Pediatrics
Answers
369.The answer is d.(Fleischer and Ludwig, pp 1761-1799.)This is a case
where nonaccidental trauma (NAT)should be considered. A spiral frac-
tureof the femur in a non-ambulating child is highly suspicious of NAT.
Metaphyseal corner fractures, fractures of the posterior ribs, sternum
scapula or spinous processes, or multiple fractures in various stages of
healing may be the only presentation of child abuse.Any type of trauma
that does not fit the mechanism should raise the suspicion and alert the
physician. In this case, it is unlikely that the patient was able to fit her leg
through the crib rails and break her femur. Although in ambulating children
it is not uncommon to have spiral fractures of the femur while running. All
states have mandatory reporting of child abuse. According to the AAP (Amer-
ican Academy of Pediatrics), the skeletal surveyis the initial test of choice
for all children suspected of being abused. It is also mandatory to contact the
localChild Protective Servicesto further investigate the situation.
Osteogenesis imperfecta (a)is a rare genetic condition caused by muta-
tions of the type I procollagen gene. Children may present with fractures in
the setting of little or no trauma. Classic blue sclerae may be present. This
type of injury (e)should not be simply splinted and discharged home.
Treatment may consist of a spica cast and close monitoring by orthopedics.
For that reason orthopedic surgery (b)should be included early in the inter-
vention. Electrolyte abnormalities (c)which may be responsible for patho-
logic fractures in children are exceedingly rare when compared to child
abuse and should only be considered once NAT is excluded or in the pres-
ence of other abnormalities in the physical examination.
370.The answer is c.(Fleischer and Ludwig, pp 823-824.)This is a case of
impetigo.It is a superficial skin infection caused most commonly by S pyogenes
(group A β-hemolyticStreptococcus). When large pustules are observed (> 1 cm)
the term used to describe this condition is bullous impetigo. The typical pre-
sentation if impetigo includes honey-crusted lesions on erythematous skin.
These tend to be pruritic and easily spread by the patient. Although possible,
systemic infection is uncommon so patients typically are well appearing.
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