Diagnosis, Management & Treatment Flashcards
Causes of a limping child under 4 years old
- Septic arthritis (requires immediate surgical intervention)
- Osteomyelitis
- DDH
- Toddler fracture.
- Soft tissue injury
- SPA
Roles of the radiographer - suspected SPA
- Document; What you have seen, The behaviour of child and parent, What has been said, Oter healthcare professionals, time and date, what has been told to you, and sign it
- Inform and discuss with line manager/senior member of staff
- Discuss with paediatrician for Child protection/Child protection advisor
- If there is any immediate concern for safety for child/staff call police
NO CHILD PROTECTION CONCERNS
5. Inform named person for appropriate follow up
CHILD CARE CONCERNS
5. Discuss with named person - agree actions s appropriate
CHILD PROTECTION CONCERNS
5. Immediate referral to one of the 3 interagency referral; social work, police or child protection advisor
Skeletal survey
- A senior clinician (paediatrician) will need to request in SPA
- For children under 2 imaging should always include a skeletal survey (CT head can be done if evidence of head trauma). For children under 1 imaging should always include a skeletal survey and a CT head.
- Skeletal surveys on children over 2 can be done on a case by case basis
- Where abdominal or thoracic injury is suspected, a CT body can be requested
- Skeletal surveys will need to occur as soon as possible within 72 hours
Limping child pathway
- Patient presents with limp
- Assess what. Could be the cause of the limp
- Does the child have any history of trauma
IF NO:
4. Assess child on basis of age and history/examinatin
IF YES:
4. Consider x-rays, referral to orthopaedics and consider child protection in younger children.
A child’s femur fracture
- A child’s femur fracture is any sort of fracture occurring below the Lesser trochanter
- A mid-diaphyseal fracture is the most common presentation (can be found in both unintentional and SPA)
- Under the age of 15 months a spiral fracture is the commonest abusive femoral fracture
- Once a child can walk, they can get a spiral fracture when falling whilst running. For a child who is not independently mobile, a femoral fracture is suspected for SPA regardless of type.
- Other elements of a child’s health should be taken into considerations, eg. Age, bone development, and social circumstances.
- Above lesser trochanter fractures account for less than 1%
Management and Treatment SPA
- A paediatric femur fracture can heal without surgery.
- A child’s bones are still growing, growing in size and length
- ORIF OR FEMORAL NAILING IS NOT APPROPRIATE; it ca hinder the normal development of the bone
- Baby under 6 months old can have a Pavlik Harness
- In children between 6 months and 5 years a Spica cast would be more appropriate (may have MUA beforehand)
Rib fractures (SPA)
- In the absence of underlying disease or major trauma, rib fractures are highly specific for SPA
- Rib fractures are commonly multiple and may be unilateral or bilateral. They often occur at the same location on adjacent ribs and typically affect ribs 4-12.
- Most common rib fractures are posterior ribs. However, first rib, anterior rib and lateral rib may also get reported.
Purpose of a skeletal survey
- Detect and describe any fractures
- Estimate the age of any fractures
- Check bones are normal identify underlying skeletal disorders
- Identify any other bony injury
Clinicians Role
- When SPA is suspected a referral must be made to the social care team as soon as possible within 24 hours
- Complete clinical information must be provided for her request which will be justified by a radiologist
- The referring clinician should explain the reason for the request to the person with parental responsibility, including the procedure and risks. An informative leaflet should also be provided
- Written consent should be obtained from the person with parental responsibility for all SPA imaging.
- If consent is declined an application will be made to the court (within 72 hours)for the procedure to be undertaken, as the child’s safety is paramount.
Radiographer considerations (SPA)
- Consent must be reaffirmed
- If consent is withdrawn at any point, skeletal survey must stop,and child must be referred back to Child protection advisor
- Skeletal survey must be completed and reported within 24 hours and no later than 72 hours.
- If trained radiographer isn’t available aim to transfer child (radiography network)
- 2 radiographers must be present be present who have performed post grad, post reg and level 3 safeguarding training
- Correct patient ID, by both radiographers verbal and written
- A nurse with level 3 training must also be present
- If there’s no immediate safety concern for child, allow parent into the room
Radiographer practicalities SPA
- Skeletal survey should be taken in a child friendly environment
- Use the parent if possible, if not at all use staff for immobilisation (document)
- Use distraction toys, consider play therapist
- If child is too distress consider sedation
- Anatomical side markers are a MUST (can be used in the court of law)
- No collimating, rotation allowed
- Complete appropriate documentation
- Send for reporting within 24 hours, must check
- Complete any additional imaging required
Skeletal survey procedure
Head, chest, spine and pelvis
• AP and lateral skull
• AP chest (include shoulders)
• Oblique chest, left and right (to include all ribs 1-12).
• AP abdomen and pelvis
• Lateral views to include whole spine (one view on children under 1-year-old)
Upper Limb
• AP of whole arm
• (AP humerus and AP forearm on larger children)
• Coned lateral elbow
• Coned lateral wrist
• DP hands and wrist
Lower Limb
• AP of whole limb
• Coned lateral knee and ankle
• Coned AP ankle
• DP foot
• (AP femur, AP tib/fib, AP knee, AP ankle, lateral knee, lateral ankle, DP foot on larger children).
Follow up imaging (SPA)
- All skeletal surveys should have followed up imaging
- Should be between 11-14 days,no later tan 28 days
- To assess fractures that become visible after healing
- Can assist with dating images
Radiographs should include:
• Chest AP and both obliques
• AP whole arm
• AP lower limb
• Radiographs of any abnormal or suspicious areas on initial SS.
• For larger children AP humerus, AP forearm, AP Femur, AP tib/fib instead of whole arm and whole leg
Other modalities SPA
- RNI is not. Used as the epiphyseal plates are dynamic and metabolically active. Fractures could be hidden.
- CT can be used for head, abdomen and chest injuries but can replace SS.
- MRI and US are also considered of soft tissue injury is suspected alongside fractures.
