Battered baby with multiple epiphyseal separations: case report and review of literature

Multiple epiphyseal separation in battered baby syndrome is a rare occurrence. We report epiphyseal separations of proximal tibia and distal humerus along with femoral shaft fracture in a child of two and half years of age. In the course of clinical, laboratory, and radiological examinations, the child was diagnosed to be a case of battered baby syndrome. The child was treated and isolated from the mother, who was the culprit for battering the child. We believe, in any epiphyseal injury below 3 years of age, particularly when the distal humerus physis is involved, diagnosis of child abuse should be considered as an etiology.     

Complete distal humeral epiphyseal separation indicating a battered child syndrome: a case report

BACKGROUND: Complete distal humeral epiphysiolysis is a rare and uncommon injury and may result from severe trauma, e.g. birth injury or battered child syndrome. CASE REPORT: This is a case report of a 5-month-old female child with distal humeral epiphysiolysis. In the course of clinical and radiological examinations, a battered child syndrome could be diagnosed. Open reduction and temporary transfixation of the distal humeral physis were performed. In the middle term follow-up, 1.5-years after the injury, the function of the elbow was nearly normal but the ulnar condyle showed growth disturbance with cubitus varus of 10 degrees . CONCLUSION: Correct diagnosis of complete distal humeral epiphysiolysis may be difficult and misinterpretation of the injury as elbow dislocation should be avoided. This particular lesion is a strong indicator of child abuse. Treatment options and the necessity of operative procedures are discussed.     

Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment

Over the past decade, nonoperative management of most pediatric blunt abdominal trauma has emerged as accepted practice. It is possible that treatment of associated hollow visceral disruption might be missed or delayed because of this nonoperative approach. In a review of all cases of intestinal perforation from blunt trauma seen over the past 6 years, we found 12 cases of intestinal disruption in more than 600 cases of significant blunt trauma. Child abuse caused eight cases and four were motor vehicle related (MVR). Seven of eight battered children had a delay of more than 48 hours from injury to hospital presentation. Three of four MVR patients had an 18-hour delay from injury to operation. Ten of 12 patients survived. The two children who succumbed were both battered and were moribund and unstable when first seen and failed to respond to aggressive stabilization and surgery. Serial physical examinations, contrast radiographic studies, and peritoneal lavage were the most helpful diagnostic modalities. There were no significant complications and no patient required more than one operation (except for ostomy closure). All surviving patients are well at followup and seven of ten have been followed for more than 3 years; two are not yet 1 year from surgery and one is lost to followup. Several principles have emerged from this review: 1) motor vehicle trauma and child abuse are the major etiologic factors in childhood blunt trauma; 2) accurate and rapid diagnosis of intestinal perforation in children is difficult; 3) recovery in the presence of stable vital signs can be expected, even with the long delays; and 4) abused children must be carefully evaluated for abdominal trauma.     

Subdural hematomas in abused children: report of six cases from Japan

In abused children, subdural hematoma is one of the most common causes of damage to the central nervous system. We report six Japanese cases of child abuse with subdural hematoma and discuss differences from those in the United States. The majority of abused children with subdural hematomas in Japan have suffered direct violence to the face and head, resulting in external signs of trauma. Failure to detect these external traces of trauma, however, might result in an incorrect diagnosis of infantile acute subdural hematoma attributed to accidental trivial head injury. Child abuse with subdural hematoma in the United States is frequently caused by whiplash shaking injury in which external signs of trauma may not be evident. In the United States, retinal hemorrhage and subdural hematoma together suggest child abuse; some cases of infantile acute subdural hematoma might be mistakenly diagnosed as child abuse. Thus, the constellation of retinal bleeding and subdural hematoma combined with the absence of visible signs of trauma is differently interpreted in the United States and Japan.     

Non-accidental injury in children--an update

The abuse of children is a universal problem. It affects children from all social classes, racial and religious groups. Child abuse involves acts of commission or omission which directly or indirectly result in harm to the child and prevent a normal development into healthy adulthood. Those responsible may be members of a family, a community or an institution. The prevalence of child abuse and neglect is difficult to measure since events tend to be unreported because they happen behind closed doors. The majority of children who have been physically abused present with soft tissue injuries, thermal injuries and fractures. This article is focused on the physical abuse of children with particular emphasis on fractures.     

Lambert-Eaton myasthenic syndrome revealing an abdominal neuroblastoma

Lambert-Eaton myasthenic syndrome is a paraneoplastic syndrome that may reveal a primitive tumor. Neuroblastoma in children and small cell lung carcinoma in adults are the leading tumors revealed or expressed by paraneoplastic phenomena. The clinical neurologic manifestations of Lambert-Eaton myasthenic syndrome are muscular weakness, sleepiness, absence of reflexes, and dysautonomia. Neurologic manifestations are explained by the induction of an autoimmune response because of the presence of antigens that are expressed by the tumor. Neurologic paraneoplastic disorders may also be the result of toxicity of drugs, coagulopathy, infection, or metabolic diseases. We describe the case of a 13-month-old child with unusual neurologic symptoms because of the presence of an abdominal neuroblastoma.     

Streptococcal necrotizing myositis: a rare entity. A report of two cases

Deep muscle abscess or bacterial myositis is not an uncommon disease in the tropics. The commonest pathogen involved is Staphylococcus aureus. However, streptococcal myositis is rare. Only a few cases have been reported in literature. Furthermore, streptococcal myositis with extensive necrosis of muscles has not been reported. In two cases of streptococcal myositis with extensive muscle necrosis, both developed severe acute infection with septicaemia. Histologic observations revealed massive necrosis of muscle tissue with acute inflammatory infiltration. This condition, which we designate streptococcal necrotizing myositis should be treated as a separate disease entity. It requires not just incision and drainage, as in bacterial myositis, but radical excision of all the necrotic muscles in addition to appropriate antibiotics. Unless it is recognized, the treatment will be inadequate and un-necessarily prolonged. Intramuscular pressure may contribute to the pathogenesis of muscle necrosis and may stimulate compartmental syndrome.     

Knotting of a Ureteric Stent in a Child

Knotting of ureteric stents is an unusual complication of their use and has not previously been reported in a child. We present a case of a 4-year-old that developed symptomatic hydronephroureter following removal of a multilength stent, which had knotted at the proximal loop. The child made a full recovery but knotting must be considered if resistance is encountered during stent removal.     

Kindesmisshandlung

Child abuse has a lot of different aspects. The number of abused children is unknown but it is clear that there is a very high number of unreported cases. Every single person is requested to help to detect child abuse. The involvement of a specialized team is mandatory if the suspicion of abuse is raised. To go and handle such a case alone is not advisable. Theoretically child abuse could be hidden behind every injury. The suspicion should be raised if the history is not congruent with the pattern of the injuries or the stage of development of the child. Even more important then to identify and treat a abused child is to prevent the abuse. Therefore the psychosocial risk factor should be well known to intervene early enough to provide help to the not coping caretakers.     

Orthopaedic aspects of child abuse

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.     

Bilateral symmetric stress fractures in a toddler

Stress fractures are a common injury among adolescent athletes and military recruits. The increase in child participation in organized sport activities has contributed to the inclusion of the skeletally immature age group among those who may suffer from this problem. Bilateral simultaneous symmetric tibial stress fractures that are infrequent in older children are even more rare in toddlers. This entity may cause a diagnostic problem as it must be differentiated from infectious disease, acute trauma or even from the result of a battered child.     

Carpal tunnel syndrome in children

Carpal tunnel syndrome (CTS) is rarely seen in children. A literature search in 1989 revealed 52 published cases. The authors review 163 additional cases that were published since that date. The majority of these cases were related with a genetic condition. The most common aetiology was lysosomal storage disease: mucopolysaccharidoses (MPS) in 95 and mucolipidoses (ML) in 22. In CTS secondary to MPS, clinical signs typical of adult CTS are rarely seen, and difficulty with fine motor tasks is the most frequent finding. CTS in MPS does not seem to be prevented by bone marrow transplantation, the usual treatment for the condition. CTS is probably due to a combination of excessive lysosomal storage in the connective tissue of the flexor retinaculum and a distorted anatomy because of underlying bone dysplasia. Mucolipidoses come next in the aetiology, with essentially similar symptoms. The authors found in the literature 11 cases of primary familial CTS, a condition which presents as an inheritable disorder of connective tissue mediated by an autosomal dominant gene; the symptoms may be more typical in some cases, but are more similar to MPS in others. A case with self-mutilation has been reported. Hereditary neuropathy with liability to pressure palsies (HNPP) is a rare autosomal dominant condition characterised by episodes of decreased sensation or palsies after slight traction or pressure on peripheral nerves; it may also give symptoms of CTS. Schwartz-Jampel syndrome (SJS), another genetic disorder with autosomal recessive skeletal dysplasia, is characterised by varying degrees of myotonia and chondrodysplasia; it has also been noted associated with CTS in a child. Melorrheostosis and Leri's syndrome have also been noted in children with CTS, as well as Déjerine-Sottas syndrome and Weill-Marchesani syndrome. Among non-genetic causes of CTS in children, idiopathic cases with children onset have been reported, usually but not always related with thickening of the transverse carpal ligament. Intensive sports practice has been reported as an aetiological factor in several cases of childhood CTS. Nerve territory oriented macrodactily, a benign localised form of gigantism, is another unusual cause of CTS in children, as are fibrolipomas of the median nerve or intraneural perineuroma or haemangioma of the median nerve. Acute cases have been reported in children with haemophilia, secondary to local bleeding. Another local cause is a musculotendinous malformation of the palmaris longus, the flexor digitorum superficialis, the flexor carpi radialis brevis (a supernumerary muscle), the first lumbricalis or the palmaris brevis. Isolated cases of childhood CTS have also been reported in Klippel-Trenaunay syndrome, in Poland's syndrome and in scleroderma. Finally, several cases have been noted following trauma, most often related with epiphysiolysis of the distal radius. Immediate reduction has cleared the problem in most cases, but exploration of the median nerve should be considered otherwise, and also in cases with delayed occurrence of symptoms. Overall 145 of the 163 reviewed cases have undergone open carpal tunnel release. Childhood CTS often has an unusual presentation, with modest complaints and children are often too young to communicate their problem. In CTS with specific aetiologies such as storage disease, the symptoms may be masked by the skeletal dysplasia and joint stiffness. Every child with even mild symptoms must be thoroughly examined and a family history must be taken. Children with storage disease may benefit from early clinical and electrophysiological screening before they develop obvious clinical signs.     

The cast syndrome incognito

This report emphasizes a potentially dangerous complication in the form of acute bowel obstruction which may confront the orthopedic surgeon as a diagnostic problem. The anatomic architecture incriminated in producing this syndrome is reviewed. The clinical criteria suggesting the diagnosis are not pathognomonic and may be misleading. Roentgenography with barium swallow is the most consistent and helpful diagnostic aid. Conservative therapy is usually successful, but duodenojejunostomy may become necessary if the conservative regimen fails. Four cases are presented in which the syndrome occurred as a complication of orthopedic treatment. The treatment of the mesenteric artery syndrome may modify the intended orthopedic regimen. It is suggested from these cases that the cast syndrome may indeed occur without a cast.     

Liver transplantation in children with biliary atresia and polysplenia syndrome

Biliary atresia is the most common indication for orthotopic liver transplantation (OLT) in children. The polysplenia syndrome anomalies, which occur in approximately 10% of children with biliary atresia, may represent special difficulties at liver transplantation. We have reviewed our experience with this syndrome in 116 children with biliary atresia who underwent liver transplantation between March 1984 and December 1989. The main features of the polysplenia syndrome, which included absence of the inferior vena cava, preduodenal portal vein, midgut malrotation, aberrant hepatic artery, and situs inversus, were encountered in 12 of the 116 children (10.3%). Severe portal vein hypoplasia (3.5 mm or smaller) was also present in 7 of these children. Eight patients received a complete and four received a reduced liver graft. The vascular anomalies increased the technical difficulty of OLT but could be surmounted, although they did contribute to the peroperative death of one child. The 1-month survival rate was 83% for the 12 children with features of the polysplenia syndrome and 88% for the other 92 children with biliary atresia alone.     

Scaphocapitate syndrome in an adolescent

Scaphocapitate syndrome is a rare injury and its incidence in immature skeleton is not well documented. We describe our experience of scaphocapitate syndrome in a 12-year-old boy and report the results after a 3-year follow-up period. Treatment involved open reduction internal fixation using K-wires. The 3-year follow-up evaluation revealed no evidence of avascular necrosis. The wrist was completely asymptomatic and the patient used it normally. The difficulty in examining an injured child and the presence of open physes on radiographs can make diagnosis difficult. Awareness among orthopedic surgeons about this injury in children is needed to avoid misdiagnosis and to initiate timely treatment.     

Diagnostic and surgical implications of child abuse

One hundred fifty-six children younger than 13 years of age with blunt abdominal injuries were reviewed, and those injured in accidents (89%) were compared with those injured by child abuse (11%). Abused children were younger (mean age, 2 1/2 years) and all presented late to medical attention with a history that was inconsistent with their physical findings. Only 65% of abused children had physical or roentgenographic signs of prior abuse, while 35% had no signs of prior abuse. The abdominal organs injured were different; 61% of accidentally injured children suffered injuries to a single, solid organ, and only 8% had hollow viscus injuries, while 65% of abused children had hollow viscus injuries. Physicians should suspect child abuse when children have unexplained injuries (especially young children with hollow viscus injuries) even when other signs of child abuse are absent, and they should suspect hollow viscus injury in abused children.     

Pathophysiology and Treatment of Streptococcal Toxic Shock Syndrome

We have recently encountered three cases of streptococcal toxic shock syndrome, each of which had a different cause. All the patients had inflammation of soft tissue in the lower extremities, and developed shock and multiple organ failure immediately after the clinical visit. The inflammation of soft tissue was necrotising fasciitis in one case, myositis in one case, and phlegmon in one. In the first case the debridement was incomplete, which resulted in an extensive ulceration. Wary of repeating this experience, we made an early diagnosis and did a thorough debridement in the second case. The patient was ultimately discharged without complications. It is rare that a patient with extensive myositis survives without amputation of the extremity. The third patient responded well to early treatment with antibiotics.     

Pathophysiology and treatment of streptococcal toxic shock syndrome.

We have recently encountered three cases of streptococcal toxic shock syndrome, each of which had a different cause. All the patients had inflammation of soft tissue in the lower extremities, and developed shock and multiple organ failure immediately after the clinical visit. The inflammation of soft tissue was necrotising fasciitis in one case, myositis in one case, and phlegmon in one. In the first case the debridement was incomplete, which resulted in an extensive ulceration. Wary of repeating this experience, we made an early diagnosis and did a thorough debridement in the second case. The patient was ultimately discharged without complications. It is rare that a patient with extensive myositis survives without amputation of the extremity. The third patient responded well to early treatment with antibiotics.     

Access to orthopaedic care for children with medicaid versus private insurance: results of a national survey

BACKGROUND: It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. METHODS: Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. RESULTS: Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. CONCLUSIONS: Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.