); normal—
line drawn down distal third of humerus, should intersect middle third of capitellum, and radius should line up with
capitellum; abnormal—fat more radiolucent than muscle; fat pad sign dark shadow like sail of boat (effusion or inflammation
at elbow joint elevates fat anterior to joint); fat pad posterior to humerus never normal (if present, assume
fracture and splint); capitellum does not line up with humerus and radius
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| Fracture of radial head: splint and refer (emergent casting contraindicated due to risk of swelling)
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| Avoid these mistakes: not obtaining true lateral x-ray (without it, subtle elbow fracture frequently missed); if fracture not
visible, but pain and swelling present and supracondylar fracture suspected, repeat x-ray; do not assume no fracture
present if none seen (if effusion present, assume fracture); misdiagnosis of supracondylar fracture as nursemaid’s
elbow—attempted reduction in patient with supracondylar fracture fruitless and painful; determine whether patient has
marked tenderness to palpation; patient with nursemaid’s elbow does not mind gentle pressure on lateral and medial
condyle (if painful, obtain films); nursemaid’s elbow never has fat pad; beware multiple fractures (in evaluating elbow
fracture, obtain films of entire radius and ulna to avoid missing problem at wrist)
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Lower Extremity Pediatric Orthopedics
| Toddler’s fracture: oblique, spiral, nondisplaced fracture of tibia; mechanism of injury—usually, jumping from height
(trampoline may be involved) and landing with sudden twist; another mechanism twisting leg by running and falling;
symptoms—limp or refusal to walk; pain on palpation can vary in intensity; rarely, minor swelling or warmth over fracture;
compression or twisting of tibia elicits pain; radiography—findings can be subtle; if AP and lateral films negative,
get oblique views; bone scan may be necessary to make diagnosis, but speaker prefers routine application of stirrup
splint; avoiding mistakes—do not assume that toddler’s fracture absent if no pain on palpation; leg sprain not frequent
injury in children; if symptoms persist, repeat films at 10 days to look for new bone; if fracture suspected, apply stirrup
splint, even if x-ray negative
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| Slipped capital femoral epiphysis (SCFE): head of femur slips in relation to metaphysis (weight of body pushing
on head of femur); can occur gradually or suddenly; may present with chronic hip pain, limp, or inability to walk;
epidemiology—most common hip problem in adolescents; more common in boys, blacks, and obese patients; usually occurs
during growth spurt; diagnosis—pain often referred to knee; hip flexion causes obligate external rotation; AP and
frog leg views of both hips needed; often long delay in diagnosis, which worsens outcome (radiographic signs may be
subtle); SCFE treatment—no weight bearing; referral to orthopedist; depending on age, amount of slip, and other criteria,
pinning with screw through femoral head may be indicated; goal to minimize amount of slip (compromise of blood
supply to femoral head can cause avascular necrosis); mistakes to avoid—getting only AP view (in one third of cases, AP
normal); not imaging both hips (disease often bilateral, even if pain unilateral); assuming no SCFE if films normal (diagnosis
may require computed tomography [CT] or MRI)
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| Legg-Calvé-Perthes disease: avascular necrosis of femoral head; occurs in young school-age children; more common
in boys; presentation—gradual onset; often presents as limp after activity; often, pain referred to groin or knee; in early
stage, x-rays may be positive without symptoms; pathology—interruption of blood supply to proximal femoral epiphysis;
infarction of bone and bone resorption; findings subtle in early stages; diagnosis—may be apparent on plain films
(sometimes more obvious on CT or MRI); one femoral head shorter and less regularly shaped than other; sometimes affected
side whiter (more radiodense) on x-ray
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Suggested Reading
Bloom DC et al: Plastic laryngeal foreign bodies in children: a diagnostic challenge. Int J Pediatr Otorhinolaryngol
69:657, 2005; Chiu CY et al: Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg
Care 21:161, 2005; Mackle T, Conlon B: Foreign bodies of the nose and ears in children. Should these be managed in
the accident and emergency setting. Int J Pediatr Otorhinolaryngol 70:425, 2006; Musharafieh RS, Macari G:
Salter-Harris I fractures of the distal radius misdiagnosed as wrist pain. J Emerg Med 19:265, 2000; Nagaraj HS, Sunil
I: Multiple foreign body ingestion and ileal perforation. Pediatr Surg Int 21:718, 2005; Pudas T et al: Magnetic resonance
imaging in pediatric elbow fractures. Acta Radiol 46:636; Schunk JE et al: Fluoroscopic Foley catheter removal
of esophageal foreign bodies in children: experience with 415 episodes. Pediatrics 94:709, 1994; Shinha DD et al: Sewing
needle appendicitis in a child. Indian J Gastroenterol 23:219, 2004; Yanchar N et al: Oh Christmas tree, oh Christmas
tree CMAJ 171:1435, 2004.
Educational Objectives
| The goal of this program is to improve foreign body detection and removal and improve management of orthopedic
emergencies in children. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnose and manage otic foreign bodies.
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| 2. Detect and treat foreign bodies of the upper and lower airways.
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| 3. Use the Salter-Harris classification system to describe various types of growth plate injuries.
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| 4. Avoid mistakes in managing common orthopedic emergencies.
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| 5. Describe effective techniques for managing specific injuries of the upper and lower extremities.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Nelson was recorded at the 18th Annual Las Vegas Postgraduate Meeting, Advances in Pediatrics, presented May 17-
20, 2007, by the American Academy of Pediatrics, California Chapter 2. The Audio-Digest Foundation thanks Dr. Nelson
and the Academy for their cooperation in the production of this program.
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