717 HEAD INJURIES IN CHILDREN Glasgow Coma Scale (children) The \200\230Eye \200\231 and \200\230Motor \200\231 compone nts of the GCS are similar as for adults ( b p.361), but a modi \201 ed \200\230Verbal sc ore \200\231 is used in small children. The pediatric version of the GCS is shown in Table 15.11 (see www.nice.org.uk ). Assessment of the best verbal response is likely to require a ssistance from parent/guardian/carer. Table 15.11 Pediatric version of the Glasgow Coma Scale. Best eye response Score Eyes open spontaneously 4 Eye opening to verbal command Eye opening to pain No eye opening Best verbal response 3 2 1 Alert, babbles, coos, words, or sentences to usual ability Less than usual ability and/or s pontaneous irritable cry Cries inappropriately Occasionally whimpers and/or moans No vocal response Best motor response 5 4 3 2 1 Obeys commands or has normal spontaneous movements Localizes to painful stimuli or withdraw s to touch Withdrawal to painful stimuli Abnormal \202 exion to pain (decorticate) Abnorm al extension to pain (decerebrate) No motor response to pain Total 6 5 4 3 2 1 3 \200\22315 In pre-verbal or intubated patients, the \200\230best grimace response \200\231 may be use d in place of the \200\230best verbal response \200\231, as shown in Table 15.12 . Table 15.12 \200\230Best grimace response \200\231 Score Spontaneous normal facial/oro-motor activity Less than usual spontaneous ability and/or onl y responds to touch Vigorous grimace to pain Mild grimace to pain No response to pain 5 4 3 2 1 Transient cortical blindness after head injury Occasionally, children present with blindnes s immediately or soon after an apparently minor head injury. The mechanism is unclear, but in most cases blindness resolves spontaneously within a few hrs. In the meantime, arrange a CT scan to exclude intracranial haematoma. 718 CHAPTER 15 Pediatric emergencies Pediatric fractures and dislocations Many pediatric fractures are similar to those in adult s and prone to similar complications. Bones in children differ from those in adults in two important respects: they have epiphyses and are softer (hence fractures are more common tha n signi \201 cant ligament injuries). Certain types of pediatric fractures re \202 ect th ese differences: Greenstick fracture An incomplete fracture in which one cortical surface of a bone breaks, whilst the other side bends. Torus ( \200\230buckle \200\231) fracture Another form of incomplete fracture characterized by a buckling of the cortex. Plastic deformation ( \200\230bowing deformation \200\231) Traumatic bending of long bone s haft without visible fracture occasionally occurs in young children. Epiphyseal injuries Injuries to the traction epiphyses are avulsion injuries (eg peroneus b revis insertion into the base of the 5th MT). Injuries to the pressure epiphyses at the end of long bones adjacent to the articular surfa ce have been classi \201 ed into 5 types \200\224 the Salter-Harris classi \201 cation ( see Fig. 15.19 ): \200 Type I : the epiphysis separates or slips on the metaphysis. \200 Type II : a small piece of metaphysis separates with the epiphysis (commonest type). Type III : a vertical fracture through the epiphysis joins that through the epiphyseal plate. Type IV : a fracture passes from articular surface through the epiphyseal plate into metaphysis. Type V : a crush injury to the epiphyseal plate (X-rays may be normal). Note that Salter \200\223Harris types I and V may not be apparent on the initial X-ray. Undisplaced type I f ractures often affect distal tibia and \201 bula and may present with circumferential ten derness around the growth plate. Treat with POP and immobilization according to clinical \201 ndings. Epiphyseal growth plate injury A concern speci \201 c to any epiphyseal injury is that pre mature fusion of a growth plate may result, with resultant limb shortening and deformity. T he risk correlates to some extent with the mechanism of injury and amount of force involved . The different Salter \200\223Harris fractures carry a different level of risk of long-ter m growth plate problems. The risk is low for types I and II (particularly if undisplaced), moderate for type III and highest for types IV and V. Problems are usually averted if Salte r \200\223Harris type III and IV injuries are accurately reduced and held (eg by internal \201 xation). Type V fractures are notoriously dif \201 cult to diagnose and often compli cated by premature fusion: fortunately they are relatively rare. Dislocations Dislocated joints are relatively unusual in children. Most commonly involved a re the patella ( b p.726) or the radial head ( \200\230pulled elbow \200\231 \200\224 b p. 724). Similarly, due to relative strengths of bone and ligament, injuries to ligaments are much less common in children than in adults. 719 pediatric FRACTURES AND DISLOCATIONS Normal Type I Type II Type III Type IV Type V Fig. 15.19 Salter \200\223Harris classi \201 cation of epiphyseal injuries. 720 CHAPTER 15 Pediatric emergencies Approach to limb injuries in children Limb injuries are very common in children. Whilst mos t of the points outlined in the general approach to trauma in adults may be successfully ap plied, certain modi \201 cations may be required. History Carefully elicit the mechanism of injury. The history may be confused or not upcomi ng: try to establish a rapport with the child (and parents) nevertheless, in order to gain the child \200\231s con \201 dence for the examination. Examination Search for evidence of a fracture (swelling, deformity, bony tenderness) and an y associated neurovascular injury. Remember the adage that the most easily missed fracture is the second fracture: examine also for additional injuries to adjacent bones and joints. Is an X-ray required? If in doubt, obtain an X-ray. The ease with which children \200\231s bones fracture and the dif \201 culties with history and examination mean that it is sensi ble to adopt a low threshold for requesting X-rays. Ensure that two views at right angles a re taken (eg AP and lateral), including associated joints. Interpreting X-rays Many fractures are subtle and easily missed. To minimize the chance of this occurring, visually trace around the cortex of each bone, looking for any irregulariti es. Interpretation of pediatric X-rays is complicated by the presence of various ossi \201 cation centers and accessory ossicles. Both are commonly mistaken for fractures (eg the ol ecranon epiphysis, the os trigonum and bipartite patella). Ossi \201 cation centers appear and fuse in a relatively predictable fashion, although the rate at which this occurs varie s slightly from child to child (see Table 15.13 ). Knowledge of this process, combined with experience of seeing many pediatric X-rays, greatly assists interpretation. If in doubt ab out an X-ray, obtain a second opinion (there is no justi \201 cation for X-raying the unin jured side to see what \200\230normal \200\231 is). As an additional safeguard, most EDs n ow operate a policy of all X-rays being reported by a radiologist within 24hr. Treatment Give prompt, appropriate analgesia ( b p.713). Follow the treatment suggested for speci \201 c fractures ( b pp.722 \200\2237). Many undisplaced fractures will unite satis factorily with a period of immobilization in POP (eg fractured distal radius), collar and c uff (eg fractured radial head) or broad arm sling (eg fractured clavicle). Minor angulation at the fracture site can be accepted, particularly in young children. Often, however, angu lated fractures require MUA. Compound fractures and dislocations Give analgesia and give IV antibiotics (eg cefuroxime 2 5mg/kg slow IV bolus) and ensure tetanus cover. Take a digital photograph of the wound and keep it covered to minimize the risk of infection. Apply a dressing, splint the injured lim b and refer the patient to the orthopedic surgeon. 721 APPROACH TO LIMB INJURIES IN CHILDREN Table 15.13 Ossi \201 cation centers Center First appears Fuses Humeral head 0 \200\2236 months 18 \200\22321 years Capitulum 3 \200\2236 months 14 \200\22316 years Medial epicondyle 4 \200\2237 years 18 \200\22321 years Lateral epicondyle 9 \200\22313 years 14 \200\22316 years Trochlea 9 \200\22310 years 14 \200\22316 years Radial head 4 \200\2235 years 14 \200\22317 years Distal radius 6 \200\22312 months 17 \200\22319 years Olecranon 9 \200\22311 years 13 \200\22316 years Distal ulna 4 \200\2235 years 16 \200\22318 years Capitate birth \200\2233 months \200\224 Hamate birth \200\2234 months \200\224 Triquetral 1 \200\2233 years \200\224 Lunate 2 \200\2234 years \200\224 Trapezium 2 \200\2234 years \200\224 Trapezoid 3 \200\2235 years \200\224 Scaphoid 3 \200\2235 years \200\224 Pisiform 9 \200\22312 years \200\224 1st MC base 1 \200\2233 years 14 \200\22317 years Femoral head birth \200\2236 months 15 \200\22319 years Greater trochanter 3 \200\2234 years 17 \200\22319 years Lesser trochanter 11 \200\22314 years 15 \200\22318 years Distal femur birth 17 \200\22320 years Patella 2 \200\2236 years 4 \200\2238 years Proximal tibia birth 15 \200\22318 years Distal tibia birth \200\2236 months 14 \200\22317 years Proximal \201 bula 2 \200\2234 years 16 \200\22319 years Distal \201 bula birth \200\2231 year 14 \200\22317 years Posterior calcaneum 5 \200\2238 years 13 \200\22316 years Central calcaneum birth 13 \200\22316 years Talus birth \200\224 Navicular 2 \200\2233 years \200\224 Cuneiform bones 1 \200\2233 years \200\224 These dates are subject to individual variation. In general, epiphyses in girls fuse before those in boys. 722 CHAPTER 15 Pediatric emergencies Pediatric upper limb injuries: 1 Some fractures and dislocations are common in both adults and children and are treated similarly. Certain injuries are either speci \201 c to childr en or are treated differently in children: these are described in the next six pages. Pedia tric fractures are painful and need appropriate immobilization and analgesia ( b p.713). Clavicle fracture Common in children and adults alike. Treatment is similar: oral analgesia , broad arm sling and fracture clinic follow-up. Even if X-rays do not appear to show a fra cture, treat as for a fracture. Warn parents about a developing lump (callus). Shoulder injuries Shoulder dislocations are relatively rare in children. Salter-Harris type s I and II epiphyseal fractures may occur in the proximal humerus: refer to the orthopedic team if signi \201 cant displacement or > 20 * angulation. Otherwise, give analgesia, coll ar and cuff, and fracture clinic follow-up. Humeral shaft fracture Check particularly for radial nerve injury. Remember to consider NAI especially if <3 years old or fracture is spiral. Treat as for adults ( b p.459). Supracondylar humeral fracture Follows a fall on an outstretched hand. Swelling may be cons iderable. Check for associated neurovascular de \201 cit (particularly brachial artery, me dian and radial nerves). 25 % of supracondylar fractures are undisplaced and may not be obv ious on X-ray, although a joint effusion will be seen. Most fractures are displaced, angula ted or rotated. The extent of angulation (both in sagittal and coronal planes) is easy to u nderestimate. Viewed from laterally, the capitulum normally makes an angle of 45 * with the humeral shaft (see Fig. 15.20 ). The anterior humeral line (drawn along the front of humer al shaft on the lateral view) normally passes through the middle of the ossi \201 cation c enter of the capitulum in the distal humerus. Also, the normal carrying angle (seen in AP v iew) is 10 * . Record radial pulse frequently and consider compartment syndrome. Treatment provide analgesia and refer for manipulation under GA if: \200 Neurovascular de \201 cit: operation is urgent if circulation is compromised. \200 > 50 % displacement. \200 > 20 * angulation of the distal part posteriorly (see Fig. 15.21 ). \200 > 10 * me dial or lateral angulation. Refer others for observation and admission if there is much swe lling. If no signi \201 cant angulation, displacement or swelling, discharge with analgesi a, a collar and cuff under a body bandage (elbow at 90 * with con \201 rmed radial pulse p resent) and fracture clinic follow-up. Consider using a padded back slab POP if signi \201 cant pain is present. Complications malunion with persistent deformity, stiffness (including myositis ossi \201 cans), neurovascular de \201 cit (eg Volkmann \200\231s contracture). 723 pediatric UPPER LIMB INJURIES: 1 Supracondylar humeral fractures 45 Fig. 15.20 Normal lateral view \200\224 the capitulum makes an angle of 45 * with the hume ral shaft. Fig. 15.21 Supracondylar fracture with > 20 * angulation and 750 % displacement. 724 CHAPTER 15 Pediatric emergencies Pediatric upper limb injuries: 2 Lateral epicondylar epiphyseal injury Salter \200\223Harri s type II injury may follow a fall on outstretched hand. The elbow is swollen, with d movem ent and maximum tenderness on the lateral aspect. X-rays demonstrate the fracture, which ma y be displaced by the pull of the forearm extensors, requiring surgical reduction. Treat un displaced fractures with a long arm back slab POP, collar and cuff at 90 * , analgesia and fracture clinic follow-up. Medial epicondylar epiphyseal injury Maximal tenderness is apparent on the medial side of t he elbow. Check carefully for ulnar nerve damage. Refer immediately if the ulnar nerve is i nvolved, or if the fracture is displaced. Treat undisplaced fractures with analgesia, colla r and cuff at 90 * under clothes (con \201 rm radial pulse is present) and fracture clinic follow-up. Radial head/neck fracture The radiocapitellar line is drawn down the axis of the proximal r adius on the lateral view of the elbow and should bisect the capitellum. Failure to do so s uggests occult radial neck fracture or radial head dislocation. Most of these fractures can be managed satisfactorily with analgesia, collar and cuff (some prefer a broad arm sling) and fracture clinic follow-up ( b p.450). Refer to the orthopedic surgeon if there is signi \201 cant angulation. Elbow injury without obvious fracture Treat elbow injuries where there is clinical suspicio n of fracture, but none seen on X- ray, along the same lines as for an undisplaced fracture (analgesia, collar and cuff, and fracture clinic follow-up). This includes children who ha ve d range of movement and whose X-rays show an elbow effusion ( \200\230fat pad sign \200 \231) \200\224 see b p. 450. Subluxation of the radial head ( \200\230pulled elbow \200\231) A direct pull on the arm of a child aged 1 \200\2235 years may result in the radial head being pulled out of the annul ar ligament ( \200\230nursemaid \200\231s elbow \200\231). The child then refuses to use th e arm. If there is a characteristic history, there is no need to X-ray. The traditional red uction technique involves \202 exing the elbow to 90 * , then supinating the elbow fully. However, manipulating the elbow into full pronation may give a better reduction rate ( www . bestbets.org.uk ). A click is sometimes felt or heard during reduction. If full pronation fails, try full supination and leave for 10min. Allow the child to play and watch: he will usually use the arm again soon. If he does not, obtain X-rays and senior help. Repeat mani pulation can be done once, but if that does not lead to a rapid improvement in function the n place the arm in a sling, give analgesia and plan to review in 1 \200\2232 days. The elbo w may reduce spontaneously or may need further manipulation. Rarely, repeated manipulation is unsuccessful until sedation is given. After successful manipulation advise the parents t o avoid pulling the arm forcefully. A pulled elbow may recur up to about age 5 if the arm i s pulled, but after that the child should have no long term problems with the elbow. 725 pediatric UPPER LIMB INJURIES: 2 Radius/ulna shaft fractures Radius and ulna shaft fractures often cause signi \201 cant di splacement or angulation: provide IV analgesia, immobilize in a broad arm sling, obtain X-r ays and refer for manipulation under GA. Never accept an isolated forearm shaft fracture wi thout X-rays demonstrating the entire radius and ulna, otherwise a Monteggia or Galeazzi fr acture-dislocation may be missed ( b Forearm fractures and related injury, p.448). Distal radial fracture (including Salter \200\223Harris type II injuries) A common fracture in all ages of children (and adults) after a fall on an outstretched hand. The fracture re sults in localized tenderness and variable swelling. Check carefully for a second injury (e g involving the thumb or scaphoid). X-rays will demonstrate the fracture and allow assessme nt of the need for MUA. Moderate displacement or slight angulation may be accepted (particularly in younger childre n): if in doubt, obtain a senior opinion. Minimally displaced or undisplaced greenstick, buckle or torus fractures commonly occur jus t proximal to the distal radial epiphysis. Treat with analgesia, elevation, a backslab fore arm POP (extend this above the elbow in children <2 years or it will fall off) and arrange review and plaster completion at 24hr. Children who present with discrete tenderness over t he distal radial growth plate, but without a fracture apparent on X-ray should be treated i dentically to those with a radiological proven fracture \200\224 presume a growth plate inj ury (sometimes a subperiosteal haematoma can be seen on ultrasound). Beware osteomyelitis ( b The limping child, p.704), which can cause tenderness over the distal radius and be mist aken for trauma. Removable splints For co-operative children (usually > 4 years old) with torus/buckle fract ures of the distal radius, an alternative option is to use removable splints. Parents and c hildren report better functioning and fewer days off school. Splints should be retained unt il pain wears off (usually <3 weeks) and follow-up is not required if pain settles as expec ted. Scaphoid fracture Despite being uncommon, particularly in younger children, seek clinical e vidence of scaphoid fracture in any child with wrist/forearm injury and obtain scaphoid vie ws if appropriate ( b p.442). Treat radiologically evident and suspected fractures as for a dults as described in b Carpal bone fractures and dislocations, p.442. Metacarpal and phalangeal injuries Treat these injuries along similar lines to those descri bed for adults ( b Hand fractures and dislocations, p.436). Remember, however, that childre n may not tolerate manipulation under LA: anesthetic help may be required. 726 CHAPTER 15 Pediatric emergencies Pediatric lower limb injuries Hip fracture Children rarely sustain neck of femur fractures similar to those seen in adults. In the pre-adolescent child, trauma may precipitate a slip ped upper femoral epiphysis ( b The painful hip, p.706). Younger children who have been sub jected to considerable violence may suffer a Salter \200\223Harris type I injury to the pro ximal femoral epiphysis \200\224 carefully exclude other injuries and refer to the orthope dic surgeon. Femoral shaft fracture May be spiral (the majority) or transverse, depending upon the mecha nism of injury. Considerable energy is required to produce a femoral fracture: check for ot her injuries. Resuscitate as necessary with IV \202 uids and provide nasal diamorphine ( b p.281) or IV opioid analgesia ( b p.280). Perform a femoral nerve block (as described on b p.304) to provide additional analgesia, using 0.2mL/kg of 0.5 % plain bupivicaine (1mg/kg ). Allow 20min for this to work, then apply skin traction. Gallows traction may be used on infants and children <2 years, but is best erected on the ward. A spiral fracture in a non- ambulatory child suggests child abuse \200\224 swelling is often not dramatic. Knee injuries Knee ligament injuries are rare in children compared with adults: suspect a f racture or epiphyseal injury instead. This is a re \202 ection of the relative strengths o f ligament and bone in the child. So, for example, an injury which might cause anterior cru ciate ligament rupture in the adult will often produce avulsion of its tibial attachment in the child. This tibial plateau fracture will produce a haemarthrosis and will be apparent on the lateral X-ray. Provide analgesia and refer to the orthopedic surgeon. Patella fractures Do not confuse a congenitally bipartite patella for a fracture. The small bony fragment in a bipartite patella lies superolaterally and has rounded edges. Patellar sleeve fractures are not uncommon in children and adolescents. These osteochondral fractures typically result from high impact jumping activities or sports. Suspect clinical ly if there is local pain and tenderness and an inability to actively extend the knee. Radi ographs can be misleading as only a small bony fragment is avulsed, usually from the inferi or pole, but a large part of the articular surface is removed with it, but is impossible to see on plain X-ray. Provide analgesia and splintage and refer to the orthopedic team for M RI to con \201 rm the diagnosis ORIF. Patella dislocation This is seen relatively frequently in children and is treated in a simi lar way to that in adults (see b p.476). Examine the X-rays carefully as associated osteoch ondral \200\230chip \200\231 fractures of the undersurface of the patella occur relatively frequently in children. 727 pediatric LOWER LIMB INJURIES Tibial shaft fracture Treat most fractures as for adults: splintage, IV analgesia, and refe rral for elevation and admission. Compound fractures require IV antibiotics and wound surge ry. Displaced or angulated fractures require MUA and POP; undisplaced fractures respond to treatment with above knee non-WB POP and subsequent mobilization using crutches. Toddler \200\231s fracture Minor trauma in 1 \200\2234-year-olds may result in characterist ic spiral undis- placed distal tibial fractures. These may not be apparent on the initial X -rays: localized warmth and tenderness with a history of trauma may suggest the diagnosis i n the otherwise wide differential of the limping child ( b p.704). If a fracture is visible on initial X-rays treat by rest in a POP and arrange fracture clinic follow-up. If the dia gnosis is made without a visible fracture, treat in POP and review clinically and radiologi cally at 10 days: further X-rays may then demonstrate a long strip of periosteal tibial new bone formation. Continue to treat according to symptoms. Ankle injuries Ankle ligament injuries are less common than in adults, but are treated simi larly (as are ankle fractures \200\224 b p.486). If there is no fracture apparent on X-ray , but there is much tenderness over the distal tibial or \201 bular epiphysis, treat as a growth plate injury (undisplaced Salter \200\223Harris type I fracture) with BKPOP, crutch es, elevation, analgesia and fracture clinic follow-up. Calcaneal and other foot injuries See b Foot fractures and dislocations, p.488. 728 CHAPTER 15 Pediatric emergencies Child abuse The boundaries of what de \201 nes acceptable behavior and what constitutes ch ild abuse are open to some debate and are certainly affected by historical and cultural fac tors. For example, corporal punishment, once considered normal and usual, is now unacceptab le. The extremes of child abuse, however, are easily de \201 ned. Types of child abuse \200 Physical abuse (NAI) \200\224 including bruises, fractures, wo unds, and burns. \200 Sexual abuse. \200 Poisoning. \200 Suffocation. \200 Neglect or emotional abuse. \200 Fabricated and induced illness (previously known as \200\230Mun chausen syndrome by proxy \200\231). Prevalence It is impossible to be sure how common child abuse is. It is generally agreed th at it is much more prevalent than was previously believed. 4 % of children are brought to t he attention of professional agencies for suspected abuse. It is believed that 8 0.1 % of U K children suffer severe physical abuse each year and it has been estimated that 100 \200 \223150 child deaths occur each year as a result of abuse by parents or carers. Etiology Child abuse affects both boys and girls. The \201 rst-born child is most frequen tly affected. Infants and young children are at most risk of serious injury or death, partl y re \202 ecting their physical vulnerability. The abuser is often a parent or cohabitant of a parent, more commonly male and may have suffered abuse themselves as a child. Sometime s the child may be targeted because they are unwanted (eg \200\230she should have been a b oy \200\231). Whilst the abuser may be a young parent with unrealistic expectations and liv ing in dif \201 cult social circumstances (unemployment, drug abuse), often they do not co nform to this standard description. Child abuse affects all levels of society. Clear links between domestic violence and physical abuse of children have been identi \201 ed. Childre n whose parents have mental health problems may be more vulnerable to abuse and neglect. Role of the junior emergency department doctor Managing the child and family where there is suspected child abuse is an extremely delicate skill, requiring considerable tact and expe rience. The role of the junior doctor is to consider the possibility of child abuse and to involve a senior doctor at an early stage. Recent NICE guidance is avail- able at http://ww w.nice.org.uk/nicemedia/live/12183/44872/44872.pdf 729 CHILD ABUSE The suspicious history Certain features should alert the doctor to the possibility of child abuse: \200 Injuries inconsistent with the history given. \200 Injuries inappropriate for developmental age (eg a baby aged <3 months \200\230rolled off a bed \200\231). Changing history of injury, or vague history, lacking vivid details. \200 Delay in seekin g medical attention. \200 Abnormal parental attitudes (eg apparent lack of concern for ch ild). \200 Frequent ED attendances. \200 Occasionally, children provide an account of a buse. 730 CHAPTER 15 Pediatric emergencies Presentation of child abuse: 1 Physical child abuse is commonly referred to as NAI. Childre n may present with a variety of injuries, which may occur singly or in combination. Bruising Children naturally sustain bruises during minor incidents as part of \200\230grow ing up \200\231. Bruising over the knees and shins is a normal \201 nding in chil- dren, particularly toddlers, who are also prone to sustaining injuries to their foreheads and chi ns as a result of falls. Older children frequently sustain bruises over the lateral aspect of their elbows and hips, during normal play and sport activities. As well as considering t he possibility of NAI, remember that bruising may occur as part of an unusual patho- logica l disease process (eg Henoch \200\223Sch nlein purpura, hemophilia, ITP, leukemia, and oth er causes of thrombocytopenia). A Mongolian blue spot is an innocuous congenital \201 ndi ng on the lower back of some young chil- dren (especially non-Caucasians), which may be con fused with bruising. The following features should prompt consideration of NAI: \200 Bruising in unusual sites (eg medial aspect of upper arms or thighs). \200 Multiple bruising of different ages (ve ry dif \201 cult for the non-expert to judge) at less common sites. \200 Uncommon injuries bilaterally. \200 Finger \200\230i mprinting \200\231 (eg grip complexes around upper limbs or slap marks). Imprints or marks from other objects (eg belt, stick). \200 Human bite marks (probably ad ult if canines > 3cm apart: ensure photographs next to a ruler are planned after admission). Petechiae on the face may re \202 ect smothering and asphyxiation (it has been previously suggested that 2 \200\22310 % of SIDS may have been smothered), but remember that petechiae also occur with forceful coughing or vomiting. Wounds and burns Children commonly sustain wounds and burns unintentionally. However, delib erately in \202 icted burns are found in a signi \201 cant proportion of physically abuse d children. The following suggest the possibility of NAI: \200 Torn frenulum of upper lip (can also r e \202 ect a \200\230normal \200\231 toddler injury). \200 Perineal wounds and burns (s ee sexual abuse b p.732). \200 Small, deep circular burns with raised edges suggest cigar ette burns. \200 Hand, lower limb, and buttock burns may follow forced immersion in bath water that is too hot. These burns tend to be of the \200\230stocking and glove \200\231 t ype, without higher splash burns. Parts of the buttocks may be spared, where skin has been in contact with the bath, not the water. 731 PRESENTATION OF CHILD ABUSE: 1 Head injuries Most head injuries result from unintentional incidents ( \200\230accidents \200\231). In infants, they often result from the parent or carer dropping the child. The f ractures caused by this tend to be single, linear, and involve the parietal bone. Consider NAI if the following occur: \200 Retinal hemorrhages (characteristic, but not di agnostic of shaking \200\224 they may also rarely be seen in CO poisoning, for example). I n the context of NAI, retinal hemorrhages are often associated with subdural haematomas. Occipital skull fracture. \200 Multiple, wide or comminuted fractures. \200 Subdural ha ematoma in an infant or toddler. Natural progression of bruises Swelling and tenderness of bruising suggests relatively rece nt origin, but this is not very reliable. Accurate assessment of the age of bruising accord ing to its color is not possible, except that a yellow bruise is almost certainly > 18hr ol d. Oft-quoted natural temporal progression of color changes of bruising allows only a guess at the age of a bruise \200\224 avoid being drawn on this issue, which may have considera ble legal implications. Instead, record the \201 ndings as accurately as possible: descri be the color, size, and distribution of the bruising. Usually a child suspected of having s uffered physical abuse will also be examined by a relevant expert, such as a pediatrician a nd/or police surgeon (clinical forensic physician). 732 CHAPTER 15 Pediatric emergencies Presentation of child abuse: 2 Fractures Certain fractures are very common in children. Pay attention to the history of injury and whether or not it appears to be consistent with the fracture(s) sustained. Multiple fractures of different ages (especially if previously undi agnosed and/or not brought to medical attention) should arouse suspicion of NAI. To help as sess the approximate age of a bony injury, see Table 15.14 . Table 15.14 Natural progression of fractures Presence of soft tissue swelling 0 \200\22310 days Periosteal new bone formation 10 \200\22314 days Loss of de \201 nition of the fracture line 14 \200\22321 days Callus formaton 14 \200\22342 days 8 1 year Remodeling Remember that times vary according to the age of the child. Consider NAI in the following f ractures \200 Multiple fractures of different ages. \200 Rib and spinal fractures. \200 Fractures in infants who are not independently mobile. \200 Long bone fractures in children <3 years old. \200 Epiphyseal separation and metaphyseal \200\230chip \200\231 fractures of the knee, wrist, elbow, and ankle. These Salter \200\223Harris I and II injuri es are associated with traction, rotation, and shaking. A few rare bone diseases may mimic NAI \200 Osteogenesis imperfecta (blue sclerae, dental abnormalities and brittle bones \200\224 autosomal dominant). Pathological fractures (through multiple cystic bone lesions). \200 Rickets (enlarged, cu pped epiphyses, craniotabes, \200\230bow legs \200\231). \200 Copper de \201 ciency (eg Menkes \200\231 kinky hair syndrome). Neglect and emotional abuse There will be an element of emotional abuse as part of other fo rms of abuse, which may be manifest in the child in a variety of ways: behavioral problems, sleep disturbance, soiling, nocturnal enuresis. The neglected child may be dirty and unkem pt, fail to thrive, and/or fall below the 3rd centile for height and weight. Occasionally, nutritional de \201 ciencies may be extreme (eg rickets). Developmental milestones are oft en delayed (and may even regress). Note the apparent attitudes of the parents/carers towards their child (eg critical and host ile or remote and unconcerned) and the child \200\231s attitude to the parents/carers (if i n doubt as to whether this seems appropriate, ask an experienced nurse). 733 PRESENTATION OF CHILD ABUSE: 2 Sexual abuse This may affect boys or girls and takes many forms, ranging from exposure to i ndecent acts through to rape. The abuser is often a male relative or carer who is well know n to the child. The child may present in a variety of ways: \200 Injury to the genitalia or anus. \200 Perineal pain, discharge, or bleeding. \200 Behavioral disturbance, enure sis, encopresis. \200 Inappropriate sexual behavior. \200 The child may allege sexual a buse. \200 Sexually transmitted disease (including anogenital warts). \200 Pregnancy. A ccurately record statements made by the child \200\230word for word \200\231 using quotati on marks. Do not pursue a genital examination, but involve a senior doctor at an early stag e, who may wish to examine the genitalia using a colposcope, in collaboration with a police surgeon (clinical forensic physician). In the context of an allegation of recent sexual as sault, the collection of forensic samples for DNA analysis is likely to be required. Fabricated or induced illness (previously known as Munchausen syndrome by proxy) A parent/c arer may invent a history of illness in a child and fabricate physical signs to substantiat e it. The history often involves one or more of the following: apnoeic episodes, \201 ts, bowel disturbances, rashes, allergies, or fevers. Classically, the deceiver is the mother. The child may be made ill by administering drugs or poisons. If suspected, do not confront the deceiver, but take blood and urine samples for a toxicology screen and refer to the pe diatric team. Bear in mind that some parents may be naturally very anxious and may exaggerate symptoms, r ather than deliberately fabricate them. 734 CHAPTER 15 Pediatric emergencies Management of child abuse Role of the junior emergency department doctor The junior ED doct or needs to be vigilant in considering abuse when initially assessing and treating children . Any suspicion of child abuse should prompt involvement of an expert senior doctor (pediat rician or ED consultant). In every hospital system there will be a designated doctor for ch ild protection who should be available for advice. He or she will examine the child and arr ange hospital admission for further investigations (eg skeletal survey) as necessary. Socia l Services and the police may need to be involved. The child may require examination by a p olice surgeon (clinical forensic physician) and samples/photographs obtained. Follow local procedures. The chief consideration is the treatment and protection of the child, so do not delay treat ment of painful or apparently life-threatening problems, whilst awaiting an \200\230expert \200\231. Ensure that all documentation is legible and meticulous. Remember that if child abuse is considered likely, siblings may also be at risk. UK law: The Children Act 1989 This act replaced previous statutes. Central to the Act is th e concept that the welfare of the child is paramount. In the short term, the 1989 Children Act may be used to obtain orders to protect children. A variety of orders may be obtained: Police Protection Order A police of \201 cer has legal powers to take any child into \200 \230police protection \200\231 for up to 72hr if deemed necessary for his/her own protectio n. This order may be used to prevent a child being taken away from the ED by a parent or gu ardian against medical advice. Emergency Protection Order This has replaced the \200\230Place of Safety Order \200\231. A court order valid for up to 8 days may be obtained if the child is believed to be at signi \201 cant risk of harm. Such an order would normally be requested by a social worker. Child Assessment Order This court order may be obtained in order to allow an assessment to be performed of a child who appears to be at risk of injury. Care Order This transfers the care of a child from the parent(s) to the local authority Soc ial Services department. If a care order is in force, matters requiring parental consent sh ould be referred to the social worker (not the foster carer). Residence Order This court order de \201 nes where a child should live and who has parenta l responsibility. 735 MANAGEMENT OF CHILD ABUSE Child Protection Plan (replaces the \200\230Child Protection Register \200\231) This regis ter is kept by the social services. It contains a list of names of those children considere d to be at current risk of harm. ED staff should be aware of how to access Child Protection Register information. Previous hospital case notes are also very useful in this respect. W hen searching for previous records, remember that many children may be known by several sur names. Child protection conferences A conference may be called by Social Services if it is suspect ed that a child has been abused. Child protection conferences should be held promptly and a im to de \201 ne a protection plan for the future protection of the child and family. Unli ke the criminal courts, where the onus is on the prosecution to prove abuse \200\230beyond reasonable doubt \200\231, child protection conferences will determine whether a child is deemed to be at risk of signi \201 cant harm and whether a protection plan is required. Ca se conferences consist of a number of individuals, including: chairman (usually a senior me mber of the Social Services department), hospital consultant, GP, social worker, police, he alth visitor, teacher, education welfare of \201 cer, child abuse advisor, local authority solicitor. Parents are always invited and older children may also attend. This page intentionally left blank 737 Index angioplasty for MI 76 anion gap 99 ankle newborn 642 \200\2235 pediatric 652 \200\2235 advanced trauma life A A2 pulley injury 440 abbreviations ix \200\223xv abdominal aortic aneurysm, support (ATLS) 321 fractures 486 injuries 484 aggression 608 , 610 AIDS and HIV 242 \200\2235 airway management 48 burns 390 , 392 , 394 \200\2235 cardiac arrest 50 children 646 , 654 foreign body 648 nasopharyngeal airway 325 n ewborn 642 spinal injury 380 surgical 326 \200\2237 ruptured 530 abdominal injury, children 714 abdominal mass, children 699 abdominal pain 504 in children 727 nerve blocks 306 \200\2237 Ottawa rules 484 \200\2235 sprains 487 ankylosing spondylitis 497 anorectal problems 518 anthrax 233 , 627 anti-D immunoglobulin 5 82 antibiotics analgesia 280 in cancer 506 in children 698 in pregnancy 590 abscess 526 bites 411 , 414 in compound fractures 422 and oral contraception 569 pneumonia 111 , 687 prophylaxis 411 anticoagulants 170 antidotes 186 \200\2237 antipsychotic drugs 61 9 aortic aneurysm, abdominal, abdominal trauma 348 , 350 abortion 584 abruptio placentae 588 , 594 abscess 526 airway obstruction 45 , 112 , 324 children 677 alcohol (ethanol) anorectal 519 Bartholin \200\231s 565 breast 599 peritonsillar 554 pilonidal 518 retrophary ngeal 555 absorption, metabolism, and elimination 622