What Are Potential Complications of Breast Surgery?

Patient Presentation
During one month a pediatrician had two patients with potential surgical breast issues.

The first was a 19-year-old female who came to clinic for her health maintenance visit. She overall was doing well but was complaining that she had upper back, shoulder and neck pain. She also complained that her breasts were so large it was difficult to find properly fitting undergarments and that “they just get in the way” of her activities. She also noted that she attracted unwanted attention because of their large size relative to her overall body size. She was noted to be 5’2″, non-obese (BMI of 24.6) and said her breasts were a size E cup. She was noted to have grooves in her shoulder where her bra shoulder straps were. She was referred to a breast surgeon and after consultation and considering the options, she decided to have bilateral breast reduction. She was very happy with the cosmetic result, but more importantly no longer had back, neck and shoulder problems and the unwanted attention had ceased.

The second patient was a 17-year-old female who came in because of a 1 day history of left-sided breast pain, mild redness and a small mass. She was mid-menstrual cycle and had mild tenderness and redness around the areola and nipple that extended medially about 1 cm. The 2-4 mm rice grain-like mass was around 4 o’clock and close to the chest wall and this was mildly tender. She had a couple of similar lesions in the right breast at 2 and 7 o’clock toward the periphery of the breast. She had inverted nipples and the overall texture of the breast felt fibrous. She was treated for mastitis versus cellulitis in the setting of what appeared to be fibrocystic breast changes. On phone followup the next day, she was improving with the oral antibiotics. At followup 1 week later the nipple redness/swelling had resolved but the masses remained the same. She did serial self-exams and noted that these changed with her menstrual cycle and this was confirmed when she was examined one week after her period and they had decreased in size. She and her parents asked for a referral to a breast surgeon as they were concerned about the inverted nipples and the possibility of this occurring again and the potential problems with breastfeeding in the future. The family was pleased with the consultation and the information it provided.

Discussion
Common reasons for seeing a breast surgeon would include management of benign or malignant masses with or without breast reconstruction, breast augmentation, and other reasons can be infection or trauma that need surgical treatment.

The breast is formed starting around the 6th week of gestation by breast buds along the mammary line. Breasts then develop from the downgrowth of epithelia into the mesenchymal tissue, which continues to grow. Around 8-9 months a pit forms as entry into the lactiferous ducts. “Nipple inversion is caused either by failure of the lactiferous ducts to develop and grow during maturation of the breast tissue or by fibrosis around the lactiferous ducts due to inflammation (e.g. mastitis, cancer, previous breast surgery). Congenital inverted nipples are caused by failure of the mesenchymal tissue to develop or the lactiferous ducts to lengthen.

Learning Point
In general, full maturation of the breast should be ensured before an elective breast procedure. Depending on the age, family history and other factors, mammography may also be appropriate before surgery.

Macromastia symptoms can occur at any age including the adolescent and young adult population. Common problems are upper back, neck, and shoulder pain. Properly fitted clothing, both under- and outer-garments, can be more difficult to find and more expensive than standard sized clothing. The skin can easily be irritated and once irritated hard to treat because of moisture, heat, maceration, poor air circulation and friction from the soft tissues or clothing. Candida skin problems are common. Additionally, patients may have psychological distress because of their own body image or because it attracts unwanted attention. Reduction mammaplasty is an option for many women (and the occasional man as they can also suffer from this problem) who want to improve the shape, size and symmetry of the breasts. There are several surgical techniques but overall patients are usually very happy with the results. Complications can include usual surgical problems such as infection, blood loss, hematoma or seroma, ischemia to tissues or grafts, and delayed wound healing. Longer term complications can include suboptimal scar formation and scar related problems such as keloids or pain, asymmetry, loss of shape, nipple malposition, abnormal sensation, breast pain, lymphedema and inability to breastfeed. Some of these problems are an expected outcome depending on the type of surgery planned.

Inverted nipples are very common (~10%) and usually do not require any treatment. However problems with body image or difficulty in breastfeeding can cause problems. For some women, the nipple can be easily everted with pressure (i.e. manual or with a nipple shield) and may maintain the projection. For other women, it may be severely retracted and cannot be everted. Nipple inversion is commonly bilateral. At least one study found a correlation between body mass index and inverted nipples (i.e. thin individuals had a more inverted nipples). Surgical technique vary and complications can include recurrence of inversion, epidermalysis, scaring and cellulitis. Loss of sensation and difficulty in breastfeeding or movement of milk through the ducts may occur, but obviously the surgeries attempt to minimize the disruption to the ducts. Cellulitis can occur with these surgeries or for other reasons as bacteria are present in the ducts. The author was unable to determine the rate of mastitis/cellulitis for patients with inverted and projected nipples.

Questions for Further Discussion
1. What are the current recommendations for screening for genetic markers and/or mammography for young women at risk for breast cancer?
2. How efficacious is breast self-examination for detecting cancer?
3. What are common causes of benign breast disease?

Related Cases

To Learn More
To view pediatric review articles about nipple pathology from the past year check PubMed – Nipple Pathology
and PubMed – Mammplasty.

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

Information prescriptions for patients can be found at MedlinePlus for these topics: Plastic and Cosmetic Surgery.

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.

Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015;136(4):531e-544e. doi:10.1097/PRS.0000000000001622

Gould DJ, Nadeau MH, Macias LH, Stevens WG. Inverted nipple repair revisited: a 7-year experience. Aesthet Surg J. 2015;35(2):156-164. doi:10.1093/asj/sju113

Greco R, Noone B. Evidence-Based Medicine: Reduction Mammaplasty. Plast Reconstr Surg. 2017;139(1):230e-239e. doi:10.1097/PRS.0000000000002856

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Areas of the Physical Examination are Important in the Pre-participation Physical Examination?

Patient Presentation
A 14-year-old female came to clinic for her sports physical as part of her comprehensive examination. She had been a runner for a couple of years and participated in cross-country and track the previous year. She had 1 ankle sprain when she was tripped during a cross-country race that had healed without incident and had not caused her any problems. She denied any other injuries, concussions or head trauma, and said she didn’t have any problems with fatigue, shortness of breath, syncope, or her heart beating funny. She denied any loose or lax joints. “I just get really tired when our coach wants us to run sprints at the end of practice,” she offered. The past medical history was otherwise non-contributory The family history was positive for diabetes, and her maternal grandfather had a coronary bypass at age 68. The review of systems was normal including her menstrual history.

The pertinent physical exam showed a thin female growing along the 75%. Her vital signs were normal. Her examination was normal including the strength and range of motion in both ankles.

The diagnosis of a healthy female was made. The physician discussed healthy eating including getting enough calcium in her diet, the importance of sleep and provided a seasonal influenza vaccination.

Discussion
Participation in organized or non-organized, recreational to elite sports activities can provide excellent recreational and leisure time activities and improve physical and mental health for participants. The Aspen Institute in 2018 reported that more kids are being physically active, more are trying different sports, and multisports play is increasing rather than strict specialization. Unfortunately they note that there is an economic inequality with children from lower-socioeconomic circumstances playing less organized sports. About 70% of children and youth participate in an individual or team sport, but unfortunately 17% still reported doing no physical activity.

The pre-participation examination sports examination (PPE) is important for identifying potential medical conditions that could become dangerous during physical activity. They are also important as the PPE may be the only contact with health care providers as many of these children/youth are well and do not seek care for other reasons. The PPE is different in that it is “…a more focused, system-based history and physical examination with specific questions and other elements used to identify issues that are known to affect sports participation.” It can be done as part of a more comprehensive health examination which would also include screening (i.e. mental health, psychosocial screening, drug use, etc.), health counseling (i.e. nutrition, sleep, etc.) and immunizations and laboratory screenings. The history is more focused and identifies about 75% of concerning medical conditions. The physical examination is also more focused concentrating mainly on the head and neck and neurological, cardiac, musculoskeletal components. “Between 3.2% and 13.9% of athletes require additional evaluation as a result of abnormal findings discovered during the PPE. Physicians disqualify 0.3% to 1.3% of athletes who undergo a PPE from athletic participation due to an underlying medical condition.”

Learning Point
The PPE consists of several areas

  • Cardiac screening
    • History
        Personal history of heart murmur, syncope or pre-syncope, chest pain, shortness of breath, fatigue, hypertension and previous cardiac testing should be asked about.
        Family history of heart disease or sudden cardiac death (SCD) and hypertrophic cardiomyopathy also should be asked. SCD can be difficult to determine as this may look like other problems such as a car accident or drowning.
    • Physical examination
        Hypertension that is consistent and not fully evaluated may require temporary disqualification from participation.
        Evaluation for Marfan syndrome stigmata and femoral pulse palpation (to exclude coaractation of the aorta) should be included in the examination.
        Heart murmurs that are grade 3 intensity, diastolic murmurs and those that increase in intensity when going from sitting to standing or with valsalva are more concerning.
    • Pre-participation electrocardiogram (ECG) is controversial. For highly trained or elite athletes, especially in certain groups such as male basketball players, there is a higher risk of cardiomyopathy or electrical abnormalities that can be noted on ECG.
      It is currently not recommended for the general pre-teen and teenage youth in sports unless there are other risk factors.
      With the new COVID 19 virus, cardiac and vascular anomalies are being reported, and evaluation and clearing patients after COVID-19 for athletics remains controversial.
  • Neurological screening
    • History
        Concussion screening is important. History of ever having a concussion, or hit/blow that caused headache, confusion or memory problems should be elicited.
        Multiple concussions, more severe symptoms or longer time to recover are certainly risk factors. The children and youth age groups are also a risk factor and data supports that these groups may take longer to recover from a concussion than collegiate and older athletes.
        Return to play and learning should be step-wise and follow current guidelines
    • Physical examination
        Usually the mental status and neurological examination will be normal during the PPE but evaluation for more acute problems should be done if appropriate.
  • Musculoskeletal screening
    • History
        History of any athletic injury or trauma including fractures (including stress fracture) or dislocations, any evaluation for an injury including going to the emergency room, or x-rays, any reason to use crutches, brace etc., any loose joints, muscles or bones that bother the patient are common questions that can be asked.
        Family history of any connective tissue disease, loose joints or arthritis can also be asked.
    • Physical examination
        All joints should be evaluated for motion, strength and stability with particular attention to any joint that was previously injured or is likely to be injured because of the activity (e.g. shoulder for a swimmer).
        Duck walking and hopping on one foot can help to identify lower extremity problems as well as balance.
        Knees are particularly vulnerable for females because of the mechanics of the body and the increased Q angle at the knee relative to males.
  • Other PPE physical examination areas
    • Height and weight – for obesity and weight changes including anorexia or female athlete triad
    • Skin – rashes and other lesions particularly that are of an infectious nature, but also to evaluate for underlying conditions that could be worsened with participation (e.g. eczema worsened by swimming pool chemical or irritated due to protective padding and equipment)
    • Eyes – acuity, anisocoria is important to note as this needs to be compared in a head trauma situation
    • Lungs – wheezing and potential evaluation for asthma
    • Abdomen – masses and organomegaly which need more evaluation and/or exclusion from some sports
    • Genitourinary – females are not necessarily examined usually, males should be evaluated for identifying hernias, absent or undescended testes or other genitourinary masses

Questions for Further Discussion
1. What conditions delay or disqualify a patient from sports participation? A review can be found here
2. What is female athlete triad and what problems can it cause?
3. What is the Q angle and why does it cause problems for females?

Related Cases

    Disease: Pre-participation Sports Physical Examination | Sports Fitness

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Health Checkup and Sports Fitness.

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.

Heinke B, Mullner J. Common Issues Encountered in Adolescent Sports Medicine. Primary Care: Clinics in Office Practice. 2014;41(3):539-558. doi:10.1016/j.pop.2014.06.001

Roberts WO, Löllgen H, Matheson GO, et al. Advancing the pre-participation Physical Evaluation: An ACSM and FIMS Joint Consensus Statement. Clin J Sport Med. 2014;24(6):6.

Lehman PJ, Carl RL. The pre-participation Physical Evaluation. Pediatric Annals. 2017;46(3):e85-e92. doi:10.3928/19382359-20170222-01

Aspen Institute. State of Play Trends and Developments 2018. Accessed September 15, 2020. https://assets.aspeninstitute.org/content/uploads/2018/10/StateofPlay2018_v4WEB_2-FINAL.pdf?_ga=2.155438523.1669166024.1541103726-725764975.1540216190

CDC. Multisystem Inflammatory Syndrome in Children (MIS-C). Centers for Disease Control and Prevention. Published February 11, 2020. Accessed September 15, 2020. https://www.cdc.gov/mis-c/

Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. Published online September 11, 2020. doi:10.1001/jamacardio.2020.4916

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common Are Bone Spurs in Young Athletes?

Patient Presentation
An 18-year-old female came to clinic after twisting her knee during her varsity soccer practice 3 days previously. She had planted her foot and then turned her body causing pain in the lateral and anterior area of the left knee. She had stopped practice and iced the area. She did not hear a popping sounds, nor felt the joint catch. She had pain with walking but was improving. She had a soccer tournament the following weekend and wanted to return to play. The past medical history showed previous muscle strains, and a right sided ankle sprain. She had been playing high-intensity soccer for many years.

The pertinent physical exam revealed a medium-build female with a mild gait abnormality when walking. She had mild tenderness near the lateral joint line but her collateral and cruciate ligament tests were normal. She had mild pain during the maneuvers but nothing significant.

The diagnosis of a left lateral ligamentous injury was made but because of the high level of participation a radiograph was taken. The radiologic evaluation of the knee showed no bony abnormalities other than a tiny right notch osteophyte. The patient had not had any problems with her knee previous so it was felt this was an incidental finding. She was counseled about working with her athletic trainer and returning to play when pain free.

Discussion
The terminology of abnormal calcification of soft tissues and uses of the terms is often muddied. Especially as the causes may be similar and multiple adjacent tissues may be involved.

  • An exostosis is an abnormal proliferation of bone from the joint. They can appear in various forms and in many locations.
  • An osteophyte is also known as a bone spur and is type of exostosis. Osteophytes are thought to be periosteal or synovial mesenchymal stems cells that become calcified. They usually have a more narrow or pointed projection from the joint. Osteophytes are a very common feature of osteoarthritis.
  • Enthesophytes are abnormal bony projections at the attachment of a tendon or ligament. These are often due to trauma and examples commonly occur at the knee or heel, such as Osgood Schlater disease.

Exostosis variants include:

  • Osteochrondroma – usually a solitary, non-tender, slow-growing mass in long bones (more commonly lower extremity). Radiographically they can be sessile or stalked in appearance.
    This is the most common skeletal tumor (10-15%). They occur especially during the bony growth period. Complications occur in about 4% of patients and include fractures, bony deformation, and compression causing neurovascular problems.
  • Hereditary multiple exostosis – an autosomal dominant disorder with multiple masses in all parts of the body except the head. They are very common in the lower extremity particularly the knee. Short stature may also be seen.
  • Trevor’s disease – usually affects the tarsal bones or epiphyses of long bones. More common in lower extremities and usually unilateral.
  • Nora’s lesion – also known as bizarre parosteal osteochondromatous proliferation seen in the hands and feet. Generally seen in adults.
  • Subungual exostosis – these occur in both the hands and feet with feet more commonly affected particularly the great toe. These are felt to be traumatically related and the bony projection comes from the nail bed. These are usually seen in teens and adults.

Normal variations or congenital anomalies can be mistaken for exostoses such as the supracondylar process of the humerus, os intermetarsale or even the bony projection within the central spinal canal that tethers and splits the spinal cord in half in diastematomyelia. Periosteal reactions can also appear similar to exostoses and include entities such as osteomyelitis, osteoid osteoma, or osteosarcoma. Myositis ossificans from trauma can cause calcification of the muscle but if deep can also show abnormal ossification of the periosteum.

Learning Point
Risk factors for osteophytes include age (older), body mass index (heavier), physical activity (heavy physical activity), diet (low amounts of various nutrients) and genetic factors.

Osteophytes or bone spurs are usually thought of in older people who have osteoarthritis. However they can occur in young people. A cross-sectional, case-controlled study of young adults (<18-36 years) found that being an athlete had a higher risk of radiographic evidence of osteophytes in the knee (odds-adjusted ratio = 2.8) and if a patient had anterior cruciate ligament surgery (odds adjusted ratio = 7.0). While this study isn’t representative of the general population, it does show that young athletes are at risk for development of osteophytes even at a young age. While this study didn’t find a difference in males and females overall for osteophytes, young female athletes are at higher risk for knee injuries particularly in sports with “cutting” type activities such as basketball or soccer.

Questions for Further Discussion
1. What are common benign bone tumors? A review can be found here
2. What is the long-term outcome of ACL repair? A review can be found here
3. What are the positive aspects of organized sports activities?

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bone Diseases and Osteoarthritis.

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.

Richardson RR. Variants of exostosis of the bone in children. Semin Roentgenol. 2005;40(4):380-390. doi:10.1053/j.ro.2005.01.020

DaCambra MP, Gupta SK, Ferri-de-Barros F. Subungual exostosis of the toes: a systematic review. Clin Orthop Relat Res. 2014;472(4):1251-1259. doi:10.1007/s11999-013-3345-4

Roemer FW, Jarraya M, Niu J, Silva J-R, Frobell R, Guermazi A. Increased risk for radiographic osteoarthritis features in young active athletes: a cross-sectional matched case-control study. Osteoarthr Cartil. 2015;23(2):239-243. doi:10.1016/j.joca.2014.11.011

Nasr B, Albert B, David CH, Marques da Fonseca P, Badra A, Gouny P. Exostoses and vascular complications in the lower limbs: two case reports and review of the literature. Ann Vasc Surg. 2015;29(6):1315.e7-1315.e14. doi:10.1016/j.avsg.2015.02.020

Wong SHJ, Chiu KY, Yan CH. Review Article: Osteophytes. J Orthop Surg (Hong Kong). 2016;24(3):403-410. doi:10.1177/1602400327

Perez-Palma L, Manzanares-Cespedes MC, de Veciana EG. Subungual Exostosis Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc. 2018;108(4):320-333. doi:10.7547/17-102

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Potential Problems Associated with Helicobacter pylori?

Patient Presentation
Two pediatricians were talking about the coincidence of each having a family who were concerned about the transmission and testing for H. pylori. Both families had young, asymptomatic children and in one family the mother was affected and in the other family the father was affected. Both parents were being given their initial treatment for H. pylori. Both pediatricians had independently read the recent guidelines for management and had concluded that the children in each family should not be tested currently but be monitored for possible problems.

Discussion
Helicobacter pylori (H. pylori) is a microaerophilis, spiral bacterium that is a prevalent human pathogen. How this infection affects individuals is different in adults and children. Overall seroprevalence rate in children world-wide was estimated to be ~33%, but this seroprevalence rate is decreasing in the developed world for both adults and children. It is acquired in childhood and can persist through colonization throughout life if untreated. Fortunately, it often is asymptomatic and generally does not cause serious disease in children.

Some serotyping data shows that within families children acquire it more often from mothers than from fathers.

Learning Point
H. pylori causes gastritis (chronic), peptic ulcer disease (PUD), gastric adenocarcinoma and MALT (mucosal-associated lymphoid tissue lymphoma) in adults. Many of the studies have been conducted in adults and extrapolating to children is not appropriate. Potential clinical problem may not be caused by H. pylori but rather may only be associated with it in children. Many of those listed below are certainly not specific to H. pylori.

  • PUD can cause upper abdominal pain and potential gastrointestinal bleeding but is not common in children. Testing is recommended if PUD is identified.
  • Functional abdominal pain – testing is not recommended
  • Iron deficiency anemia – testing is not recommended for initial investigation, but may be appropriate for refractory anemia
  • Chronic immune thrombocytopenic purpura – testing may be considered
  • Short stature and failure to thrive – testing is not recommended
  • Henoch-Schonlein purpura – testing is not recommended
  • Obstructive sleep apnea – testing is not recommended
  • Diabetes mellitus – testing is not recommended
  • Asthma/atopic dermatitis – testing is not recommended
  • Celiac disease (having H. pylori possibly has a protective effect)

Guidelines for management for children and adolescents from Europe and North America were published in 2017 (see To Learn More below). Testing of relatives with gastric cancer that were previously included in guidelines have been removed from this iteration. Test and treat strategy for children is not recommended as the clinical goal is to identify the cause of the upper abdominal pain and/or other symptoms rather than identifying H. pylori infection. Patients should have appropriate diagnostic testing (i.e. endoscopy with biopsy, urea breath hydrogen testing, stool antigen testing) with antimicrobial susceptibility testing to guide treatment. Even with biopsies, H. pylori can be an incidental finding. Treatment depends on age, antibiotic susceptibility testing and include antibiotics and proton pump inhibitors for 7-14 days depending on the protocol. Adherence to protocol has been shown to be a key to treatment success and more than 90% adherence is recommended. The main cause of treatment failure is clarithromycin resistance and non-adherence. Post treatment re-testing for treatment success or failure is recommended at least 4 weeks after treatment. There has been a vaccine trial in China with children. The efficacy rate was “…71% and 55% at 12 months and 3 years after vaccination.” One problem was “…that 20% of younger children in the study were not protected [from H. pylori].”

Questions for Further Discussion
1. How common are gastric ulcers? A review can be found here
2. What are the ROME criteria for functional abdominal pain? A review can be found here
3. What causes abdominal pain? A review can be found here

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Helicobacter Pylori infections

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.

Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594

Kalach N, Bontems P, Raymond J. Helicobacter pylori infection in children. Helicobacter. 2017;22 Suppl 1. doi:10.1111/hel.12414

Kotilea K, Kalach N, Homan M, Bontems P. Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies. Paediatr Drugs. 2018;20(4):337-351. doi:10.1007/s40272-018-0296-y

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa