Sudden pop in the Lt ankle while playing soccer

15y/o healthy ♂; was playing soccer; while running backwards, felt a sudden pop a/w immediate onset of severe pain in the left ankle; fell on the ground; wasn’t able to mobilize initially; limping now; no prior similar episodes; no ankle pain prior to this incident; no previous injuries to the Lt ankle; ROS non-contributory; 

PMH: non-contributory; 

E/O: VSSA; 

Lt ankle: mild posterior swelling and ecchymosis; no erythema; no atrophy; tenderness over Achilles tendon with a palpable gap 4cm above its calcaneal insertion; Thompson’s test +ve; 

I/P: Achilles tendon rupture; NSAIDs; RICE; urgent ortho consult; 

Discussion^(1-2):

>75% occur in 30-40 yr olds; Male/Female=10/1; usually happens 30-40min after the start of the activity; Patients feel as if “I was kicked in the back of the leg” a/w a painful snap; 

Total rupture: Thompson’s/Simmonds’ calf squeeze test +ve; “Hatchet strike” defect (palpable, tender defect 3-6cm proximal to the calcaneal insertion) may be present in the immediate post rupture period; not palpable after a few days due to swelling; Only 25% of the tendon fibers are needed for normal Achilles tendon function, hence the difficulty in Dx of partial tears; Weak or absent active dorsiflexion; 

NSAIDs prn; RICE; ortho consult; surgical vs conservative management; needs careful patient selection; recent trend toward conservative Rx with early ROM (cast for 2wk then functional brace); conservative Rx earlier return to function; surgery less re-rupture at 1-4% (conservative at 10-30%), but ↑complications (infection, DVT & PE, adhesions); 

References: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8

2. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill.

Exposure to measles in a 9mo infant

ID: 9 mo/o infant was brought in after exposure to measles; 

HPI: Pt came into contact with an adult family member with skin rash and cold like Sx 5/7 ago; the adult patient was later diagnosed as measles; anxious parents want to know what options if any are available to prevent measles in their child; currently the child is completely asymptomatic;

PMH: non-contributory

E/O: Looks well; VSSA; 

Physical examination is completely normal.

A/P: 

A healthy 9mo/o infant exposed to measles before receiving first MMR injection which was due to be done @ 12mo;

Immune globulin (IG) 0.5ml/kg IM (IGIM) once; continue with the vaccination as planned @ 12-15mo; 

Discussion⁽¹⁾:

General rule (post exposure, non-immune): MMR vaccine within 72h; immune globulin (IG) if >72h but <6d; if non-immune and receive IG should still receive MMR, but not earlier than 6mo after IGIM, and 8mo after IGIV; IG should not be used for outbreak control; 

Post exposure, non-immune, @ ↑risk of complications (infants, pregnant women, immunocompromised) 

Infants ≤12mo: IGIM 0.5ml/kg once (infants 6-11mo may receive MMR, but IGIM preferable to MMR if household contact due to ↑transmission risk); should receive MMR as scheduled @12 mo with second booster prior to school entry; 

Pregnant women: IGIV 400mg/kg once;  

Immunocompromised: IGIV 400mg/kg once; 

Reference: 

1. http://www.uptodate.com/contents/prevention-and-treatment-of-measles?source=search_result&search=measles+prevention&selectedTitle=1%7E150

Ankle pain in a teenager

ID: 13 y/o healthy ♂ with gradual onset of Rt ankle pain 2/52 ago; now limping; not able to fully weight bear on the Rt foot; 

HPI: dull aching pain with activity; no pain at rest; no radiation; pain has gotten worse over the past 2 wk; no recent injury; Hx of mild remote injury 2mo ago while ice skating, did not seek medical advice at that time and the pain resolved completely after a few days, with no pain in the interim; no similar Sx in other joints; no previous similar episodes; involved in competitive ice skating; skipped a few ice skating practice sessions; ⊘fever/chills; ⊘B-Sx; ⊘blurred vision; ⊘GI Sx; ⊘am stiffness; 

PMH: non contributory

E/O: looks well, NAD, VSSA

Rt lower limb: 
Hip and knee joints unremarkable with full ROM.
Ankle: ⊘swelling, ⊘erythema, ⊘skin ▵s, ⊘atrophy, symmetrical compared to the Lt ankle; limited, painful dorsiflexion, ROM otherwise Ⓝ; post. heel area tender to touch; no plantar tenderness; unable to stand on tiptoe due to sever pain; pes planus; neuromuscular unremarkable;  

I/P: Rt heel pain due to Sever’s disease; RICE; reduction of athletic activities; NSAIDs prn; gradual increase of activity when pain better to a pain tolerance level; good quality shoes; vesicoelastic heel caps; f/u if pain refractory to conservative management; 

Discussion(1): 

Sever’s disease (calcaneal apophysitis) is the foot equivalent of Osgood-Schlatter disease; a traction over use syndrome; not an inflammatory condition (apophysitis is a misnomer); pain can be so sever that pt needs to use crutches; 

A cause of late childhood, early adolescent heel pain; most often between the ages of 8 and 13 yr; bilateral in ≈60%; 

Usually pt is involved in sports that need a lot of running (esp. on hard surfaces with low heeled shoes) & jumping; 

Dx is clinical; X-ray is not necessary; medial/lateral compression causes pain in the pos 3rd of the heel; sever pain with standing of tiptoe (Sever sign); Pain on foot dorsiflexion; X-ray if Dx is in question or refractory to conservative Rx (may indicate calcaneal stress # which needs immobilization 3-4wk); 

DDx may include: 

1. calcaneal bursitis
2. Achilles tendinitis
3. plantar fasciitis
4. calcaneal stress #

Rx is conservative if no response ➜ short leg cast or walker boot (duration? probably determined by the severity of the Sx); good quality shoes with adequate shock absorption and firm heel counter; ⊘ long-term sequelae; time to resolution variable, but complete resolution with skeletal maturity; 

Reference: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8

CATCH Rule in Pediatric Head Trauma

ID: 10y/o boy; referred to EM from a walk-in clinic following a fall while playing with a friend in his PE class. 

HPI: Was dragged from behind while playing, fell on the ground, and  hit his head. 15min witnessed LOC. He remembers being assessed in the office at school. Mom was notified, and took him to a walk in clinic. After vomiting once in the walk-in clinic, was referred to the ER. Was seen in the ER approximately 4h after the incident. Vomited once again in triage. Generalized head ache(HA) which was getting better, no N/V, anterograde amnesia of about 15min. 

PMH: Previously healthy. 

Meds: Non

Allergies: NKDA

E/P: Drowsy, Oriented ✗ 3, Not in acute distress (NAD), 

VSSA

HEENT: 3 ✗ 3cm bruise on the Rt temple. No racoon or Battle's signs, No otorrhea/rhinorrhea/hemotympanum. Palpation of facial bones showed no #.

Neuro:  GCS 15

Pupils symmetric, reactive; No RAPD

CN II-XII normal; Motor/Sensory normal; Gail normal

MSK: Able to move limbs ✗ 4 w/o pain.

I/P: 11y/o boy with a minor head injury, does not meet CATCH criteria for CT head. Admit for a short period of observation. D/C with f/u precautions. F/U with GP in 1wk if residual sx. 

Discussion:

The length of observation in the ER probably depends on the reliability of the caregiver, and distance of their residence from the ER. 

The CT head rule does not apply to children. Instead the CATCH rule can be used for the paediatric population with mild head injury. You can also use PECARN algorithms(3) to decide whether or not a CT head is necessary.

Canadian Assessment of Tomography for Childhood Head injury: the CATCH rule

CT of the head is required only for children with minor head injury* and any one of the following findings(1):

High risk (need for neurologic intervention)

1. Glasgow Coma Scale score < 15 at two hours after injury 

2. Suspected open or depressed skull fracture

3. History of worsening headache

4. Irritability on examination

Medium risk (brain injury on CT scan)

5. Any sign of basal skull fracture(e.g.,hemotympanum, “raccoon” eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, Battle’s sign)

6. Large,boggy hematoma of the scalp

7. Dangerous mechanism of injury(e.g.,motorvehiclecrash,

fall from elevation ≥ 3 ft [≥ 91 cm] or 5 stairs, fall from bicycle with no helmet)

*Minor head injury is defined as injury within the past 24 hours associated with witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (more than one episode) or persistent irritability (in a child under two years of age) in a patient with a Glasgow Coma Scale score of 13–15.

Below is the Canadian CT Head rule for comparison. Keep in mind that CT Head Rule dose not apply in the following situations:

- Non-trauma cases

- GCS < 13

- Age < 16 years

- Coumadin or bleeding disorder

- Obvious open skull fracture

Canadian CT Head Rule(2): 

CT Head Rule: CT Head is only required for patients with minor head injuries

with any one of the following:

High risk (for neurological intervention)

● GCS score <15 at 2 h after injury

● Suspected open or depressed skull fracture

● Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes,

cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)

● Vomiting two episodes

● Age 65 years

Medium risk (for brain injury on CT)

● Amnesia before impact >30 min

● Dangerous mechanism (pedestrian struck by motor vehicle,

occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15.

References:

1. Osmond, M., for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group, Pediat Emergency Res Canada PERC H, & Pediatric Emergency Research Canada (PERC) Head Injury Study Group. (2010). CATCH: A clinical decision rule for the use of computed tomography in children with minor head injury. Cmaj, 182(4), 341-348. doi:10.1503/cmaj.091421

2. Stiell, I. G., Cass, D., Eisenhauer, M. E., Greenberg, G., Worthington, J., Wells, G. A., . . . CCC Study Grp. (2001). The canadian CT head rule for patients with minor head injury. Lancet, 357(9266), 1391-1396. doi:10.1016/S0140-6736(00)04561-X


3. Kuppermann, N., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., . . . PECARN. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet, 374(9696), 1160-1170. doi:10.1016/S0140-6736(09)61558-0