What is the Mnemonic for the Elbow Ossification Centers?

Patient Presentation
A 12-year-old male came to clinic with a 5 day history where he had been playing around with his brother and fell on his arm. He is unclear of the exact position, but says that it was away from his body and slightly behind. He did not hear or feel a “popping” sensation, but had pain right away. There was mild pain and swelling of the elbow, but in the past day the swelling has increased along with bruising of the area. The past medical history is non-contributory.

The pertinent physical exam shows a healthy male with normal growth parameters and is Tanner II. His left elbow has marked generalized swelling and bruising especially posterior and distal to the elbow. He can extend the elbow to approximately 110 degrees. Forearm supination and pronation do not appear to be specifically affected. Distal pulses, wrist and hand movements are intact. The radiologic evaluation of a plain AP and lateral radiolograph showed an anterior fat pad sign due to hemarthosis without a specific fracture identified. All ossification centers were ossified. Contralateral views were ordered and again no specific fractures when compared were seen. The diagnosis of an elbow injury with hemarthosis was made. The patient was seen by the orthopaedic service and placed into a sling for one week of immobilization. At that time he had decreased swelling and the repeat films showed no fracture but with decreased range of motion because of pain. He was referred to physical therapy for range of motion exercises and was to followup in 3 weeks.

Case Image

Figure 94 – AP and lateral radiographs of the left elbow show elevation of the anterior fat pad, indicating the presence of a hemarthrosis. No definite fracture is identified.

Discussion
Injuries to the pediatric elbow are difficult to diagnose because of the anatomy and normal growth and ossification of the elbow.
Swelling, tenderness, ecchymosis, with or without deformity are common signs of fracture. Physical examination should include a careful neurovascular examination for distal pulses and capillary refill, paresthesias, increased pain with movement distal to the elbow or paralysis of the hand muscles as any of these may indicate compartment syndrome.

Common radiographs obtained are AP and lateral plain radiographs. Oblique films and comparison films of the contralateral elbow are also often needed to distinguish between a fracture and normal growth plate. The alignment of the anterior humerus line and the fat pads should be reviewed as misalignment may indicate occult fracture. Subtle fractures such as torus and nondisplaced fractures can be very difficult to determine. An effusion may or may not indicate a fracture.

Treatment for many fractures includes immobilization and casting for minimally displaced fractures. All non-minimally displaced fractures require urgent orthopaedic referral, and may require open reduction and/or fixation. Close orthopaedic follow-up is recommended for almost all elbow fractures.

Supracondylar fractures are 50% of elbow fractures and are usually caused by a fall on an outstretched arm. Posterior displacement of the distal fracture piece or posterior angulation usually occur but can be subtle. Complications can include range of motion and neurovascular problems.

Lateral condylar fractures are caused by a fall on an extended and abducted arm. They are Salter-Harris IV fractures because they involve an articulating surface, and therefore may have poorer outcomes. Treatment includes immobilization and casting, but may require surgical pinning with increased displacement of the fracture.

Medial epicondylar fractures usually occur with falls on an outstretchened arm or an extended and abducted elbow.

Distal humerus physeal fractures usually occur in young children and may be caused by child maltreatment. Posterior displacement of the radius and ulna relative to the humerus is a common finding.

Olecranon fractures that are isolated are uncommon. They usually occur with other elbow injuries especially dislocation or fracture of the radial head. Difficulties with elbow extension and hemarthosis is common, but visualization of the fracture may be difficult with only fat pad abnormalities seen.

Radial head and neck fractures occur with a fall on a supinated outstretch arm. These are usually Salter-Harris I and II or pure metaphyseal fractures. Like olecranon fractures they are often associated with other fractures.

Elbow dislocations are uncommon but are the most common joint dislocated in children and adolescents. It occurs by a fall on a supinated forearm with an extended or partially flexed arm (i.e. backward fall). The radius and ulna are usually laterally and posteriorly displaced. Neurovascular problems can be associated and need prompt treatment and close followup.

Radial head subluxation or nursemaid’s elbow is the most common problem involving the elbow. It usually occurs when a pronated and extended arm has axial traction applied. Early reduction can decrease the pain and anxiety of the patient and family. For more information please review What Methods Can Be Used to Reduce Radial Head Subluxation?.

Learning Point
CRMTOL is a commonly used mnemonic used to describe the usual order of appearance of the elbow ossification centers. The average age when they are seen is also given below.

  • Capitellum – 3 months
  • Radial head – 4.5 years
  • Medial epicondyle – 5 years
  • Trochlea – 8 years
  • Olecranon – 9 years
  • Lateral epicondyle – 10 years

Questions for Further Discussion
1. What is the technique for replacing a dislocated elbow?
2. How common are shoulder dislocations in children?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Elbow Injuries and Disorders and Arm Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:676-679.

Pritchett JW, Porembski MA. Olecrenon Fractures. http://emedicine.medscape.com/article/1231557-overview(rev. 6/7/11, cited 11/16/11).

Shore RM, Grayhack J. Imaging in Pediatric Elbow Trauma. http://emedicine.medscape.com/article/415822-overview(rev. 4/11/11, cited 11/16/11).

Keany JE, McKeever D. Elbow Dislocation in Emergency Medicine Clinical Presentation. http://emedicine.medscape.com/article/823277-clinical(rev. 7/20/2011, cited 11/16/11).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Can Parents Do To Keep Their Children Safe on Playgrounds?

    Patient Presentation
    A 7-year-old male came to clinic after falling off monkey bars at school 45 minutes previously. He had no loss of consciousness and was otherwise well. The pertinent physical exam showed a well-appearing child with normal growth parameters who was holding his left arm. There was pain in the mid shaft with a small amount of generalized swelling. The rest of his examination was negative.

    The radiologic evaluation revealed the diagnosis of a non-displaced diaphyseal fracture of the radius. The patient was casted and had followup arranged with orthopedics. This was the second fracture from the same playground in a few weeks. The physician asked the child about the playground and found out that there was little wood mulch under the structures, so he contacted the school about the playground conditions. He was told that the playground had been recently inspected and additional mulch was ordered. He recommended that in the meantime that the structure not be used and alternative activities be provided for the children. The principal said that he appreciated the telephone call and would take the recommendation back to the school district to see if the mulch could be available sooner.

    Discussion
    About 200,000 children are injured each year on playgrounds costing an estimated 1.2 billion dollars. Most of the playground injuries are at schools and daycare centers and gender rates and age rates depend on the study. More injuries occur in the summer months. Rates of severe injuries varies depending on classification and the specific study conducted. Fractures, lacerations, contusion/abrasion, and strains/sprains all are common injuries. Falls contribute to about 80% of injuries. Between 1990-2000, 147 children died from playground injuries – 82 from strangulation and 31 from falls. The number decreased from 2001-2008 to 40 deaths with 27 due to strangulation and 7 due to head injury. Climbing equipment and swings cause the most equipment-related injures.

    Learning Point
    The National Program for Playground Safety has a quick checklist for parents.

    The S.A.F.E. checklist stands for

      Supervision is present, but strings and ropes aren’t.
        Adult presence is needed to watch for potential hazards, observe, intercede and facilitate play when necessary. Strings on clothing or ropes used for play can cause accidental strangulation if caught on equipment.

      All children play on Age-appropriate equipment.

        Preschoolers, ages 2 – 5, and children ages 5 – 12, are developmentally different and need different equipment located in separate areas to keep the playground safe and fun for all.

      Falls to surface are cushioned.

        Nearly 70 percent of all playground injuries are related to falls to the surface. Acceptable surfaces include hardwood fiber/mulch, pea gravel, sand and synthetic materials such as poured-in-place, rubber mats or tiles. Playground surfaces should not be concrete, asphalt, grass, blacktop, packed dirt or rocks.

      Equipment is safe.

        Check to make sure the equipment is anchored safely in the ground, all equipment pieces are in good working order, S-hooks are entirely closed, bolts are not protruding, there are no exposed footings, etc.”

    More extensive checklists include:

    • Adult Supervision
      • Supervise children while they play.
      • Make sure the equipment is age-appropriate.
      • Remove drawstrings, bicycle and sports helmets, necklaces, hoods, etc. that can get caught on equipment. No drawstrings as they can potentially strangle a child especially on clothing for the head, but also on waistbands. Alternatives are to cut the strings just long enough to tie and then to also sew the drawstring in the center of the clothing so it cannot be pulled out too long.
      • Never attach or allow children to attach, ropes, jump ropes, clotheslines, or pet leashes to play equipment; children can strangle on these.
      • Report problems to the appropriate person so the they can be repaired.
    • Equipment
      • Surfaces around playground equipment should be filled with at least 12 inches of loose fill, such as wood chips, mulch, sand, pea gravel, or shredded rubber. Rubber matting that has been approved and installed correctly is also appropriate.
      • Material that may have been moved during normal use should be replaced at frequent intervals. Dirt, asphalt and concrete are not appropriate surfaces but can “filled in” with appropriate materials. Specific information can be found in the CPSC public playground safety handbook.
      • Chromated copper arsenate or CCA is a chemical that helps prevent wood rot. It was used from the 1930’s to around 2003/4 in the United States. It can be difficult to tell if the wood is treated or not, so contacting the manufacturer may be necessary. If unsure, assume it is and appropriate removal should be done.
      • Most stationary equipment should have a “use-zone” of at least 6 feet in all directions. For swings, the use zone extends back and forth and at least twice the height of the suspending bar.
      • Stationary equipment more than 30 inches high should be spaced at least 9 feet apart from another piece of equipment.
      • Any equipment openings should be less than 3.5 inches apart or more than 9 inches to prevent body part entrapment
      • Guardrails should surround all elevated platforms and ramps beginning at 29 inches of height.
      • Check for sharp edges or pointed edges on the equipment. Wood equipment should be without splinters or rot. Check the temperature of the equipment to prevent burn injuries.
      • Check for dangerous hardware such as open “S” hooks (more than a dime width) or protruding bolts (more than 2 bolt threads).
    • Playground Area
      • Check for trip hazards such as rocks, tree roots, concrete footings etc.
      • Check for hazards such as broken glass or metal on the ground.

    The Consumer Product Safety Commission has two handbooks available on home playground safety and public playground safety

    Questions for Further Discussion
    1. Name some health issues that playgrounds help to treat or prevent?
    2. Where can you find the legal requirements for playgrounds in your state or location?
    3. Where can you find certified playground safety inspector?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Fractures

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Centers for Disease Control. Playground Injuries: Fact Sheet. Available from the Internet at http://www.cdc.gov/HomeandRecreationalSafety/Playground-Injuries/playgroundinjuries-factsheet.htm statistics (rev. 1/19/2009, cited 11/4/11)

    National Safety Council. Playground Safety. Available from the Internet at www.nsc.org/news_resources/resources/documents/playground_safety.pdf (rev. 4/2009, cited 11/4/11)

    National Program for Playground Safety. Research – Injuries. Available from the Internet at http://www.playgroundsafety.org/research/index.htm (rev. 2006, cited 11/4/11)

    National Program for Playground Safety. Quick Checklist for Parents. Available from the Internet at http://www.playgroundsafety.org/safety/checklist.htm (rev. 2006, cited 11/4/11)

    Consumer Product Safety Commission. Is Your Home Playground a Safe Place to Play? Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/Pg1.pdf (cited 11/4/11)

    Consumer Product Safety Commission. Outdoor Home Playground Safety Handbook. Available from the Internet at http://www.cpsc.gov/cpscpub/pubs/324.pdf (rev. 2009, cited 11/4/11)

    Consumer Product Safety Commission. Public Playground Safety Handbook. Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/325.pdf (rev. 11/2010, cited 11/4/11)

    Consumer Product Safety Commission. Tips for Public Playground Safety. Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/Playfct.pdf (cited 11/4/11)

    Consumer Product Safety Commission. Chromated Copper Arsenate (CCA) – Treated Wood Used in Playground Equipment. Available from the Internet at http://www.cpsc.gov/phth/ccafact.html (cited 11/4/11)

    University of Michigan. Playground and Outdoor Play Safety. Available from the Internet at http://www.med.umich.edu/yourchild/topics/outdoor.htm (rev. 2008, cited 11/4/11)

    Injury Free Coalition for Kids. Parents Playground Injury Prevention Checklist. Available from the Internet at http://www.injuryfree.org/resources/PlaygroundInjuryPreventionChecklist.pdf (cited 11/4/11)

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Can You Stop A Habit?

    Patient Presentation
    A 6-year-old female came to clinic because teachers and parents had noticed that she was more fidgetty when sitting. She would cross and uncross her legs frequently especially the lower legs but more often the entire leg. This would cause her to shift her weight to her hip and sit awkwardly in a chair. There had been an increase in this behavior since the beginning of school and she seemed to not notice the problem. The teachers had offered frequent bathroom breaks thinking this was a urine holding behavior but this did not improve the problem. The parents said that she didn’t have increased frequency or urgency with urination. She denied pain or itching of the perineum. She had soft bowel movements. The past medical history showed a healthy female with normal development who had thumb sucking until 5 years of age. The family history was negative for genitourinary problems and neurologic problems. There was a distant cousin with depression, but no tics or verbal dysfluency in the family. The review of systems was negative.

    The pertinent physical exam showed a healthy female with growth parameters in the 50-75%. Her abdominal, genitourinary and neurological examinations were normal. During the interview she was noted to do the behavior when she was reading a book. The laboratory evaluation of a urinalysis was negative. Stool for ova and parasites including pinworms was negative. The diagnosis of a simple habit was felt to be most consistent, but testing for possible other common problems was done. The patient was encouraged to sit properly and to put her legs around the chair, desk or table that she was sitting at. She was also offered the option to sit cross-legged. Parents and teachers helped support these changes and during a subsequent acute care visit the mother reported that she had much less fidgeting than before.

    Discussion
    In 1973, Azrin and Nunn published the first paper on habit reversal. Their 12 patients (ages 5-64 years) had immediate improvement in a variety of problems including nail-biting, thumb-sucking, hair pulling and tic behaviors. Others have built upon their methods and shown efficacy in a number of habits including tics, stuttering, hair pulling, skin picking, nail biting, finger sucking, etc.

    Habits can be automatic or focused. Automatic being that the habit occurs when the patient is not aware (e.g. studying, sitting in a car, etc.). Patients are not aware of the habit until sometime later or the episode is complete (e.g. nail is ripped off). Focused is when there is a awareness of the episode, but the patient does the habit anyways.

    As patients need some cognitive awarness to be able to do habit reversal techniques, children younger than 5 years may not be able to comply with the methods. Additionally, habits that are bothersome to others but are not causing problems to the child socially, mentally or physically may not need treatment.

    Learning Point
    Habit reversal training has 3 main components:

    • Awareness training – methods to make the patient more aware of the habit including being aware of its warning signs (e.g. tickle in throat before tic), movements that make up the habit (e.g. moving head down and arm up to pull hair), and the circumstances around the habit (e.g. finger sucking worse when tired).
      • Methods can include:
        • Daily recording of the number of times the habit is performed
        • Listing problems the habit is causing
        • Identifying the situation, people and activities that cause the habit to occur
        • Documenting how the habit physically takes place
        • Practicing how to deal with the habit in various situations
    • Competing response training – teaching the patient to do something that competes with performing the habit, i.e. substitute a different behavior (e.g. deep breathing to lessen tic, clinching fists for hair pulling, pulling on clothing or chair for nail biting, etc.) The competing response should be something that competes with the habit, is easily physically possible and is inconspicuous.
    • Social support – having family and friends support the patient to perform these activities.
      • Methods can include:
        • Having family and friends positively comment when the patient performs the competing response
        • Having family and friends gently remind the patient to be more aware and perform the competing response when they perform the habit
        • Having the family and friends support the patient in situations they may have avoided because it increases the habit

    Other habit reversal methods can include performing relaxation techniques and massed practice (having the patient do the habit multiple times at different times of the day).

    For example, a teen who knows that she inadvertenly does skin picking when she is stressed, tired and/or doing homework, could try to use hand lotion during those times as a competing response. This also helps to briefly decrease the skin dryness which is also a contributor. A child like the one was taught to wrap her feet around the legs of the chair, and sit cross-legged instead of frequently criss-crossing her legs.

    Questions for Further Discussion
    1. What signs or symptoms would make one concerned about an underlying psychiatric diagnosis and not a simple habit?
    2. When does a habit need psychological treatment?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Children’s Health and Mental Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973 Nov;11(4):619-28.

    Christophersen ER. Behavior Management Theory and Practice. In Behavioral and Developmental Pediatrics, Parker S and Zuckerman B, eds.. Little Brown and Co. Boston, MA, 2005;50-51.

    de Kinkelder M, Boelens H. Habit-reversal treatment for children’s stuttering: assessment in three settings. J Behav Ther Exp Psychiatry. 1998 Sep;29(3):261-5.

    Piacentini J, Chang S. Habit reversal training for tic disorders in children and adolescents. Behav Modif. 2005 Nov;29(6):803-22.

    Chida Y, Steptoe A, Hirakawa N, Sudo N, Kubo C. The effects of psychological intervention on atopic dermatitis. A systematic review and meta-analysis. Int Arch Allergy Immunol. 2007;144(1):1-9.

    Flessner CA, Busch AM, Heideman PW, Woods DW. Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behav Modif. 2008 Sep;32(5):579-94.

    Flessner CA. Cognitive-behavioral therapy for childhood repetitive behavior disorders: tic disorders and trichotillomania. Child Adolesc Psychiatr Clin N Am. 2011 Apr;20(2):319-28.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    . Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Is More Treatment Needed for Infantile Hemangiomas?

    Patient Presentation
    A 9-month-old male came to clinic with a 2 day history of intermittent bleeding from one of his hemangiomas on his left arm. The bleeding was mainly of serous fluid with a small amount of blood. It was easily controlled with pressure and a bandage changed 2-3 times per day contained the fluid. The patient did not appear in pain and did not have redness around the lesion or fever. The patient was otherwise well. His mother was concerned because she had been told that if bleeding kept happening then he might need some treatment. The past medical history showed a healthy male infant who had his first hemangioma on his left lateral back appear around 6 weeks of age. Three others than appeared on his left arm, left flank and right anterior chest. All had increased in size but had been stable per his mother for a couple of months.

    The pertinent physical exam showed a smiling infant with growth parameters in the 10-50%. His cardiac and abdominal examinations were negative. His skin examination showed one 0.5 cm cafe-au-lait spot on his right posterior calf. The left lateral back had a 5 mm x 2 mm raised red lesion that was circular. The left flank had a 10 mm x 3 mm raised red lesion that was circular. The right anterior chest had a 12 mm x 3 mm raised red lesion that was mainly oval but slightly more irregular. All had distinct borders and consistent coloration. The left arm was 22 mm x 5 mm raised red lesion that was circular. About 10 o’clock to the center of the lesion was a “crack” with a minimal amount of serous fluid. A thin wet scab was present. No pain or tenderness was elicited and there was no red streaking from the lesion. There was full range of motion in the arm. Documentation from previous visits showed the lesions to be about the same size previously. The diagnosis of a probably traumatized hemangioma was made. The mother was told to continue to monitor it and try to minimize repeated trauma if possible. She was also told how to control bleeding if necessary. The physician reiterated the natural history of the lesions and didn’t believe further treatment was necessary at this time unless the bleeding got worse or would not resolve.

    Discussion
    Infantile hemangiomas (IH) are the most common soft tissue tumors in infants. They are usually considered birthmarks but are dynamic lesions. They usually begin in the first few weeks of life and rapidly grow in the first 3-5 months of life. By 5 months, most lesions will have achieved 80% of their final size. Almost all IH have cessation of growth after 9 month of age. Images of IH can be seen in the To Learn More section below.

    Learning Point
    Often no treatment is necessary for IH other than expectant monitoring. Additional treatment may be necessary depending on the patient’s age, lesion type, location, size and complication being considered.

    The results of a prospective cohort of 1058 children in 7 pediatric dermatology clinics found that overall 24% of patients had complications and 38% needed treatment. Hemangiomas are more likely to have complications and receive treatment if they are:

    • Type: segmental (55.5%) or intermediate (24.9%); localized (9.6%) or multifocal (9.1%) were less likely
    • Location: perineum (47.9%), face (43.0%) and head and neck (31.1%). Those on the extremity (20.6%) and the trunk (11.5%) are less likely
    • Size: Large are more likely than small

    Hemangioma complications include:

    • Ulceration – the most common complication. A white discoloration on the lesion may be involution or ulceration. Ulceration is painful and usually heals with scaring.
    • Bleeding – significant hemorrahage is rare
    • Cardiac failure
    • Infection – cellulitis, abscess
    • Obstruction of vital organs with associated morbidity- eye, airway
    • Element of syndrome or other process
      • Hypothyroidism
      • Diffuse neonatal hemangiomatosis
      • Kasabach-Merritt phenomenon
      • PHACE syndrome
      • PELVIS or SACRAL syndrome
      • Occult spinal dysraphism
    • Scaring/disfigurement
    • Psychosocial problems for patient and family

    Treatment includes antibiotics, dressings, pulsed-dye laser or other type of laser surgery, surgical excision, propanolol, corticosteroids, and recombinant growth factors.
    Consultations with dermatology, otolaryngology, ophthalmology, and plastic surgery may be necessary.

    Questions for Further Discussion
    1. What birthmarks are potential signs of an underlying medical problem?
    2. What treatment options can be considered for recurrent bleeding in infantile hemangioma?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Benign Tumor and Birthmark.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, Lucky AW, Mancini AJ, Metry DW, Newell B, Nopper AJ, Frieden IJ. Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment. Pediatrics. 2006 Sep;118(3):882-7.

    Chang LC, Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, Lucky AW, Mancini AJ, Metry DW, Nopper AJ, Frieden IJ; Hemangioma Investigator Group. Growth characteristics of infantile hemangiomas: implications for management. Pediatrics. 2008 Aug;122(2):360-7.

    Antaya RJ, Dirk M, Elston DM. Infantile Hemangioma. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/1083849-treatment (rev. 7/27/2011, cited 10/24/11).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital