Applicability of Ottawa knee rule for knee injury in children.

OBJECTIVE: Previous studies have shown that the application of the Ottawa knee rule (OKR) reduces the need for radiographs in adults with acute knee injuries. Our objectives were to describe the epidemiology and incidence of knee injuries in children with acute knee trauma and to validate the OKR in a pediatric population. DESIGN: A prospective, consecutive study. SETTINGS: Two urban pediatric emergency departments. METHODS: All children 18 years of age and under who presented with acute traumatic knee injury of less than 1 week's duration, excluding patients with a normal knee examination, superficial skin injuries, prior history of knee injury, underlying bone disease, serious injuries involving two or more organ systems, or altered mental status were enrolled. Physicians assessed each patient for 22 standardized clinical findings prior to radiography. The OKR was applied to each patient by the investigating physician. RESULTS: All 234 patients eligible for the study had radiographs of the affected knee. The median age was 13 years with a range of 2 to 18 years. Using the OKR criteria for obtaining knee radiographs, 12 of 13 patients with fractures were identified (sensitivity 92%; 95% CI= 64-99). The missed case was an 8-year-old male who had sustained a nondisplaced fracture of the proximal tibia after a fall. If the OKR were applied to the pediatric population, it would have reduced the need for radiography in 46% of children. CONCLUSIONS: In the pediatric population studied, the OKR did not identify all patients with knee fractures. Future studies may consider modifying the OKR to accommodate the differences between pediatric and adult patients to improve the sensitivity of the rule while maintaining its specificity, before it can be applied routinely in clinical practice.

Dental concerns unrelated to trauma in the pediatric emergency department: barriers to care.

OBJECTIVES: To describe patients with nontraumatic dental problems treated in our pediatric emergency department (PED) and to determine if barriers to access prompted seeking care in the PED rather than from a dentist or dental clinic. DESIGN: Questionnaire administered to a convenience sample of patients with nontraumatic dental complaints. SETTING: An urban PED. MAIN OUTCOME MEASURES: Insurance status, primary medical and dental care, duration of symptoms, diagnosis, and reason for seeking care in the PED. RESULTS: Two hundred patients were enrolled. Median age was 17 years (range, 1-22 years). Forty-five percent were African American. Forty-nine percent had Medicaid. Fifty percent identified a regular dentist, whereas 71% had a primary care physician. Thirty-four percent of patients 4 years and older had not seen a dentist in more than a year. Children younger than 13 years were more likely than teenagers to identify a regular dentist (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.3-6.1). Those with a regular medical provider were more likely to have a regular dentist (OR = 7.7; 95% CI, 3.4-18). The most common reasons for not going to a dentist were as follows: dentist closed, 34%; lack of dental insurance or money, 17%; and lack of a dentist, 16%. Patients with symptoms for more than 72 hours were more likely to cite lack of a dentist as their reason for coming to the PED (OR = 7.4; 95% CI, 1.9-33). CONCLUSIONS: Many pediatric patients do not have regular dental care, and this is associated with a lack of primary medical care. Access barriers to acute dental care include lack of insurance or funds, lack of a dentist, and limited hours of dental care sites. Improved insurance reimbursement, active enrollment of adolescents into preventive dental care, and expansion of provider hours may limit PED dental visits and improve the health of patients.

The use of physical and chemical restraints in the pediatric emergency department.

Restraining patients is potentially dangerous and should be viewed as a last resort, to be used when no other modality of care is sufficient or when other efforts to calm the patient have been exhausted. Protocols and staff training are essential to limit inappropriate use of restraints and to protect both the patient and staff. Further clinical studies are needed in the area of chemical restraint of children and to evaluate the safety and efficacy of different methods of physical restraint.

Emergency diagnosis and management of physical abuse and neglect of children.

Injuries due to child abuse have continued to attract the attention of investigators. There was new evidence to show that cardiopulmonary resuscitation is a rare cause of rib fracture and that posterior rib fractures without a history of significant trauma are highly suggestive of abuse. An autopsy study examined ocular nerve sheath hemorrhage in deaths caused by abuse. The incidence and characteristics of abuse and neglect were studied for drowning victims. Female circumcision was well described, and physicians need to familiarize themselves with this cultural practice. The American Academy of Pediatrics published policy statements on sudden infant death and shaken baby syndrome. They stressed the need for protocols to deal with unexpected childhood deaths and to obtain autopsies in such cases. Reviews of fractures of abuse and retinal hemorrhages were enlightening. Reporting abuse and coping with violence remained topics of interest.

Congenital syphilis presenting in infants after the newborn period.

BACKGROUND AND METHODS: There has been a recent, dramatic increase in the incidence of congenital syphilis, particularly in urban areas. We describe seven infants seen during one year who were first given a diagnosis of congenital syphilis at 3 to 14 weeks of age, when symptoms developed. We reviewed these infants' charts in order to ascertain the reasons for the failure to diagnose syphilis at birth and to identify the signs and symptoms of congenital syphilis in this group of infants. RESULTS: At delivery, four of the infants and their mothers had negative qualitative rapid-plasma-reagin tests for syphilis. The other three mothers had been seronegative during the pregnancy and were therefore not tested at delivery; two of their infants were seronegative at birth, and one was not tested. When the infants became symptomatic between 3 and 14 weeks of age and were admitted to the hospital, all seven infants and the five mothers available for testing were found to be seropositive for syphilis. Four infants presented with a characteristic diffuse rash; the other three presented with fever and were found on admission to have aseptic meningitis. All these infants had multisystem disease, as evidenced by hepatomegaly, increased aminotransferase and alkaline phosphatase levels, anemia, and monocytosis. In all the infants syphilis responded to parenteral penicillin. CONCLUSIONS: Congenital syphilis may be missed if serologic tests are not performed for both the mother and her infant at the time of delivery. Even when these tests are performed, some infants are not identified as having syphilis, probably because the infection is very recent and there has been insufficient time for an antibody response to develop. Some infants with congenital syphilis of later onset do not present with a typical rash; therefore, at least in areas where the disease is prevalent, serologic tests for syphilis should be included in the evaluation of all febrile infants, even those with negative results on serologic testing at birth.