Paediatric surgery and trauma

Question 1

Appendicitis

Answer 1

Commonest surgical emergency in children - lifetime risk 8.5% for boys and 6.7% for girls. obstruction of the lumen causes distension, ischemia, infection and inflammation

Question 2

Stages of appendicitis

Answer 2

Acute>suppurative>Gangrenous>perforation> abscess

In older children adhesions may form between the appendix and the surrounding bowel and omentum

Question 3

Symptoms of an appendicitis

Answer 3

Initially colicky abdominal pain which moves from the umbilicus to the RIF - this can vary on appendix position. Can also display anorexia or nausea after onset of pain. vomiting may happen but frequent bilious vomiting indicates bowel obstruction. mucusy Diarrhoea is also seen in children

Question 4

Signs in appendicitis

Answer 4

Unwell, pale or flushed. movement is painful with explicit guarding of the right side. Mild pyrexia may be present but will be much higher if peritonitis is present. dehydrated. PR is generally not needed if there is a firm diagnosis

Question 5

Investigations in acute appendicitis

Answer 5

50% of children will show raised WCC. Urine may be positive for blood and protein due to bladder irritation. AXR will revel a faecolith in 20% of cases. abdo USS can be very effective and specific depending on the centre

Question 6

Management of acute appendicitis

Answer 6

Surgery should be performed immediately but if there is peritonitis adequate resuscitation should be performed first to stabilise the child.
Right Lanz incision is generally used in children as it has a better cosmetic result than Mcburney’s

Question 7

Appendicitis in the young child

Answer 7

Can be hard meaning the disease may be very advanced on presentation – 80% are perforated by the time of operation. All attempts must be made to make sensitive examination possible so that signs are not missed

Question 8

Intussusception

Answer 8

An invagination of bowel into itself - cutting off the blood supply causing necrosis.This can occur between 3months and 3yrs, most common between 3 and 10months – 2x risk in boys

Question 9

Symptoms of intussusception

Answer 9

Sudden onset abdo pain causing screaming and leg flexion lasting 5-20mins. Vomiting is common, bile stained if persistent. half of cases have mucus and blood (red current jelly stool) passage PR.

Question 10

Causes of intussusception

Answer 10

1/3 will have a preceeding viral illness (GI or URTI) which causes inflammation of the peyer’s patches in the terminal ileum
2% of cases start with appendix, meckels or polyp
Haematuria or rash could point to co-existing HSP

Question 11

Investigation of intussusception

Answer 11

If diagnosis is not firm clinically then AXR or USS can be useful (target sign).
Contast enema can be used as well

Question 12

Non-operative Treatment of intussusception

Answer 12

Air insufflation PR is cheap, safe and up to 95% effective. This has a 10% reccurance rate, and should be used cautiously if there is marked small bowel distension or rectum involvement - if there is reccurance air insufflation can be tried again

Question 13

Operative treatment of intussusception

Answer 13

Surgical management should be used if other methods have failed, there is perforation or peritonism. Access is gained with a transverse right para-umbilical incision and resection is sometimes needed

Question 14

Infantile hypertrophic pyloric stenosis

Answer 14

Most common surgical cause of vomiting - 0.01-0.025% incidence 5x risk for males but possibly greater genetic element for female patients
Olive sized pyloric tumour palpable in the upper right quadrant

Question 15

Symptoms of pyloric stenosis

Answer 15

Frequent and projectile vomiting of milk from the first weeks of life - duration of vomiting controls level of dehydration – forceful, bile free vomit and visible peristalsis are pathognomonic

Question 16

Pre-operative management of pyloric stenosis

Answer 16

Electrolyte balance and dehydration should be properly assessed and managed – classically will have metabolic alkalosis, hypochloremia, hyponatreamia, hypokalaemia. Initial management is rehydration

Question 17

Operative management of pyloric stenosis

Answer 17

Pyloromyotomy - right transverse, upper abdominal incision – the pylorus is then debulked – feeding can be started the next morning starting with water. complications – vomiting (10%), wound infection or dehiscence

Question 18

Investigations of pyloric stenosis

Answer 18

USS confirms the diagnosis in 95% of cases - lumen is <8mm.
Only needed when a pyloric tumour cannot be felt.
Barium meal can also be used

Question 19

Testicular torsion - incidence and presentation

Answer 19

35% of acute scrotal presentations – total necrosis in 6hrs. Occurs most in first month of life and teenage years. sudden onset severe scrotal pain with N&V+low abdo pain
No fever or urinary symptoms

Question 20

Torsion of the testicular appendages - presentation

Answer 20

42% of acute scrotal presentations – mullerian duct produce appendages which can tort giving rise to gradual (24hrs) scrotal pain without autonomic symptoms

Question 21

Epididymo-orchitits (6)

Answer 21

Infection from blood or urinary reflux causing gradual onset of pain in pubertal/postpubertal boys – may have spread to the lower abdomen or loin, dysuria or discharge, tender & swollen epididymis, oedematous or erythematous scrotum – testicle is usually normal
Accounts for 10% of acute scrotal presentations

Question 22

Idiopathic scrotal oedema

Answer 22

Common and likely unreported – onset and offset sudden
painless oedema of the scrotal skin with erythema
otherwise healthy and no treatment is required

Question 23

Traumatic chest injuries in children

Answer 23

Rib cage is springy so organs can be damaged without fractures occuring – cannot assume the organs avoided damage just because no ribs were broken

Question 24

Testicular torsion - examination and treatments

Answer 24

testicle is high, swollen and tender – reactive hydrocele and skin oedema gradually obscures the contents. Immediate surgery is needed to untort and fix (both testes) or remove dead one

Question 25

Torsion of testicular appendages - exam and treatment

Answer 25

a small tender nodule may be palpated (blue dot sign) before oedema, and rarely, hydrocele develops – USS or surgery is needed to confirm
If clear can be managed conservatively or removed

Question 26

Interssuspection - examination

Answer 26

In 60% of cases a sausage shaped abdominal mass is present in the upper right quadrant (or rarely around the anus). If advanced they may present with peritonitis and shock

Question 27

Hypospadias

Answer 27

The urethra opens on the ventral surface and in severe cases can lead to ventral curvature (chordee). 3/1000 births and corrective surgery is performed before 2yrs using the foreskin for reconstruction.