Point tenderness at 1 of 5 locations and limited elbow extension identify significant injury in children with acute elbow trauma: a study of diagnostic accuracy.

OBJECTIVE: Our goal was to determine whether the combination of tenderness at 1 of 5 commonly fractured sites and elbow extension accurately predicts the presence of acute elbow fractures or isolated effusions in children. METHODS: A prospective cohort study was performed using a convenience sample of patients. Children 0 to 18 years old with acute elbow injuries without elbow deformities or radial head subluxations were prospectively enrolled. The treating physicians assessed the injured elbow for the presence of tenderness at 5 locations and for abnormal active extension. The examination was defined as positive if any one component was present and negative if all were absent. The radiologist's report or a structured follow-up phone call was used as an a priori-determined composite reference standard for the diagnosis of (1) fracture or isolated effusion and (2) fracture. RESULTS: A total of 332 patients were enrolled; 183 (55.1%) were diagnosed with a fracture (31.0%) or effusion (24.1%). A negative examination result was present in 33 (9.9%), among whom 6 were diagnosed with a small effusion and 1 with a radial neck fracture. The examination's sensitivity, specificity, and positive and negative predictive values (95% confidence interval) were 96.2% (92.0-98.3), 17.4% (11.9-24.7), 58.4% (52.6-64.2), and 60.3% (47.8-72.9), respectively, for fracture or isolated effusion and 99.0% (97.1-100), 14.0% (9.5-18.5), 34.1% (28.7-39.5), and 97.0% (91.1-100.0), respectively, for fracture. A planned subgroup analysis of children younger than 3 years was performed; the elbow extension test was insensitive (sensitivity, 73.3% [51.0-95.7]) at excluding elbow injuries, albeit, when combined with point tenderness, it identified 100% of elbow fractures or effusions. CONCLUSION: The addition of point tenderness to the elbow extension test is highly sensitive at identifying injuries in children with acute elbow injuries, albeit nonspecific. Although the significance of omitting 10% of radiographs is questionable, a cost-benefit analysis would help clarify its potential savings in terms of expenditure and/or radiation exposure when compared to the risk of missing 2% of children with elbow injuries (albeit mainly small effusions).

Homocystinuria with lower gastrointestinal bleeding: first case report.

OBJECTIVE: To report a rare complication of homocystinuria in a child and highlight the association of homocystinuria with lower gastrointestinal bleeding and intestinal thrombosis. CLINICAL PRESENTATION AND INTERVENTION: A 7-year-old boy with homocystinuria and poor compliance with treatment presented with abdominal pain and bloody stools. Doppler ultrasound showed superior mesenteric and middle colic vein thrombosis. Laparotomy demonstrated ischemic small bowel necessitating resection. The patient improved clinically following resection and the initiation of the anticoagulation with homocystinuria treatment and was discharged home. CONCLUSION: This case showed the need to sustain a high index of suspicion of thromboembolism in a patient with homocystinuria and lower gastrointestinal bleeding and the importance of compliance with treatment to avoid vascular complications.