Registro de traumatismos craneoencefálicos leves: estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas / Registry of mild craniocerebral trauma: Multicentre study from the Spanish Association of Pediatric emergencies

Objetivo: Revisar la actuación habitual ante un traumatismo craneal (TCE) leve en los Servicios de Urgencias y determinar los factores predictivos más importantes de lesión intracraneal (LIC). Material y métodos: Estudio multicéntrico prospectivo de 18 meses de duración realizado en 9 hospitales españoles. Se recogieron los datos de los pacientes menores de 18 años atendidos en Urgencias por TCE leve (puntuación en la escala de Glasgow de 13 a 15) en las 72h previas. Resultados: Se incluyeron 1.070 pacientes (61,2% de sexo masculino). La mediana de edad fue de 2,4 años (P 25-75%; de 0,9 a 6,4 años). La mediana de tiempo trascurrido desde el TCE hasta la consulta fue de 1h (P 25-75%; de 0,6 a 2,5h). Se practicó radiografía simple de cráneo al 64,5% de los niños y tomografía computarizada al 9%, resultó normal el 91,4% y el 84,4%, respectivamente. La prevalencia de LIC fue del 1,4% en la muestra total (intervalo de confianza [IC] del 95%: de 0,8 a 2,3). Precisó ingreso el 25,3% de los pacientes, 4 (3,7%) requirieron neurocirugía y ningún niño falleció. En el análisis multivariante, las variables que se asociaron a un riesgo incrementado de LIC fueron la pérdida de conciencia (odds ratio [OR] de 4,2; IC del 95%: de 1,1 a 17; p = 0,045), el deterioro neurológico (OR de 8,8; IC del 95%: de 2,1 a 37,6; p = 0,003) y la detección de un cefalohematoma (OR de 14,6; IC del 95%: de 4,9 a 44; p<0,001). Conclusiones: La combinación de parámetros clínicos permite seleccionar de forma adecuada a los pacientes con TCE leve que precisan exploraciones complementarias. En consecuencia, el uso rutinario de la radiografía de cráneo no parece justificado (AU)

Objective: To determine management practices of minor head trauma in children evaluated at Spanish Hospital Emergency Departments and to determine patient variables associated with intracranial injury. Methods: Multicenter and prospective study during 18 months in 9 hospitals in Spain. Patients up to the age of 18 years with minor head trauma (Glasgow Coma Scale score higher than or equal to 13 on admission), treated in Emergency Departments and with a maximum onset of 72h since the traumatism, were included in the study. Results: A total of 1070 patients were studied with a median age of 2.4 years (p25-75 0.9 6.4 years); 61.2% were male. The median time between head trauma and medical consultation was 1 hour (p25-75 0.6 2.5h). Skull X-rays were performed on 64.5% of the children and a head CT scan on 9%; 91.4% of X-ray and 84.4% of CT were normal. The prevalence of intracranial injury was 1.4% (95% CI: 0.8 2.3). Twenty-five point three percent of the patients were admitted; 4 (3.7%) required neurosurgical intervention during admission. None of the patients died. Multiple logistic regression analysis identified loss of consciousness (OR 4.2, 95% CI: 1.1 17; P=0.045), neurological deterioration (OR 8.8, 95% CI: 2.1 37.6; P=0.003) and cephalhaematoma (OR 14.6, 95% CI: 4.9 44; P <0.001) as independent predictors of intracranial injury. Conclusions: The combination of clinical parameters allows selection of patients with minor head trauma who need complementary explorations. In consequence, the routine use of skull X-ray in their initial evaluation is unnecessary (AU)

[Registry of mild craniocerebral trauma: multicentre study from the Spanish Association of Pediatric emergencies]. / Registro de traumatismos craneoencefálicos leves: estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas.

OBJECTIVE: To determine management practices of minor head trauma in children evaluated at Spanish Hospital Emergency Departments and to determine patient variables associated with intracranial injury. METHODS: Multicenter and prospective study during 18 months in 9 hospitals in Spain. Patients up to the age of 18 years with minor head trauma (Glasgow Coma Scale score higher than or equal to 13 on admission), treated in Emergency Departments and with a maximum onset of 72h since the traumatism, were included in the study. RESULTS: A total of 1070 patients were studied with a median age of 2.4 years (p25-75 0.9-6.4 years); 61.2% were male. The median time between head trauma and medical consultation was 1 hour (p25-75 0.6-2.5h). Skull X-rays were performed on 64.5% of the children and a head CT scan on 9%; 91.4% of X-ray and 84.4% of CT were normal. The prevalence of intracranial injury was 1.4% (95% CI: 0.8-2.3). Twenty-five point three percent of the patients were admitted; 4 (3.7%) required neurosurgical intervention during admission. None of the patients died. Multiple logistic regression analysis identified loss of consciousness (OR 4.2, 95% CI: 1.1-17; P=0.045), neurological deterioration (OR 8.8, 95% CI: 2.1-37.6; P=0.003) and cephalhaematoma (OR 14.6, 95% CI: 4.9-44; P <0.001) as independent predictors of intracranial injury. CONCLUSIONS: The combination of clinical parameters allows selection of patients with minor head trauma who need complementary explorations. In consequence, the routine use of skull X-ray in their initial evaluation is unnecessary.

Tortícolis secundaria a subluxación rotatoria atlanto-axial / Torticollis secondary to atlantoaxial rotatory subluxation

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Fracturas ocultas en lactantes: a propósito de 2 casos / Occult fractures in infants: a report of two cases

La fractura de Toddler es una fractura espiroidea de tibia, no desplazada, que se produce en niños pequeños secundariamente a un traumatismo, muchas veces inadvertido. Está causada por fuerzas de torsióncuando el niño gira, cae en su cuna y/o está aprendiendo a caminar y cae con frecuencia. La clínica suele ser inespecífica y, con frecuencia, no es visible en las radiografías convencionales, a veces sólo es demostrable en una de las proyecciones, por lo que a menudo se diagnostica tardíamente, al aparecer el callo de fractura. Suele confundirse con otras enfermedades que causan cojera en la infancia, como la sinovitis transitoria de cadera o las infecciones osteoarticulares. En ocasiones, es ssecundaria a un maltrato infantil. A continuación presentamos 2 casos que ilustran la dificultad diagnóstica de este tipo de fracturas en un servicio de urgencias. El primero se orientó como una sinovitis transitoria de cadera y el segundo como una osteomielitis aguda, y en ambos se realizó el diagnóstico de forma tardía

Toddler´s fracture is a nondisplaced spiral fracture of the tibia in a small child. It is due to a twisting force, and often goes undetected. The etiology is a low energy trauma. Examination may detect a pain response at the fracture site, and conventional radiographs are usually normal. Thus, these fractures may be diagnosed some weeks after injury because of periosteal new bone formation requiring the exclusion of other causes of limping in childhood (transient hip synovitis, septic arthritis, tumors). The possibility of physical abuse should be considered. We present two cases observed in our emergency department that illustrate the diagnostic difficulties posed by fractures of this type. One was initially diagnosed as transient synovitis and the other as acute osteomyelitis, until we discovered, some weeks later, that we were dealing with occult fractures

Bone mass, bone metabolism, gonadal status and body mass index.

Weight and gonadal status are the main determinants of bone mass in women. Because of this it is important to study which influences it more. The effect of weight (expressed as body mass index, BMI) and gonadal status of women on total-body bone mineral content (TBBMC) and regional bone mineral content (BMC) was investigated. A total of 373 normal women (mean age 48.9 +/- 13.4 years) were studied: 171 postmenopausal women (mean age 59.3 +/- 9.5 years; years since menopause 11.3 +/- 6.7 years); 76 perimenopausal women (mean age 48.9 +/- 2.2 years); and 126 premenopausal women (mean age 34.7 +/- 7.4 years). In all the women, TBBMC and regional BMC were determined by dual-energy X-ray absorptiometry. Also biochemical markers of bone metabolism (total alkaline phosphatase and tartrate-resistant acid phosphatase) and serum estrone and estradiol were determined. When the women were stratified by gonadal status and BMI, thin women (BMI <20 kg/m2) had significantly lower TBBMC and regional BMC, lower gonadal steroid concentration and higher levels of biochemical markers than overweight (BMI 25-30 kg/m2) and obese (BMI >30 kg/m2) women, regardless of gonadal status. Overweight and obese women had findings suggestive of increased parathyroid activity, but greater bone mass. Weight rather than gonadal steroid concentration is the main determinant of bone mass in women regardless of gonadal status.

Can a determination of tartrate-resistant acid phosphatase predict postmenopausal loss of bone mass?

BACKGROUND: A study was carried out over a 24-month interval to determine if an initial measurement of serum tartrate-resistant acid phosphatase would be predictive of bone mass loss quantified by dual-energy X-ray absorptiometry, as total bone mineral content and total bone mineral content corrected for weight. DESIGN: Sixty-two women were studied (at onset: mean age 59.7 +/- 8.9 years, 10.8 +/- 8.8 years since menopause; at conclusion: mean age 61.9 +/- 8.8 and 13.0 +/- 8.7 since menopause). RESULTS: A paired Wilcoxon test showed a small, but significant, increase in weight (P < 0.05) and decrease in height (P < 0.05). Total bone mineral content and total bone mineral content corrected for weight decreased (P < 0.005 and 0.0001, respectively). Serum tartrate-resistant acid phosphatase increased (P < 0.005). Single-regression analysis showed that the per cent bone mass loss observed between the first and second body bone mineral content measurements correlated negatively with the first serum tartrate-resistant acid phosphatase determination (r = -0.62, P < 0.0001). Changes in tartrate-resistant acid phosphatase correlated negatively with changes in total bone mineral content (r = -0.79, P < 0.0001). In a multiple regression analysis of per cent change in bone mass against initially important variables such as age, years since menopause, weight, and tartrate-resistant acid phosphatase, only tartrate-resistant acid phosphatase was significant (P < 0.0001). The sensitivity and specifity of tartrate-resistant acid phosphatase for evaluating bone loss were 86% and 78%, respectively, and the area under the curve was of 0.83 (95% CI 0.71-0.95). CONCLUSION: These results show that a simple measurement of serum tartrate-resistant acid phosphatase can help to predict the potential rate of bone mass loss in women.