Minor injuries - three questions that will determine what to do every time (Easter Egg - Finger injuries)

What is a minor injury?  What is minor to you or to me may not be minor to the child or parent.  Many a time I have been surprised by how pleased a child is to need a cast, or how distressed they are to be given a splint or dressing that needs to be kept dry.  I seem to ruin many a trip to Skeg Vegas in this way.

So, since our opinion seems unimportant, we must ask the important questions.  There are only three:

Lets try these questions on an injured finger.  Jacinda has injured a couple of fingers when they were hyperextended (bent back) by a basketball.

Question 1 - Does it need to be fixed?

Fingers are quite good in this respect because they are easy to inspect and (most) people have a finger on the other side to compare to.  So we allow the finger to fall as it is and see how it aligns with the other fingers.  If a finger is angulated or rotated it will need to be fixed.

Fingers should look well aligned when relaxed.

If there is an apparent angulation or rotation, this needs to be corrected before the fracture sets otherwise there may be a long term functional defect.

Question 2 - Might there be a sneaky injury?

That is very unlikely, but then that is what is so sneaky about sneaky injuries.  They come too rarely for us to expect them.  In fingers, there are three possibilities.

Possibility one is a flexor tendon rupture.  All we need to do to check for this is check flexion twice.  The first time is a simple flexion to test the deep flexor tendon (FDS) and the second is with the other fingers held in extension by the examiner.  This inactivates the deep flexor tendon  so that the superficial tendon (FDS) can be tested.

Possibility two is an extensor tendon rupture.  This is essential to detect and easy to test for.  The finger must be extended against the examiner's finger in order to exclude the 'mallet finger' injury.

Possibility three is a collateral ligament rupture. Gentle lateral force will detect any instability of the interphalangeal joints.

Question 3 - Does it need to be immobilised?

Jacinda's finger wasn't bent or twisted on examination.  Nothing was ruptured.  It just hurts.  It may even have a fracture.  The question remains, can and should it be immobilised?

The figure below, from Elselvier Journals "Isolated finger injuries in children — incidence and aetiology" shows that fingertips are the most common finger injury in children.

The thing about fingertips is that you can't really immobilise them and they don't really need it.  The fibrous sheath does that job for you.  You can immobilise the distal interphalangeal joint if needed but in doing so you will put pressure on the fingertip.  So, immobilisation can make pain worse as well as better.  Each injury is judged on its own merits.

Immobilisation can also make things worse by making things stiff.  Taking an extreme example, when someone comes out of a cast after a month or more- their joint is so stiff that it may not move at all.  If immobilisation is not needed, it is best to avoid making things worse.

More on that story in a later post.

Finally, one of the most easily treated finger injuries.  As per the above research, finger tips are often injured.  One common problem is the subungual haematoma.  Because nailbeds are sensitive, the pressure of a collection of blood trapped under a finger nail is very painful.

A hole made in the middle of the nail overlying the haematoma will relieve that pressure and reduce the pain considerably.  This can be done with a special tool but if you are patient, a standard needle also gets there in the end.

Many thanks to the hand models for consenting to their fingers to be photographed in the name of science. So, go ahead and treat a finger.  All you have to do is answer three questions.

Edward Snelson
@sailordoctor
Southwest Sheffield Thumb War Champion 1994

Disclaimer: All rights reserved on images in this post.  Feel free to post your reservations.

Reference
N.V Doraiswamy, Isolated finger injuries in children — incidence and aetiology, Injury

You might also like to read about the general principles of treating (and not treating) minor injuries in children.

The Dysfunctional Dictionary of Developmental Delay

Children who have not reached a developmental milestone frequently present to primary care.  Sometimes the concern is raised by a parent but often it is another family member, a teacher or a health care professional who spots the ‘delay’.   Often, there is no significant problem.  Some children just do their developing differently.  This is not developmental delay.  However, true developmental delay is quite prevalent and the terminology used is frankly misleading both to clinicians and parents.  Understanding what is wrong with the words used is the key to coming to grips with this difficult subject.

The Dysfunctional Dictionary of Child Development

Milestones – this word is used to describe the age at which a child should do a thing.  In the same way that children behave unpredictably, they may not meet these targets.  These ‘norms’ are based on population studies.  Because children vary they may not fall within a specific milestone norm.  Some children skip a milestone entirely (e.g. crawling) but hit their next milestone (e.g. cruising) normally.

Developmental delay – This term suggests that a child is simply late getting to a developmental level.  If there is a pathological developmental delay, this is unlikely to be the case.  If a child has true delay, they will almost certainly be permanently behind their chronological age. In other words they will not 'catch up'.  (see diagram above)

Developmental delay – Another problem is that the term implies there is always a neurodevelopmental cause.  This fails to give weight to the fact that delay can be due to something which obstructs development.

Global Developmental Delay – A child has GDD if they are delayed in at least two of the developmental domains.  They can be developing normally in the other two and is therefore a misnomer.

Developmental impairment – This is a more accurate term than developmental delay.  It’s just that I think that it doesn’t sound very nice.

Intellectual impairment – this is the correct term if we are talking about the over 5 year old.  Developmental delay or impairment should only be used for the under five year old.  Who knew?

Of course we need terminology and this vocabulary is what we have to work with.  We just need to know the limitations of the words we use so that they cause minimal confusion.

What is a primary care clinician to do when a child has a possible developmental delay?  Because there is so much variability in children it is reasonable to watch and wait (in the absence of red flags) when there is a ‘late’ milestone in an isolated domain.  If the delay persists or involves more than one domain then the chances of a significant problem is higher.

It is worth considering the causes of delay that can be relatively easily identified.  Delay in one domain is more likely to have such a cause.  For example, a child under the age of 2 who is not meeting their gross motor milestones may have dislocated hips.*  A child with speech delay may have ‘glue ear’.  These problems will obstruct development so early identification of such things can be life-changing.

Another cause that could be identified in Primary care is Muscular Dystrophy.  Although rare, this is an important cause of delayed mobility in boys.  A normal Creatinine Kinase (CK) is an easy way to rule this out if a boy is not achieving gross motor milestones.

What should I do in primary care?

• Take the history
• Examine the child including
• Primitive reflexes
• Tone and posture
• Head circumference
• If delay is limited to one domain, look for an identifiable/ treatable cause
• Speech – hearing test/ speech and language assessment
• Gross motor – check lower limbs including hip dislocation. Test CK in boys.
• Fine motor – test visual acuity
• Social – encourage environmental stimulation if appropriate.  Consider possible autistic spectrum disorder.
• Observe initially if appropriate or refer if red flags

While most cases of true developmental delay are idiopathic, advances in genetic testing mean that a cause can often be found. Although this rarely leads to specific treatment that does not mean that we should not investigate for a cause.  It is very important to most parents to find out why their child has developmental delay both for understanding and to help get appropriate support.  In addition a diagnosis may have a recurrence risk in future pregnancies.

Edward Snelson
@sailordoctor
Dysfunctional Lexicographer

*Congenitally dislocated hips is now more correctly named 'Developemental Dysplasia of the Hip')

Kids get hit in the head a lot

A few weeks ago, I wrote about some general principles for assessing minor injuries in children.  I promised to follow this up with posts about specific injuries and instead wrote about some other nonsense.  But then I do get hit in the head a lot.

Head injury is the most common type of minor trauma presentation in children.  This is not just because they bump their heads easily.  It is also because there is a fear that there will be more significant consequences from that injury.  Because the head contains the brain, there is a concern that there may be some internal damage that cannot be seen.  This anxiety is obvious in the parents but is also often there in the clinician.  We therefore need to know when to worry and when not to, otherwise too many children have unnecessary time spent in emergency departments or worse still, have unnecessary investigations.  The good news is that anxiety is often unnecessary.

Thanks to much research on the subject, there is a lot known about what is likely to indicate a significant head injury.  As a result, those working on the front line have good evidence to back up a clinical, common sense approach to assessing children following a head injury.

Firstly, let me remind clinicians of the ‘special patient’ rule, since that is either absent or poorly emphasised in most guidelines.

For the rest, there are two main questions to be asked:

• What happened at the time of the injury?
• How is the child now?

The ‘what happened?’ question is about two things.  Firstly, what was the mechanism?  The amount of force delivered and the way that it was delivered are both important.  If a child falls 8m and lands on a snow drift, they might be OK.  If they fall out of a ground floor window onto a hard surface they will still probably be OK.  If they fall 5m out of a window head first onto a rock, then they have a good chance of a skull fracture.  Mechanism is especially useful in children who are more difficult to assess such as neonates.  A study published last year (2) found that "Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI (intracranial injury) or skull fracture."

The second part of ‘what happened?’ is the effect on the child.  The absence of red flags occurring immediately after the injury is very reassuring.

This is where things can become a little tricky.  History and examination of children following head injuries can be full of vague and uncertain information.  That is not a problem.  First of all find out what you can be sure of, and then decide about what to do with the rest.  Often, the certainties make the uncertainties irrelevant.

Note that it is not necessary to assume the worst.  Many injuries are not directly witnessed.  Even when they are, the information may be confused or unreliable.  That is fine.  I think that it all depends on how the child is when they present.  If they are back to normal, it is safe to take the approach of only counting definite loss of consciousness as having occurred.  Being briefly unrousable is probably too vague.  Similarly, if the child is confused or lethargic at presentation, there is no need to deliberate about whether there was or wasn’t enough vomiting to be called persistent.  The child’s condition now over-rules that speculation.

That brings us onto how the child is when they present for assessment.  This is the most important filter.  In most cases, a child will declare themselves fully fit.  A child who is back to being their normal self and shows interest in normal activities is telling you that their highest brain functions are normal.  You should take that as the gift that it is.

Again, there may be some uncertainties.  It is always difficult if the child is now tired or grumpy to be sure that they are back to normal.  If the mechanism was benign and there were no ‘at the time’ red flags, it is often possible to avoid over-caution even in these circumstances.  However, if there is uncertainty about a loss of consciousness and about how alert the child is, caution is probably wise.

But what about the lump?  This is the subject of one of the great paediatric myths.  Parents are always worried that a lump is a bad sign.  Of course in a baby, it is.  A growing skull has enough give so that soft tissue swellings are rare.  There just isn’t usually much energy transmitted to the soft tissue.

When a baby gets a swelling on their head after an injury this is often a haematoma.  The presumption is that this has been caused by skull fracture and the subsequent bleeding.  For this reason, a ‘boggy’ (squishy) swelling on a baby’s skull is a skull fracture until proven otherwise.  They may not even appear unwell since their open sutures allow the brain to avoid any pressure effects (initially).

In an older child, a swelling in a well child is not the same deal at all.  If a 12 year old gets a swelling on their head after a knock, but are otherwise well, they almost certainly have a soft tissue swelling.  It takes a lot of force to fracture the skull of a 12 year old and such injuries should flag themselves up in some other way than simply as a lump.

The NICE guidelines for head injury published in 2014 (2) made this distinction by specifying that it is the under one year old group for whom lumps on heads are a concern.

So, there are often uncertainties but these should rarely get in the way.  Children will present to many health care setting with head injuries and if they declare themselves well, it should not matter too much who or where you are.  What matters is that you have the skills to assess a child and evaluate what you see and hear.  If you hear and see nothing bad, then it really is as simple as that.  But don’t take my word for it.  I get hit in the head a lot.

Edward Snelson
PhD in age-specific phrenology
@sailordoctor

Disclaimer: If you’re uncertain about your uncertainties, it is probably best to send them my way so that I can be uncertain for you.  After all, that is my job.

References

1. P. Burrows et al, Head injury from falls in children younger than 6 years of age, Arch. Dis. Child. 2016;0:2016 archdischild-2015-308424v-archdischild-2015-308424
2. Head Injury: Assessment and Early Management, NICE, 2014