Quantifying the ossification of the carpus in skeletal age estimation: Radiographic standards for Australian subadults.

An evaluation of the development of a child's skeleton and estimation of bone age provides an insight into a child's overall maturation. This study aimed to introduce a contemporary method for assessing bone age of Australian children using formulae incorporating carpal areal measurements. The standards introduced in this study can be used to assess the developmental status of Australian children who may be affected by growth-related illnesses. Additionally, in situations where the living age of a subadult is unknown, methodologies to accurately estimate age are required, particularly in the Western world where knowledge of the age of an individual is necessary for legal reasons. The sample consisted of retrospective hand and wrist radiographs acquired from 541 children (females: 246, males: 295) aged from birth to 20 years. Using the DICOM viewer Weasis, the carpal area ratio (B.Ar/T.Ar) was calculated for each individual radiograph by measuring the carpal bone area (B.Ar) and total tissue area of the carpus (T.Ar). A changepoint regression model demonstrated that the model constructed in this study was the most accurate in the younger age groups and was able to accurately determine whether a child was under 12 years if female and 13 years if male. A rapid acceleration of growth was observed at approximately 12-13 years in our sample, which may represent the onset of the pubertal growth spurt; this resulted in a high data variance and low model prediction accuracy in female and male children older than 12 and 13 years, respectively.

CT or not CT--that is the question. Whether 'tis better to evaluate clinically and x ray than to undertake a CT head scan!

OBJECTIVE: To evaluate the usage of computed tomography (CT) head scanning in children at the Royal Aberdeen Children's Hospital after the publication of the National Institute of Clinical Excellence (NICE) guidelines on the management of head injury. METHODS: The Accident and Emergency case records of all children presenting with a head injury over a three month period were reviewed and the number of attendances, radiographs, and CT head scans undertaken were noted. Also noted was the number of additional CT head scans that would have been performed if the NICE guidelines had been rigidly followed. RESULTS: Five hundred and thirty seven children were included in the study: 67% were boys. Two hundred and ten (39%) had skull radiographs: six demonstrated skull fractures and eight (1.5%) underwent CT head scan, with one positive report of a skull fracture. There were no reports of intracranial abnormalities. Ninety nine (18.4%) were admitted. Strictly applying all the NICE criteria for CT scanning would have resulted in an additional 54 patients being scanned. CONCLUSION: Rigid adherence to the NICE guidelines in all children with head injuries would have resulted in an almost eightfold increase in CT head scans performed. None of these children had clinical signs of intracranial injury and would have been exposed to a large amount of ionising radiation. The use of guidelines in practice must always be considered in conjunction with clinical judgement.

An unusual presentation of immersion foot.

We report a case of "green foot" in a child with a plaster cast applied for a fractured metatarsal who subsequently re-presented with circulatory compromise. The foot was green and smelly and profuse Pseudomonas aeruginosa was cultured. The infection cleared with simple exposure to air. Perhaps this diagnosis should be considered in patients presenting with circulatory compromise in a cast as severe infection can result in amputation.

Don't save the ball!

OBJECTIVES: To identify, over a period of 12 months, all attendances at an accident and emergency department by children over the age of 5 years with an injury to a wrist, hand, or finger, and to examine those sustained as a result of a blow from a ball. METHODS: The case notes of all children aged 6-13 years attending the Accident and Emergency Department of the Royal Aberdeen Children's Hospital in the year 2001 as a result of a wrist, hand, or finger injury sustained from a blow by a ball were reviewed, and the cause, type, and severity of the injury noted. RESULTS: A total of 187 children were identified; 69% were boys and football was the main sport involved. Most (93%) were radiographed, and 40% were positive; most fractures were sustained outwith school. Hand dominance was not significant. CONCLUSIONS: These injuries are common and may be preventable with modification of rules, equipment, and coaching. A register of youth sporting injuries may show if there are any detrimental long term effects.

Effect of weather on attendance with injury at a paediatric emergency department.

OBJECTIVES: To ascertain whether the weather affects the attendance rate of children with injuries at a paediatric accident and emergency department. METHODS: The maximum daily temperature and weather conditions (rain/cloud/sun) were noted over a three month period in spring/summer 2002, together with the number of children attending with new injuries or trauma. RESULTS: There was a direct association between trauma attendance and clement weather with higher attendances on dry and sunny days. There was a less obvious association between maximum daily temperature and attendance. CONCLUSIONS: These findings confirm the anecdotal belief that warm sunny weather results in a higher attendance of paediatric injuries.

Accident and emergency attendances by children under the age of 1 year as a result of injury.

OBJECTIVES: To examine all accident and emergency (A&E) department attendances by children under the age of 1 year over a period of 12 months. Also to try to identify the prevalence and severity of accident types in small children and to suggest ways to reduce such accidents. METHODS: The A&E department of the Royal Aberdeen Children's Hospital (RACH) serves a population of over half a million. All children under 1 year of age attending this department in the year 2000 had their case notes reviewed by the author and the cause, type, and severity of the illness or injury noted. RESULTS: During the 12 month audit period 1416 new cases under the age of 1 year presented to RACH, 790 of which presented directly to A&E. Six hundred and eighteen (78%) were self referred and 116 children attended A&E on more than one occasion during the year. Four hundred and thirty four (55%) of the A&E attendances were classed as "accidents", the remainder were mainly for medical conditions such as respiratory distress. Two hundred and sixty four (61%) were caused by falls and 38% were admitted for inpatient management. Two hundred and twenty nine (29%) required radiographs, which revealed 30 fractures. Thirty seven children sustained scalds/burns and there were 33 accidental ingestions. Six cases were judged to be non-accidental. CONCLUSIONS: There is a surprisingly high rate of "accidental" injury in this age group, bringing into question the effectiveness of current accident prevention strategies. Perhaps specific prevention advice should be targeted at parents and carers of young children. There should always be a high index of suspicion for non-accidental injury.

Golf related head injuries in children.

OBJECTIVES: To assess the incidence and severity of head injuries to children sustained by a blow from a golf club or ball and to highlight the potential for significant injury. An increase in public awareness of these risks might result in a reduction in morbidity. METHODS: Over a period of seven months, all children aged 3-13 years, attending the accident and emergency department with a head injury sustained from a golf club or ball had their case notes reviewed by the author. RESULTS: Thirty seven children, 78% of whom were boys, were identified as having sustained such a head injury, commonly during the school holiday months. Thirty three of the injuries were caused by golf clubs, the other four by a golf ball. Half of the injuries were to the frontal area. Twenty five children (68%) had skull radiographs but only one was positive--one child sustaining a compound depressed fracture of the frontal area. One child required cleaning and suturing of a wound under a general anaesthetic. A known epileptic child had a fit immediately after being hit on the head by a golf ball. Twenty two (60%) sustained lacerations that were repaired with steristrips or glue. Twelve had haematomas, seven complained of dizziness/drowsiness, and two had nausea/vomiting. CONCLUSIONS: Other authors have reported fatal head injuries, and it would seem that parents are unaware of the risks of serious and permanent head injury, with the potential for death, attributable to blows to the head from golf clubs and balls. The need for early tuition in the safety aspects of the game cannot be underestimated and parent and player education strategies are suggested as the main means of reducing injuries in this popular sport.

The risks of ear piercing in children.

Body piercing, and particularly ear piercing is becoming increasingly common in young children who may not be capable of properly caring for the pierced site. This may result in infection at the site and embedding of the earring. Infection and the subsequent necessity of removal of such earrings can cause considerable pain and distress. There is also a proven risk of inducing nickel allergy in these children which can be a problem in later life. The potential for serious infection such as Hepatitis B, Hepatitis C and HIV is not appreciated by the parents of these children.

Sunburn in children -- the Aberdeen experience.

Sun exposure in children is known to be a risk factor for the development of malignant melanoma in later life. The incidence of melanoma in the UK is increasing more rapidly than that of most other malignant tumours and there is now increasing awareness in adults of the necessity to protect against over-exposure and sunburn. However sun protection of children in the UK is generally less than optimum and it would appear that parents and children are unaware of the long-term risks of over-exposure to the sun. This study demonstrates significant morbidity from sunburn even in the temperate climes of the north-east of Scotland. It is suggested that strategies to reduce melanoma incidence should begin at an early age with preventative education for children, their parents, carers and teachers.

Nintendonitis? A case report of repetitive strain injury in a child as a result of playing computer games.

Repetitive strain injury is a common occupational hazard but has not been previously reported in a child. With the escalating use of computers both in the home for recreational purposes and in schools for teaching, the possible incidence of hand and wrist problems may need to be highlighted. Perhaps "hand care" instruction should be implemented in UK schools as prophylaxis.

Injuries associated with falls from beds.

OBJECTIVES: To assess the severity of injuries due to falls from upper bunks and lower beds and cots, and to ascertain the age group most at risk of such injuries. SETTING: The accident and emergency (A&E) department in the Royal Aberdeen Children's Hospital which has the only paediatric A&E department in the north east of Scotland, serving a catchment area of over half a million people. METHODS: All children attending with an injury sustained due to a fall from a bed or top bunk over five months had their case notes reviewed by the author. RESULTS: Eighty five children were identified, a majority of whom were reported to have fallen out of bed while sleeping. Twenty five sustained a fracture, 27 a head injury, 12 a laceration requiring treatment, and 21 sustained a soft tissue injury to a limb. Fourteen (16%) required admission. Sixty six (78%) of the injuries occurred in children under the age of 6 years. CONCLUSION: These results show a higher incidence of significant injury than previously reported, and demonstrate the inadvisability of letting children under the age of 6 years sleep in upper bunks. In an attempt to make parents more aware of the risks it is recommended that these dangers should be brought to public attention.

Fingertip trauma in children from doors.

Fingertip and nailbed trauma caused by doors is common in children, occurring when fingers are either shut in the door itself or are trapped in the hinge as the door is closed. An audit was carried out over five months of all fingertip and nailbed injuries due to trauma from a door. One hundred and eighty eight children, 2% of all attendances in this period, had sustained such trauma, 39% of these occurring in children under four years of age. One hundred and forty seven children (75%) had sustained relatively minor soft-tissue injury to the finger, However the remaining forty seven (25%) of the injuries sustained were more serious e.g. Avulsion of the nail from the nailbed or amputation of part of the fingertip and 29 (15%) of all the cases required a general anaesthetic for exploration, cleaning and repair. The Plastic Surgery department followed up these 29 children and 71 Accident & Emergency follow-up appointments were generated by the remaining injuries. The incidence of significant injury was higher than expected and caused considerable distress to both the children and their parents, It is suggested that home safety protocols should feature advice on how to avoid these injuries.

School referral survey.

Many schools refer children who have sustained an injury, directly to the local Accident & Emergency (A&E) department. This prospective study monitored these referrals for one school term (08.01.96-31.03.96). During this time 200 children under the age of 14 years presented from school to the A&E department of the Royal Aberdeen Childrens Hospital (RACH). The majority presented with trivial or mild injuries and 45% of parents felt that attending A&E was inappropriate. Half the accidents happened to unsupervised children. Rural children and children of working parents were less likely to attend A&E. In Grampian Region school referrals to A&E generate a significant workload for the A&E department with resultant cost implications. It would appear that a large number of these attendances are medically unnecessary and result from a desire by the school to avoid any complaint or litigation.

Evaluation of doxapram for arousal from general anaesthesia in outpatients.

In a double-blind study of 100 outpatients receiving methohexitone, nitrous oxide and halothane, the administration of doxapram 80 mg i.v. was associated with a significantly more rapid recovery from anaesthesia, the effect being more obvious in women than men. Doxapram produced a reduction of 3-4 min in the time of recovery to a safe level of consciousness. The effect was probably a result of the more rapid elimination of halothane caused by stimulation of respiration. In the patients who received doxapram the incidence of minor complications during recovery was reduced and there was some evidence of an improvement in the quality of recovery.