General Paediatrics

Question 1

Differential diagnoses for child not using a limb

Answer 1

• Fracture
• NAI
• Chronic osteomyelitis
• Osteoid osteoma
• Congenital cyst
• Other infection

Question 2

How do you assess for dislocated hip on x-ray?

Answer 2

Look at whether Shenton line is intact (forms an arc) or broken (=dislocated)

Question 3

Discuss femoral fractures in NAI

Answer 3

• Proximal femoral fractures are rare
• 2 types of #: shaft, distal metaphysis (classic metaphyseal lesion, bucket-handle fracture - rare but very strongly associated with NAI)

Question 4

Discuss corner fractures

Answer 4

• Bone is knocked off edge of subperiosteal collar
• Microfractures through primary spongiosa
• Can be difficult to distinguish between metaphyseal fractures and spurs - assess via F/U x-ray 2/52 later

Question 5

What findings are pathognomonic of child abuse?

Answer 5

There are no findings pathognomonic of child abuse - don’t choose this answer in MCQs

Question 6

What are the most common fractures found in child abuse <1yr old?

Answer 6

• Skull fractures
• Extremity fractures (esp humerus, femur)
• Rib fractures

Question 7

Which fractures have the highest specificity for child abuse?

Answer 7

• Rib fractures (usually posterior, paravertebral, transverse processes) and metaphyseal fractures
• Rib fractures usually undisplaced, so don’t see on x-ray until ~day 5 when callous forms. Repeat x-ray 2/52 later if high suspicion of fracture

Question 8

If suspicious of NAI, what is the risk of finding an abnormality of skeletal survey?

Answer 8

• 20%

- Skeletal survey mandatory in all suspicions <2y/o, optional >2y/o

Question 9

Why do you get an enlarged zone of calcification in Vitamin D deficiency?

Answer 9

• Phosphate has a role in apoptosis
• Vit D def -> low phosphate -> decr apoptosis -> enlarged zone of calcification
• Vitamin D deficiency doesn’t predispose to fractures unless there are clear radiological changes evident of severe Vit D deficiency

Question 10

What is the classic pattern of bruising in toddlers?

Answer 10

• Forearm
• Shins
• “T” shaped forehead/face

Question 11

What is the “Ten 4” rule in NAI?

Answer 11

• Bruising on the torso, ears, neck, soft tissues of face (+ frenulum, angle of jaw, buccal, eyelids, subconjunctival) <4yrs concerning for abuse
• Any bruise <4m age
• Patterned bruising

Question 12

What are the different shapes of hymen?

Answer 12

• Annular
• Crescentic (most common ~7yo)
• Fimbriated (folded in on itself, due to excess oestrogen)
• Septate
• Sleeve-like
• Can only make comments about abnormalities located from 3-9 o’clock as anterior to this there are too many anatomical variants

Question 13

What is a hymenal bump?

Answer 13

Intravaginal ridge, normal variant

Question 14

What percentage of children referred for sexual abuse have an abnormal examination finding?

Answer 14

4% (96% normal exam)

Question 15

What can cause retinal hemorrhages?

Answer 15

• Late onset hemorrhagic disease of newborn
• Meningococcal meningitis
• Head injury in vWD
• Pertussis?
• NAI
• Should not be seen in SIDS

Question 16

What are the spinal findings in abusive head trauma?

Answer 16

• Spinal subdural haemorrhage 40-60% (passive gravitation of SDH from brain, not often seen in accidental HT)
• Cervical spinal ligamentous injury 35-75% (due to hyperflexion/extension injury of the neck)
• Bony vertebral injury up to 5%

Question 17

What is the risk of a subdural hemorrhage following a vaginal delivery?

Answer 17

Up to 50% (uncommon with C-section), resolve by 28 days. Rarely seen in posterior fossa until 90 days, asymptomatic

Question 18

Widespread brain damage (hyperintensity) seen on diffusion-weighted MRI is suggestive of?

Answer 18

• Hypoxic-ischaemic injury
• Common finding in abusive head trauma, rarely seen in accidental injury
• Changes seen by 5-7 days post injury, then get atrophy and porencephaly (areas of dead brain)
• Due to 1) delay in seeking help 2) apnoea associated with hyperflex/ext of cervicomedullary junction
• Hypoxia doubles mortality and morbidity