What Causes Muscle Weakness?

Patient Presentation
A 9-year-old male came to clinic with rhinitis and left ear pain that began 2 days before. The ear pain was intermittent and there was no fever. He had been otherwise well and had not seen a physician for 3-4 years, “Because he’s never sick,” said his father. The past medical history was non-contributory. The family history was positive for stroke and depression. There were no mental, genetic, or neurological diseases in the family. The father had an adult male first cousin who walks on his toes without any other gait problems.

The pertinent physical exam showed a healthy boy with normal growth parameters. His temperature was 100.6°F. HEENT showed clear rhinorrhea and a normal pharynx. His left ear had a small amount of fluid but was grey and had normal landmarks. During the examination the physician noted that the boy seemed somewhat floppy in the way he walked to the table and got onto it. His neurological examination was remarkable for some mild hypotonia generally, muscle strength that was against gravity and some resistence, but he easily tired. There were 4 beats of clonus in both ankles. He had normal rapid alternating movements, finger-to-nose and no pronator drift. No soft neurological signs were seen during the examination. When asked to heel-toe walk along a line on the tiles he was not able to coordinate it, nor could he duck walk. When walking normally he would toe walk. His heel cords were somewhat tight. When attempting a Gower maneuver he was able to stand without assistance but did rest one hand on a leg. When he got up from a chair he was also observed to push off the father and the chair.

The diagnosis of otalgia with serous otitis media was made. The father reported that his son was “not the most athletic or coordinated” and the boy had a lot of problems with handwriting. It took him a long time to write and it was very messy. The father denied him sitting in a “W” position or wrapping his legs around chairs for stability. The diagnosis of a possible underlying neuromuscular problem was considered because of the toe-walking, mild hypotonia and weakness.

The work-up included calcium, magnesium, phosphorus, potassium, creatinine phosphokinase, lactate dehydrogenase, aldolase and thyroid function tests which were performed and were normal. The physician talked with the family that this could be a mild form of a neuromuscular problem that the child should be evaluated for so that possible treatments and assistance could be offered. The patient was referred to a pediatric neurologist and some exercises to stretch his heel cords were demonstrated. The physician said that other help such as formal physical therapy, occupational therapy, or orthopaedics consultations might be done based on what the neurologist discovered.

Discussion
Muscle tone is the slight tension that is felt in a muscle when it is voluntarily relaxed. It can be assessed by asking the patient to relax and then taking the muscles through a range of motion such as moving the wrists, forearm and upper arm. Muscle strength is the muscle’s force against active resistance. Impaired strength is called weakness or paresis. There are 5 levels of muscle strength.

  • 0 = No muscle contraction detected
  • 1 = Barely detected flicker of contraction
  • 2 = Active movement with gravity eliminated
  • 3 = Active movement against gravity
  • 4 = Active movement against gravity and some resistance
  • 5 = Active movement against full resistance. This is normal muscle strength.

Toe walking is common in toddlers who are learning to walk. It becomes less common as children age. The most common reason for toewalking is tight heel cords or an undiagnosed neurological problems such as mild spastic diplegic cerebral palsy, muscular dystrophy, or spina bifida occulta.
Stretching of heel cords can improve the problem.

Learning Point
The differential diagnosis of hypotonia with and without weakness includes:

  • Hypotonia with weakness
    • Acute
      • Botulism
      • Diphtheria
      • Hypokalemia
      • Guillian Barre syndrome
      • Mental illness
        • Hysteria
        • Malingering
      • Polyneuropathies
      • Poliomyelitis
      • Transverse myelitis
    • Chronic
      • Muscle or nerve disease
        • Muscular dystrophy – Duchenne’s, Wernig-Hoffman syndrome, myotonic dystrophy
        • Peroneal nerve atrophy
        • Spinal muscle atrophy
      • Autoimmune
        • Dermatomyositis
        • Myasthenia gravis
        • Systemic lupus erythematosis
      • Central nervous system
        • Amyotrophic lateral sclerosis
        • Cervical spinal cord injury
        • Static encephalopathy
        • Space occupying lesions
      • Metabolic
        • Glycogenoses
        • Lipoidoses
        • Mucopolysaccharidoses
        • Myoglobinuria
        • Organic acidurias
        • Parathyroidism – hypo and hyper
        • Porphyria
      • Syndromes
        • Leigh
        • Krabbe
        • Lowe
        • McCardle
        • Refsum
      • Disuse
    • Hypotonia without weakness
      • Cerebral palsy – hypotonic form
      • Benign congenital hypotonia
      • Metabolic disease
        • Celiac Disease
        • Congenital heart disease
        • Hypothyroidism
        • Hypercalcemia
        • Renal tubal acidosis
        • Rickets
      • Syndrome and Genetic diseases
        • Down syndrome
        • Ehler-Dahlos
        • Marfan
        • Prader-Willi
        • Rett

    For hypotonia in an infant, click here.

    Questions for Further Discussion
    1. What other professionals might be needed by this child?
    2. What are indications for a muscle biopsy?
    3. What are indications for a genetics evaluation?

    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: Myositis and Muscular Dystrophy.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube

    Sheldon SH Levy HB. Pediatric Differential Diagnosis. 2nd Edit. Second Edition. Raven Press: New York. 1985:177-183.

    Bates B. Guide to Physical Examination. Third Edit. Lippincott Company, Philadelphia, PA. 1986:390.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:256-260.

    Huff KR. Hypotonia, in Pediatrics a Primary Care Approach, Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;369-373.

    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.

  • 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 Causes Acute Urticaria?

    Patient Presentation
    A 4-year-old female came to clinic with a pruritic rash of 1 day duration. She had upper respiratory symptoms for 4 days and the previous evening she began to have a rash on her trunk, upper arms and legs. Her mother described transient lesions, but themselves each appears slightly papular with a lighter center and erythematous base. She had tried a topical steroid without relief. The past medical history was non-contributory. The pertinent physical exam revealed a healthy female with normal vital signs and growth parameters. HEENT showed clear rhinitis and a small amount of fluid in both ears at the bases. Her skin examination had 3-5 mm erythematous macular lesions with a slight papular component centrally. Some seemed to be fading and others progressing. The patient had obviously been scratching areas of the trunk, arms, and legs. The rest of her examination was normal.

    The diagnosis of acute urticaria was made. The mother was told that it was most likely due to the upper respiratory tract infection and the natural history was discussed. She was advised to try a diphenhydramine for the pruritis and to return if there were any problems with swallowing or difficulty breathing or if the symptoms did not resolve in a few days.

    Discussion
    Urticaria or hives is a systemic disease with cutaneous results. An agent triggers a histamine reaction with cutaneous pruritic lesions being the result. Urticaria usually has intact, erythematous lesions with a papular component that is usually paler in color. Lesions are of various sizes and wax and wane. The lesions may coalesce and blanch with pressure. Scratches and excoriations may be seen. Bullae can be seen in certain circumstances.

    Evaluation for systemic reaction is important such as hoarseness, stridor, wheezing, difficulty breathing, arrhythmias, difficulty swallowing or tingling. Acute urticaria is defined as urticaria for less than 6 weeks. Chronic urticaria is defined as wheals that occur at least twice weekly for more than 6 weeks. Because this is a broad definition, some people add that the wheals must be present for more than 1 hour (which distinguishes chronic urticaria from dermatographism) and less than 24-36 hours (which distinguishes it from urticaria-vasculitis). The maintstays of treatment are antihistamines, short-acting ones for acute urticaria and long-acting ones for chronic urticaria.

    Mastocytosis or angioedema may appear similar to urticaria but are different. Angioedema frequently occurs in mucous membranes and may or may not have urticarial wheals present. Mastocytosis is a heterogeneous group of mast cell disorders which may cause wheal-like lesions on the skin.

    Learning Point
    The most common cause of acute urticaria is respiratory viral infections.

    The differential diagnosis of acute urticaria includes:

    • Blood products
    • Contact/Topical exposure – soaps, lotions, detergents
    • Drugs – many including antibiotics, ACE inhibitors, NSAIDS, opiates, radiocontrast, components of biological agents, preservatives
    • Food – peanuts, tree nuts, eggs, milk, shellfish, strawberries, chocolate, etc.
    • Dyes and preservatives
    • Environmental and inhalant
    • Idiopathic
    • Insect bites
    • Infections – hepatitis, Epstein-Barr virus, upper respiratory tract infections, Streptococcus
    • Physical – dermographism, cold, cholinergic, heat or solar, aquagenic

    Questions for Further Discussion
    1. What are indications for evaluation by an allergist?
    2. What are indications for prescribing prophylactic epinephrine (i.e. Epi-Pen®)?

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:352.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:221.

    Leech S, Grattan C, Lloyd K, Deacock S, Williams L, Langford A, Warner J; Science and Research Department, Royal College of Paediatrics and Child Health.The RCPCH care pathway for children with urticaria, angio-oedema or mastocytosis: an evidence and consensus based national approach. The RCPCH care pathway for children with urticaria, angio-oedema or mastocytosis: an evidence and consensus based national approach. Arch Dis Child. 2011 Nov;96 Suppl 2:i34-7.

    Marrouche N, Grattan C. Childhood urticaria. Curr Opin Allergy Clin Immunol. 2012 Oct;12(5):485-90.

    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.

    Author

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

  • What is the Maximal Exercise Heart Rate?

    Patient Presentation
    A 19-year-old male came to clinic for his health supervision visit. He was a freshman in college and had returned for this visit during a fall school break. He said that he was doing well in school, but had noticed that he had gained 6 pounds since the summer. “I used to be so active, but I’m studying so much more and then there’s all the food available in the cafeteria,” he lamented. The past medical history showed a healthy male who had been a runner and swimmer in high school. The pertinent physical exam revealed normal vital signs including a blood pressure of 118/72, body mass index of 26.2, and weight that was 6 pounds more than a visit 3 months previously. His examination was otherwise unremarkable.

    The diagnosis of a healthy male with concerns about weight gain and poor exercise was made. The physician discussed building in opportunities for exercise including walking and taking the stairs instead of an elevator. He emphasized that building in exercise into daily life could be in 10-20 minute intervals and didn’t always have to be for long times at a gym. He also counseled to take only one serving of an item on his plate at a meal and second servings should be only fruits and vegetables. Even at a salad bar, he said that the patient had to be careful of adding lots of cheese, protein or oils to the salad that would increase the calories. “Of course, any alcohol has a lot of calories too, so make good decisions not only about alcohol in general but also because of the calories.”

    The patient said that he wanted to get back into doing some running or swimming and knew that there was a maximal target heart rate but didn’t know what it was. The physician said that it was around 200 beats/minute for someone his age. He counseled the patient to start slow with only 20 minutes of running at 50-60% of his target heart rate, and then to slowly increase the amount of time and effort over several weeks. Plus, he added, “It might be hard to figure out where to do the running 2-3 times or more a week on a regular basis, so don’t push it and be happy that you are making the effort.” The physician also said that the patient might want to buy an inexpensive pedometer to monitor his steps/day which was another way to check if he was getting enough exercise. “You could also buy a heart rate monitor but those are more expensive, but since you were an athlete before it might help you to keep the intensity at a lower level as you work up, and then you might not try to increase the workouts too fast.”

    When he returned 4 months later, he was somewhat happy with his clinical course. He was running or swimming at 30 minutes or more 2-3 times per week which he said helped with the stress of school. He was using a pedometer and said that usually on the days he didn’t work out, he was getting 5000-7000 steps/day. He weight was unchanged. “I think once the spring comes, I can be a little more active, plus I haven’t been very good about watching what I eat,” he noted. “I will try to work on that next.”

    Discussion
    Being physically active is an important part of health and with the U.S.’s more sedentary lifestyle it can be difficult to get enough activity. Normal transitions are a time where it can be difficult to incorporate old habits or to start new ones. Moving away to college with its new challenges such as erratic schedules, more time needed to study, increased access to food and alcohol can make it difficult for college students to develop good habits and make good choices regarding their health.

    Because steps are easy to measure with inexpensive pedometers, the President’s Council on Physical Fitness has a President’s Challenge which recommends the following activity:

    • Youth <18 years
      • 60 minutes/day
      • Activity done in blocks of at least 5 minutes or more
      • 5 days/week
      • 11-13,000 steps/day
    • Adults
      • 30 minutes/day
      • Activity done in blocks of at least 5 minutes or more
      • 5 days/week
      • 8500 steps/day

    2000 steps is about 1 mile. Activities and the equivalent steps can be found at How Far is 10,000 Steps?

    Research has shown that exercise alone may improve fitness and health, but usually will not result in weight loss. Therefore diet and exercise are needed. Interval training with periods of increased intensity and then returning to baseline has been shown to burn more calories than exercising at a consistent exertion level. Other research has shown that music and being around others will also improves the psychological outlook on the exercise and may improve adherence to an exercise routine. Exergaming, that is exercising using videogaming technology, which is increasingly popular has mixed results of increased activity depending on the game type.

    The American College of Sports Medicine recommends that adults exercise:

    • 3-5 times per week
    • at an intensity of 55/65%-90% of maximal heart rate, with lower intensity levels for unfit individuals
    • for 20-60 minutes (with a minimum of 10 minute intervals accumulated throughout the day)
    • performing an “…activity that uses large muscle groups, which can be maintained continuously, and is rhythmical and aerobic in nature.”

    They also recommend resistance and flexibility training as part of overall fitness and health.

    Learning Point
    Maximal heart rate for adults can be roughly estimated by:

    220 beats/minutes – age in years = maximal heart rate

    This is an estimate and should be individualized. For children, this author was unable to determine a maximum heart rate, but it would be common sense that it should not be higher than 200 beats/minute and should be greatly individualized for the child and activity.

    Questions for Further Discussion
    1. What types of resistance training is recommended for overall fitness?
    2. What types of flexibility training is recommended for overall fitness?
    3. What other tips do you have to help patients and families to improve their physical activity?

    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: Exercise and Physical Fitness and Exercise for Children.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaing Cardiorespiratory and Muscular Fitness, and Flexility in Adults. Med Sci Sports Exerc. 1998:30(6);975-991. Available from the Internet at http://www.mhhe.com/hper/nutrition/williams/student/appendix_i.pdf (rev. 1998, cited 10/15/13).

    Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics. 2001 Sep;108(3):E44.

    Plante TG, Gustafson C, Brecht C, Imberi J, Sanchez J. Exercising with an iPod, friend, or neither: which is better for psychological benefits? Am J Health Behav. 2011 Mar-Apr;35(2):199-208.

    Castelli DM, Hillman CH, Hirsch J, Hirsch A, Drollette E. FIT Kids: Time in target heart zone and cognitive performance. Prev Med. 2011 Jun;52 Suppl 1:S55-9.

    Kraft JA, Russell WD, Bowman TA, Selsor CW 3rd, Foster GD. Heart rate and perceived exertion during self-selected intensities for exergaming compared to traditional exercise in college-age participants. J Strength Cond Res. 2011 Jun;25(6):1736-42.

    Melone L. The Heart Rate Debate. American College of Sports Medicine. Available from the Internet at http://www.acsm.org/access-public-information/articles/2012/01/13/the-heart-rate-debate (rev. 1/13/2012, cited 10/15/13).

    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.

  • 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.

  • 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

  • How Are Mandibular Fractures Treated?

    Patient Presentation
    A 9-year-old female came to the emergency room after tripping at school and falling straight down onto a tiled floor. A teacher had witnessed the fall and reported that the child had seemingly been wiped off her feet landing with a great deal of force straight onto her chin. The teacher said there was no loss of consciousness. Her mother brought her to the emergency room after being called by school personnel. She reportedly had blood in her mouth originally but this had stopped and she was having pain at the point of the chin and by the temperomandibular joint on the left side. The past medical history was non-contributory.

    The pertinent physical exam showed a female in some pain. Her vital signs were normal including growth parameters that were in the 10-25%. HEENT showed a laceration underneath her chin that was 2 cm in length that was through the skin. After cleaning it was found to be easily approximated. Her ear exam was negative. She refused to open her mouth fully and when she tried she complained of some pain with palpation anterior to the left ear. Her oral exam was grossly normal without pain on tapping of teeth that could be reached and there was a minor laceration inside the left cheek without bleeding. Her neck exam and rest of her head examination was normal. Her neurological examination was negative with her being alert and oriented but refusing to open her mouth fully. The rest of her examination was negative. The diagnosis of probable mandibular trauma along with other possible intraoral trauma was made. The pediatric dentists were consulted. They did not find any significant intraoral trauma. The radiologic evaluation of a panorex of the maxilla and mandible revealed the diagnosis of a left mandibular condylar fracture. She was begun on a no chew diet after repair of the chin laceration and her clinical course showed radiographic and clinical improvement after 3 weeks. She was to continue on the diet until another 3 week followup.

    Discussion
    The most common mandibular fractures are condylar fractures (30-40%) followed by fractures of the symphysis, angle and body respectively. Mandibular condyle fractures also account for 11-16% of all facial fractures. The causes of mandibular fractures are motor vehicle accidents, falls and sports. Pain, edema, malocclusion, hematoma and bruising, crepitus, trismus, decreased movement and lost sensation are common presenting signs and symptoms. Patients are diagnosed by history and radiographs (usually a CT scan). Potential complications of condylar fractures include decreased movement, muscle spasms, pain, malocclusion, facial asymmetry, ankylosis and osteonecrosis. Complicated mandibular fractures can have permanent tooth damage, facial asymmetry, and nerve damage. Mandibular fractures can also be isolated or part of neurocranial or multi-organ system trauma.

    Learning Point
    “Whereas absolute reduction and fixation of fractures is indicated in adults, concern for minimal manipulation of the facial skeleton is mandated in children. The small size of the jaw, existing active bony growth centers and the contained, overwhelmingly crowded deciduous teeth with permanent tooth buds located in great proximity to the mandibular and mental nerves, all significantly increase the therapy-related risks of pediatric mandibular fractures and their growth related abnormalities. Intact active mandibular growth centers are important for preserving mandibular function, which have a significant influence on future facial development. Thus, restoration of the mandibular continuity after fracture is important not only for immediate function but also for future craniofacial development.”

    Options for treatment of mandibular fractures include:

    • Close observation with analgesics, liquid-to-soft diets and no activities that present risks such as sports.
      This is usually used for greenstick fractures without displacement or malocclusion.

    • Splints – prefabricated acrylic splints, staples or orthodontic devices. These have the advantage of being relatively easy to apply and remove, can be done in an outpatient setting or with decreased general anesthesia time.
    • Open reduction (including wiring of the jaws) is used for more complicated fractures including those that are significantly displaced.

    Questions for Further Discussion
    1. Besides dentists, what other professionals may be helpful in managing mandibular fractures?
    2. How are the nutritional needs of a patient with a mandibular fracture met?

    Related Cases

      Symptom/Presentation: Pain

    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: Jaw Injuries and Disorders.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol. 2009 Dec;25(6):565-70.

    Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J Craniofac Surg. 2012 Jan;23(1):47-56.

    Chrcanovic BR. Open versus closed reduction: mandibular condylar fractures in children. Oral Maxillofac Surg. 2012 Sep;16(3):245-55.

    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.

  • 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
    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