A child has juvenile polyposis.
What is the most common symptom to be seen in this patient?
Correct Answer B:
The most common symptom is painless rectal bleeding. Other warning signs include polyps protruding in the rectum; slipping of one part of the intestine into another; or malnutrition.
A juvenile polyp is a growth that projects from the lining of the intestine and originates in the tissues supporting that lining. It does not arise from the colonocytes (colonic lining cells) themselves but from the tissues underneath the lining cells. It is not neoplastic but hamartomatous. A hamartoma is a growth that arises from normal tissues. It is self-limiting and benign. Juvenile polyps can be solitary or multiple.
Juvenile polyps occur in children, they typically outgrow their blood supply and auto-amputate some time during or after puberty. Treatment is required only for uncontrollable bleeding or intussusception.
After diagnosis and treatment of a recurrent urinary tract infection in a 3-year-old female child, further investigation should include:
Recurrent UTIs are sometimes seen in conjunction with conditions, such as: vesico-ureteral reflux (VUR) and hydronephrosis.
VUR which is found in 30% to 50% of children diagnosed with a UTI and is a congenital condition in which urine flows backward from the bladder to the ureters and sometimes reaches the kidneys. If the urine in the bladder is infected with bacteria, VUR can lead to pyelonephritis.
Hydronephrosis, which is an enlargement of one or both kidneys due to backup or blockage of urine flow and is usually caused by severe VUR or a blocked ureter. In children < 5 years old with recurrent UTI diagnostic workup should include ultrasound and voiding cystourethrogram (choice B).
→ Renal ultrasonography (choice A) is the best initial imaging in this child with recurrent UTI to assess the kidneys for size, parenchymal thickness, and collecting system dilation. However, it is not sufficient to exclude vesicoureteral reflux.
→ Intravenous pyelogram only (choice C) and (choice E) are incorrect. Renal ultrasound has largely replaced intravenous pyelogram as the screening test of choice for the upper urinary tract because of the absence of radiation, elimination of contrast reaction risk, and noninvasive technique.
→ Voiding cystogram only (choice D) is recommended as the initial study in boys. For girls, renal ultrasound is done first.
A child is brought into the ED by his mother. She states "he screamed and started crying when I pulled his arms up (holding hands) to make him fly since he likes that a lot. He has never cried before when we played like this."
Physical exam shows that one arm is adducted and the forearm is pronated.
What is the most likely diagnosis?
Correct Answer C:
This is a case of radial head subluxations (nursemaid's elbow). In toddlers (about 2 to 3 years old), the radial head is no wider than the radial neck and can easily slip through these ligaments (radial head subluxation). Subluxation results from traction on the forearm as when a caregiver pulls a reluctant toddler forward or catches the toddler by the wrist during a fall—actions many caregivers do not remember. Symptoms may include pain and tenderness; however, many toddlers cannot describe their symptoms and simply avoid moving the affected elbow (pseudoparalysis).
Plain x-rays are normal and considered unnecessary by some experts unless an alternate diagnosis is clinically suspected. Reduction may be diagnostic and therapeutic. The elbow is completely extended and supinated, then flexed, usually without sedation or analgesia. Reduction is often marked by a subtle palpable pop or click as the radial head resumes normal position. Children may start to move the elbow after about 20 min. Immobilization is unnecessary. If pain or dysfunction lasts longer than 24 hours, incomplete reduction or an occult fracture should be suspected.
A 3-year-old white female is brought to your office because she is complaining of pain in her right arm. Her mother tells you the pain began after she pulled her daughter by the arm while the girl was fighting with her brother. You examine the child and diagnose “nursemaid’s elbow”.
You recommend which one of the following?
Correct Answer A:
Subluxation of the radial head (nursemaid’s elbow) is a common childhood orthopedic problem. There is conflicting information in various textbooks on the proper technique to reduce the subluxed radial head. However, a study comparing hyperpronation to supination/ flexion found that hyperpronation had a higher success rate. If a fracture is diagnosed, then a sling would be helpful. Neither a wrist splint nor a long arm cast is helpful in this situation. After several failed attempts at reduction, radiographs of the arm should be obtained to evaluate for fractures of the radius or ulna. The child with normal radiographs who refuses to use the arm should be referred to an orthopedist.
A toddler presents to your office with his left arm held semi flexed, adducted, and pronated. The lateral elbow has mild tenderness, and attempts to pronate or supinate the forearm cause pain. His parents don't remember any unusual recent events that could have caused this and they report that this has never happened before. The attending physician performs a rapid maneuver, and within 20 minutes the child is using the arm normally.
Which of the following is true?
Correct Answer D:
This is ordinary “nursemaid's elbow” (or pulled elbow), which is a subluxation of the radial head. It is usually an innocent injury, which typically results from a quick pull on a child's arm.
→ Radiographs (choice A) are usually not typically necessary, provided no history of significant trauma and no deformity or local tenderness (apart from at the radial head) are noted.
→ Upon presentation of any injured child, the physician must consider possible abuse (choice B), especially in cases of recurrent subluxation. However, this patient presents with the diagnosis for the first time and no other complaints, which makes child abuse unlikely.
→ Supination technique is the classic method of reduction (80-92% success rate):
→ When longitudinal axial traction is placed on an extended pronated arm, the radial head (not ulnar head, choice E) may therefore slip or tear through the weak annular ligament into the radiocapitellar articulation. This results in entrapment of the annular ligament and a subluxation (or partial dislocation) of the radial head.
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