How is Renal Trauma Categorized?

Patient Presentation
A 17-year-old female came to the emergency room with a history of being hit on her left side playing soccer. She had some pain in her flank but continued playing. This pain stopped after the playing but her left inner leg began to hurt. About two hours after the hit she had painless gross hematuria. She denied any other trauma, or illnesses. Her last menstrual period was 1 week prior. The family history was negative for kidney disease, autoimmune disease, congenital abnormalities or hearing problems. The review of systems was negative.

The pertinent physical exam showed a healthy teen with some limping of her left leg. Her vital signs were normal including her blood pressure. Her physical examination was notable for pain of the medial upper thigh especially with abduction. Abdominal and genitourinary examination were negative. The diagnosis of presumed renal contusion and muscle strain were made. Because of the risk of renal injury a computed tomography study of the abdomen and pelvis was ordered and was negative. Urinalysis showed grossly bloody urine without clots and no white cells. Complete blood count was normal. The patient’s clinical course at her 3 day followup showed that the gross hematuria cleared around 24 hours after injury. She was sent home with urine dipsticks. On day 8 during a previously scheduled health maintenance examination she reported negative microscopic urine testing since day 5. She still was having some mild pain with active exercise in her leg but was much improved.

Discussion
Gross hematuria has many causes (see here for a differential diagnosis) but in the setting of trauma causes concern. The integrity of the urinary system has been breached and can be anywhere within the system from the kidney itself to urethral opening caused by blunt or cutting forces. Other injuries including to the renal pedicle, and abdomen and pelvis need to be considered, evaluated and treated. Blunt trauma from motor vehicles, bikes, falls, assaults and sports are common causes of gross hematuria in children.

Patients should have a through history and physical examination searching for additional injuries and assessment of hemodynamic stability. Laboratory evaluation should include a urinalysis and complete blood count plus other laboratories depending on clinical circumstances. Imaging usually begins with computed tomography of the abdomen and pelvis also to help identify other potential injuries.

There are different injury scales that are designed to assist in the description, management of different organ systems. A list of various scales can be found here. The American Association for the Surgery of Trauma’s Organ Injury Scale and is one organ system scale . AIS score is the abbreviated injury score. “The AIS provides standardized terminology to describe injuries and ranks injuries by severity.” This is independent of the organ system.

The AIS Scores are:

  • 1 = Minor
  • 2 = Moderate
  • 3 = Serious
  • 4 = Severe
  • 5 = Critical
  • 6 = Unsurvivable

Learning Point
Renal trauma is categorized by the Organ Injury Scale into 5 groups:

  • Grade 1 – (AIS 2)
    • Contusion with hematuria (microscopic or gross), normal urological studies
    • Hematoma that is subcapsular without parenchymal laceration and is not expanding
  • Grade 2 – (AIS 2)
    • Perirenal hematoma continued to the renal retroperitoneum that is not expanding
    • Laceration of < 1 cm of renal cortex parenchyma without urinary extravasation
  • Grade 3 – (AIS 3)
    • Laceration of > 1 cm depth of renal cortex parenchyma with urinary extravasation or collecting system rupture
  • Grade 4
    • (AIS 4) Laceration extending through the renal cortex parenchyma, medulla and collecting system, has urinary extravasation
    • (AIS 5) Main renal artery or vein injury with controlled hemorrhage
  • Grade 5 – (AIS 5)
    • Completely shattered kidney
    • Hilar avulsion or major renovascular injury with uncontrolled hemorrhage

Note: the AIS classification increases by one level if there are multiple injuries to same organ.

Renal trauma treatment depends on the trauma grade and associated injuries. Many renal injuries can be treated conservatively with rest and close monitoring. Others such as level 5 require emergency exploration for hemodynamic control and possible nephrectomy.

Questions for Further Discussion
1. What is the Organ Injury Scale rating for the patient described?
2. What are indications for imaging for gross hematuria?
3. What are indications for nephrology or urology consultation for hematuria?

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: Kidney Disease.

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

To view images related to this topic check Google Images.

Ahn JH, Morey AF, McAninch JW. Workup and management of traumatic hematuria. Emerg Med Clin North Am. 1998 Feb;16(1):145-64.

Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol. 2004 Feb;171(2 Pt 1):822-5.

Trauma.org. Organ Injury Scale. Available from the Internet at http://www.trauma.org/archive/scores/ois.html (rev. 2012 cited 6/15/12).

Trauma.org. Abbreviated Injury Scale. Available from the Internet at http://www.trauma.org/archive/scores/ais.html (rev. 2012, cited 6/15/12).

United State Army Military Institute. Pediatric Surgery and Medicine for Hostile Environments. Available from the Internet at http://www.bordeninstitute.army.mil/other_pub/pediatric/21GUTractFinal2.pdf (rev. 3/10/11, cited 6/15/12).

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.

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

  • What Guidance Can I Offer to Divorcing Parents?

    Patient Presentation
    A 5-year-old male came to clinic for well-child care. He was excited about starting Kindergarten in the fall. His mother was concerned because his father and her had recently separated and were living apart. Both parents were seeing some behavioral problems around the transitions between the homes. Mainly he would cry when leaving either parent but generally did well after being in the new location for a while. His mother said that he kept making remarks or drawing pictures about his parents reuniting in the future, and she wasn’t sure how to handle that. She had been working more but family members that had provided child care were continuing to provide care. The parents were in counseling but she expected that they would not reunite. She laughed and said, “We just can’t get along as a couple, but we both love [him]. We’re trying to get along about things to do with [him].” The boy said that he didn’t like moving between the houses and that it made him mad and sad. “I’m sad because I don’t want to go (with the other parent). I’m mad because we don’t live together.” The boy reported that he talked with both parents and grandparents about the separation. The pertinent physical exam showed a healthy made with normal vital signs and growth parameters in the 75-90%. His exam was normal.

    The diagnosis of a healthy male with recently separated parents was made. The pediatrician encouraged the boy to continue to talk with his parents and grandparents about how he was feeling and also to ask questions when he was confused. The pediatrician encouraged the mother to continue to try to talk with the father and to work from issues where they had common ground such as schedules and routines. He told the mother to be honest about the chances of reconciliation. He said to tell the child that he was loved, and that Mom and Dad are having problems themselves. You have two houses now and it probably will be like that in the future. He offered to meet with the parents and/or provide referrals for mental health counseling if needed.

    Discussion
    Separation and/or divorce (divorce) is unfortunately a common problem with just less than 50% of first marriages ending in divorce and there is a higher rate for subsequent marriages. It is difficult to separate out the problems that children have specifically with the divorce, and the other issues that are intertwined with it such as transitions between households, decreased parental contact (including non-custodial parent, financially needing to work more outside, increased work inside the home, etc.), economic stress, children’s own and parents’ emotional problems including anxiety and depression, parental dating and remarriage, blending of families, violence victimization, substance abuse, etc.. Children’s responses to these and other multiple stressors depends on the age and developmental level of the children. Boys tend to have more externalizing problems such as behavioral acting out, whereas girls tend to have more internalizing problems. These problems may not be exhibited initially but show up in adolescence. Preschool children tend to show regressive behaviors and physical problems such as bowel or bladder problems and sleep disturbances. Young school age often show sadness, fearfulness and have many hopes for family reconciliation. Older school age show grief, anger, want to clarify the responsibility for the divorce, and do more caretaking of the parent. Adolescents show more anger, acting out and depression, and may have premature emancipation.

    Parents can help their children by acknowledging the failure of the marriage, but not failing in the divorce itself. A failed divorce is when the marriage conflicts are never resolved and the ex-spouses’ unmet needs continue to generate hostility and unproductive behaviors. In a successful divorce, ex-spouses proactively work at communication even when it is difficult, behave like an adult themselves and continue to actively parent the children.

    Communication issues are key both between the ex-spouses and between the parents and children. One author states, “Parents should be encouraged to view their relationship as a neutral business-like partnership with the children as their joint investment. Divorced parents can benefit from clear rules on visitation, discipline, holidays, finances and other issues. Clear regulations avoid conflict and decrease contact (between ex-spouses). When contact is necessary, it can be civil, polite, and time-limited, much as a business relationship.” “Parents of children of divorce continue to be their parents for life….The parents must see the value in attending to the needs of their children, even when their own adult lives are in turmoil. They must continue to set limits, enforce bedtimes, assign chores. If both parents are to be involved in rearing the children, they must learn to co-parent with some consistency.” Unfortunately the hallmark of many divorces is erratic and inconsistent parenting.

    Learning Point
    Some guidance for parents who are divorcing includes:

    • Tell the children about the divorce
      • Explain the reasons for the divorce
      • Use neutral terms in a language they will understand
      • Both parents should be present
      • All children should be told at the same time if at all possible
      • Repeat all explanations as many times as necessary for the children to understand. Parents will/may need to do this many times over days/weeks/months/years.
    • Tell the children the divorce is not their fault
      • Reassure the children that you love them
    • Tell the children of the expected family structure after the divorce
      • Where will they live
      • How will visitation occur
    • Tell the children in advance of anyone moving households
      • Except if there are concerns about immediate safety concerns or abusive relationships
    • Be an adult
      • Do not belittle your ex-spouse where your children can hear. Children believe their parents and do not understand when you may say something out of anger, frustration or sarcasm.
      • Do not lie or cover up irresponsible behavior by the other parent though. Use a neutral tone to explain the situation. Children quickly figure out when people are lying and parents’ credibility suffers.
      • Do not discuss details of financial issues. Children should be told the truth about the financial situation in general terms such as, “Like everyone else, we can’t afford to buy everything and today we are not going to choose to buy XXX.”
      • Set clear rules together about schedules, discipline, school, extracurricular and other issues.
      • Set up times to discuss issues with your ex-spouse. Don’t spring issues on them.
        • E-mail, text or other quick message ahead of time alerts the ex-spouse about an issue to discuss, and makes it easier to discuss the issue calmly.
        • Also, an appropriate amount of time can be set. For example, figuring out the carpool arrangements can often be done while dropping/picking up a child, but discussing failing school grades probably needs a separate time set aside.
        • Your ex-spouse does not need to know all your personal business, but if it impacts the child’s parenting then it should be discussed honestly.
          • For example, new significant other, plans for new marriage, new children entering the family, financial windfall, job loss, increased work travel, death of a friend, etc.
      • Realize you and your ex-spouse will not always agree on parenting issues. Try to find areas of agreement and work out a plan from those areas. For example, scheduling time with extended family such as grandparents.
      • Support your ex-spouse for their parenting. Don’t allow the children to manipulate one parent against another. For example, “Mom took me to the R rated movie last weekend. How come you won’t take me to this R movie this weekend?”
        • Tell the child that there are different rules in different households (supporting the parent who made a decision at that time, and also supporting your own currently) and if you disagree with your ex-spouse’s decision, then make a time to discuss it with the ex-spouse.
      • Do not force a child to take sides. Both parents love the child and the child can love both parents.
    • Be a parent
      • Set rules and be consistent. This is probably the most important issue of all for children.
        • Chores, responsibilities, privileges and discipline should be clear and consistently enforced
        • Discuss in general terms that there are two households which each will have the same basic rules, but that there will be some different rules in each. For example, at Dad’s house on a Saturday night you might get to stay up a little later because you don’t have school the next day. But at Mom’s house on a school night, you will go to bed on time.
      • Support your children
        • Support your child’s love for the other parent. For example, “I’m glad you like reading with your Dad” reaffirms the special time they spend together. It also supports the father’s parenting.
        • Provide for your child’s physical needs with financial or other support.
        • Being physically present as much as you can. When you cannot, find another way to keep in touch. Write a note, instant message, email, call on the phone or video chat.
        • Talk with your children. Let them tell you about their world, their concerns, worries, triumphs, and tragedies. Listen.
        • Be honest about things you have done right and things you haven’t done right. Don’t unburden yourself but use your own examples to show how you have made good and not so good choices and how you have handled the ups and downs of life.
      • Do not make children adults.
        • While children may necessarily need to take on certain duties within the household, they should be age appropriate and the amount of time is appropriate.

    Questions for Further Discussion
    1. What other guidance could be offered to parents who are divorced?
    2. What resources are available in the local community for parents who are divorced?
    3. What is the pediatrician legal responsibilities to the child and each parent after a divorce?

    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: Divorce

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

    To view images related to this topic check Google Images.

    Bryner CL Jr. Children of divorce. J Am Board Fam Pract. 2001 May-Jun;14(3):201-10.

    Cohen GJ, Committee on Psychosocial Aspects of Child and Family Health. Helping Children and Families Deal With Divorce and Separation. Pediatrics. 2002;110:1019-1023.

    Troxel WM, Matthews KA. What are the costs of marital conflict and dissolution to children’s physical health? Clin Child Fam Psychol Rev. 2004 Mar;7(1):29-57.

    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.
    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.

  • 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.

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

    Author

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

  • What Are the Different Types of Tinea?

    Patient Presentation
    A 10-year-old male came to clinic for some peeling skin on his feet. His mother had noticed it the night before and was concerned that it was “athlete’s foot” or that it might spread into the nails. He denied any pain, pruritis, redness, or swelling. He had a recent blister from wearing flip-flops while playing a sport. The pertinent physical exam showed a healthy male in no distress. His skin examination overall showed some freckling of his face and arms, and a mild healing sunburn. On the plantar surface of his right great toe there was an unroofed blister and some dried, fissured areas on the instep of the ball of the foot consistent with callus formation. There were no skin changes between the digits.

    The diagnosis of callus formation, a healing unroofed blister and sunburn was made. The physician recommended conservative treatments for the feet and sunscreen use before going outside. The mother said that she was very worried because she was going to cosmetology school and had been reading and reviewing pictures about fungal scalp and nail infections. The physician re-iterated that the minor skin peeling and fissuring appeared to be because of overuse. He also told the mother that if the foot became painful, had burning, itching, or redness especially between the toes, then the child may need to be treated for a fungal infection.

    Discussion
    Tinea infections are caused by fungi that infect the outer layer of skin, hair and nails and are generally classified by anatomic location. Tinea is also called ringworm particularly if located on the body. Tinea can be spread in 3 different ways with human-to-human transmission being the most common.

    • Anthropophiic organisms – human-to-human transmission.
      Common examples include Trichophyton rubrum, Triphophyton mentagrophytes Trichophyton tonsurans, Epidermophyton floccosum

    • Zoophilic – animal-to-human transmission. Common examples include Microsporum canis, Trichophyton verrucosum
    • Geophilic – soil or fomite-to-human transmission. A common example includes Microsporum gypseum

    Species greatly differ around the world and over time and by body location. Overall the most common dermatophyte is Trichophyton rubrum.

    The differential diagnosis of tinea commonly includes:

    • Contact dermatitis
    • Eczema
    • Herpes
    • Impetigo/pyoderma
    • Pediculosis
    • Psoriasis
    • Seborrhea

    If nails are involved then onchodystrophy is also a possibility. If in a hairy area, alopecia areata, traction alopecia or trichotillomania should also be considered. Drug eruptions should be considered especially if lesions are located on the body.

    Learning Point
    Common presentations of tinea include:

    • Barbae
      • Location: beard and surrounding skin of male adolescents and adults
      • Description: may be isolated or confluent, highly inflammatory reaction with papules, pustules, exudates, crusts, hair may be absent or loose
      • Common causative species: Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton verrucosum
      • Common treatment: Griseofulvin
    • Capitus
      • Location: head
      • Description: round or oval, single or multiple patches with broken hairs near base of shaft. May have alopecia.
      • Common causative species: Trichophyton tonsurans, Microsporum canis
      • Common treatment: Griseofulvin, terbinafine
    • Corporis
      • Location: body
      • Description: non-hairy areas with annular, ovoid or circular lesions. Central clearing with finer scale at the edge is characteristic.
      • Common causative species: Trichophyton rubrum, Epidermophyton floccosum
      • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
    • Cruris
      • Location: groin and upper thighs
      • Description: often sharply marcated lesions or area, occurs symmetrically often, may be confluent or have central clearing, pruritis is common
      • Common causative species: Trichophyton rubrum, Trichophyton mentagrophytes
      • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
    • Imbricata
      • Location: Body
      • Description: tile-like or shingle-like plaques, may be circumferential
      • Common causative species: Trichophyton concentricum
      • Common treatment: Griseofulvin, Terbinafine
      • Other: Other name is Tokelau, occurs in the archipeligos of South Pacific, South Asia and some areas of South America
    • Nigra
      • Location: hands
      • Description: brown or black macules on palmar or dorsal surfaces
      • Common causative species: Hortaea werneckii (a mold)
      • Common treatment: benzoic acid or midazole
    • Manuum
      • Location: hand
      • Description: erythematous, often confluent areas with scale at the edge
      • Common causative species: Tinea rubrum
      • Common treatment: Terbinafine, Miconazole, Clotrimazole,
    • Pedis
      • Location: foot
      • Description: erythematous, often confluent areas with scale at the edge which may be macerated. Fissuring and pruritis is common. Interdigital location is common
      • Common causative species:Trichophyton rubris, Trichophyton mentagrophytes
      • Common treatment: Terbinafine, Miconazole, Clotrimazole, Ketoconazole
      • Other: A common name is Athlete’s foot
    • Unguium
      • Location: nails
      • Description: lateral and distal nail edges but all of nail may be involved. Hyperkeratosis with discoloration of the nail. Concurrent tinea pedis or manuum is common.
      • Common causative species: Trichophyton rubris, Trichophyton mentagrophytes, Epidermophyton floccosum
      • Common treatment: Griseofulvin, Terinafine, Itraconazole
    • Versicolor
      • Location: trunk, face arms
      • Description: oval macules and patches with multiple scales, hypo or hyper-pigmentation is common
      • Common causative species: Pityrosporum orbiculare (yeast)
      • Common treatment: Selenium sulfide, topical antifungals, Ketoconazole
      • Other: Other name is Pityriasis versicolor

    Tineas that aren’t real tineas

    • Tinea incognito – the true clinical appearance of tinea is masked because of inappropriate treatment, such as a topical steroid.
    • Tinea ambiantacea – also known as pityriasis amiatacea is a papulosquamous disorder associated with psoriasis and not a mycosis.

    Questions for Further Discussion
    1. What is the cause of a kerion?
    2. When are oral antifungal medication indicated?

    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: Tinea Infection.

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

    To view images related to this topic check Google Images.

    Hurwitz S. Clinical Pediatric Dermatology. Second Edit. WB. Saunders and Co. Philadelphia PA. 1993:108-109, 373-389.

    Andrews MD, Burns M. Common tinea infections in children. Am Fam Physician. 2008 May 15;77(10):1415-20.

    Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of dermatophyte infections. Mycopathologia. 2008 Nov-Dec;166(5-6):335-52.

    Andrews RM, McCarthy J, Carapetis JR, Currie BJ. Skin Disorders, Including Pyoderma, Scabies, and Tinea Infections. Pediatric Clin N Am. 2009;56:1421-1440.

    Bonifaz A, Vazquez-Gonzalez D. Tinea imbricata in the Americas. Curr Opin Infect Dis. 2011 Apr;24(2):106-11.

    University of Adelaide. Tinea nigra. Mycology online.Available from the Internet at http://www.mycology.adelaide.edu.au/Mycoses/Superficial/Tinea_nigra/ (rev. 2012, cited 6/4/12).

    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.

    Author

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

  • What Causes Scoliosis?

    Patient Presentation
    A 6-year-old male came to clinic for well child care who had severe spastic cerebral palsy. Overall he was doing well with his multiple therapies and was mobile with assistance for part of the day. His father was concerned that his back seemed to be curving more when he walked with his walker and when sitting in his wheelchair. He felt this was getting worse recently. His son was non-verbal but the father didn’t feel that there was any pain or discomfort. He also didn’t notice any skin changes from chair positioning. The father had not asked the child’s physical therapists if they had any concerns.

    The pertinent physical exam showed a non-communicative male with spastic cerebral palsy. He sat preferentially leaning to the left in his chair. With lying on the table, the physician noticed him leaning more to the left, and anteriorly no chest wall asymmetry was noted. When prone there was no specific spinal curvature noted, and there was normal alignment of the scapula and shoulders. It was difficult for him to lie flat because his hips which were held in a flexed and abducted position. No skin breakdown was noted and his bilateral ankle-foot orthosis fit properly. The diagnosis of spastic cerebral palsy was again conformed. The physician wasn’t entirely sure what the problem was but felt that the abnormal hip flexion was probably causing malpositioning. She was not sure if there was actual scoliosis but his underlying condition increased its possibility. The patient had not seen his orthopaedic physician recently and was re-referred. A hip dysplasia was diagnosed and surgery was recommended in the near future. His wheelchair was also modified for better positioning.

    Discussion
    Alignment of the spine is measured from a plumbline dropped from C7 vertebrae as the line of reference. Lordosis is anterior curving, kyphosis is posterior curving and scoliosis is lateral curving relative to this line. Scoliosis has a large differential diagnosis with neuromuscular and spinal abnormalities being the most common as groups. Adolescent idiopathic scoliosis is the most common type of idiopathic scoliosis and the most common type of scoliosis (as a distinct entity) overall. By mid- to late- adolescence, 2-3% will have a 10-degree angle or more. The Cobb angle measures the degree of curvature and its determination can be seen here.

    Treatment for scoliosis consists of 3 O’s – observation, orthosis (bracing) and operation.

    Learning Point
    The differential diagnosis of scoliosis includes:

    • Compensatory – because of unequal leg length discrepencies
    • Posture – ceases with repositioning or bending over
    • Structural – persists with bending over
      • Idiopathic
      • Neuromuscular
        • Arnold-Chiari malformation
        • Arthrogryposis
        • Cerebral palsy
        • Down syndrome
        • Ehler-Dahlos syndrome
        • Friedrich’s ataxia
        • Klippel-Feil syndrome
        • Muscular dystrophy
        • Neurofibromatosis
        • Poliomyelitis
        • Prader-Willi syndrome
        • Spinal abscess
        • Spinal cord trauma
        • Spinal tumor
        • Spinal muscular atrophy
        • Syringomyelia
      • Spinal deformity
        • Achrondroplasia
        • Bone tumor
        • Congenital scoliosis
          • Hemivertebrae
          • Spina bifida
        • Juvenile rheumatoid arthritis
        • Osteogenesis imperfecta
        • Rickets
        • Spinal irradiation (post)
        • Spinal trauma

    Questions for Further Discussion
    1. How is congenital scoliosis different from other forms of scoliosis?
    2. What criteria are used for determining treatment using orthosis or surgical operations?

    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: Scoliosis and Cerebral Palsy.

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

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:255-256.

    Dobbs MD. Neuromuscular Scoliosis.Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/1266097-overview#a0102 (rev. 4/27/2010, cited 6/4/12).

    Letts RM. Congenital Spinal Deformity. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/1260442-overview (rev. 2/7/2012, cited 6/4/12).

    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.

  • 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.
    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