Blistering Distal Dactylitis

Blistering Distal DactylitisInfectious diseases seem to be omnipresent in the Ped ED and, thus, have their own dedicated Category of the PedEMMorsels.  Additionally, unusual dermatologic eruptions are also quite prevalently encountered when caring for children (see Approach to Rash).  While individually each category is fun to think about, the excitement more than doubles when they occur concurrently (perhaps I am being facetious). Let’s review Blistering Distal Dactylics! (say that 6 times fast in a row – I dare you)

 

Blistering Distal Dactylitis: What It Is

  • Superficial infection of the distal finger (just like the name would imply)
  • Tense bulla forms over the volar aspect / finger pad [Tessaro, 2016]
    • May extend dorsally to the lateral nail folds.
    • Oval shaped
    • Erythematous base
    • Often a singular lesion
  • Filled with purulent material (yuk).
  • Caused by:
    • Group A Streptococcus pyogenes
      • Most common pathogen
      • Unclear how it causes bullae to develop
      • Don’t forget other interesting Strep Infections:
    • S. aureus
      • Less common, but known to cause bullous disease (see Staph Scalded Skin)
      • Multiple lesions may predict infection with S. aureus.
      • Rarely is MRSA implicated. [Fretzayas, 2011]
    • S. epidermidis 
    • Group B Streptococcus
  • Typically affects kids 2 years to 16 years, but has been shown in children <2 years as well. [Lyon, 2004]

 

Blistering Distal Dactylitis: Ddx

  • Herpetic Whitlow
  • Burns
  • Bullous impetigo
  • Paronychia
  • Insect bites
  • Blistering disorders
  • Dyshidrotic eczema
  • Friction blisters and other mechanical irritants

 

Blistering Distal Dactylitis: Diagnosis It!

  • Clinical diagnosis for the most part.
    • Consider other etiologies like Herpetic Whitlow.
    • May have concurrent infection at another remote site (ex, URI, pharyngitis).
    • Multiple lesions suggests Staph as causative agent.
  • Can confirm with testing:
    • Gram-stain and culture of debris and fluid from blister.
    • May perform rapid strep testing on fluid/debris. [Cohen, 2014; Wollner, 2014]
      • Rapid Strep Test has similar test characteristics/performance as it does when applied to patients with pharyngitis.

 

Blistering Distal Dactylitis: Treat It!

  • Local Wound Care
    • No definitive recommendations for incision and drainage, but often the blister is unroofed to collect specimen. [Tessaro, 2016]
    • Once unroofed, wet-to-dry dressings are appropriate.
  • Systemic Antibiotics
    • Coverage for strep and staph is paramount.
      • Beta-lactamase-resistant antibiotic often selected.
      • Empiric covered for MRSA is not likely beneficial at this point, but keep local resistance patterns in mind.
    • 10 Day course often cited.
    • Topical antibiotics alone are inadequate.

 

References

Arch Pediatr. 2014 Nov;21 Suppl 2:S93-6. PMID: 25456688. [PubMed] [Read by QxMD]

Arch Pediatr. 2014 Nov;21 Suppl 2:S84-6. PMID: 25456686. [PubMed] [Read by QxMD]

Fretzayas A1, Moustaki M, Tsagris V, Brozou T, Nicolaidou P. MRSA blistering distal dactylitis and review of reported cases. Pediatr Dermatol. 2011 Jul-Aug;28(4):433-5. PMID: 21438916. [PubMed] [Read by QxMD]

Scheinfeld NS1. Is blistering distal dactylitis a variant of bullous impetigo? Clin Exp Dermatol. 2007 May;32(3):314-6. PMID: 17362240. [PubMed] [Read by QxMD]

Lyon M1, Doehring MC. Blistering distal dactylitis: a case series in children under nine months of age. J Emerg Med. 2004 May;26(4):421-3. PMID: 15093848. [PubMed] [Read by QxMD]

Eczema Herpeticum

Eczema HerpeticumThe evaluation of pediatric patients with rashes is a common occurrence in the Ped ED… and a common area of frustration for many of us (ok, maybe it is just me).  We have previously covered an approach to the evaluation of the Pediatric Rash.  We have also covered a variety of common causes of pediatric rashes (ex, Scabies, Tinea, Diaper Dermatitis and Molluscum) including eczema. While many of these conditions are simple nuisances, some can become more problematic. Let’s make sure we stay vigilant for Eczema Herpeticum.

 

Eczema Herpeticum: Basics

  • Atopic dermatitis is an inflammatory skin disease
  • The inflammatory states creates an impaired skin barrier
  • The impaired protection increases risk for bacterial and viral infections
  • Eczema herpeticum
    • HSV skin infection that occurs in patients with atopic dermatitis.
    • Occurs in 3-6% of patients with atopic dermatitis.
    • Can be due to HSV1 or HSV2, but also other viruses can cause it (ex, varicella, poxvirus)
    • May occur with either primary or recurrent HSV infection. [Wollenberg, 2003]
    • More likely to occur in those patients with:
      • Extensive eczema skin involvement
      • Early onset of eczema [Wollenberg, 2003]
      • Eczema lesions on head and neck
      • High IgE levels
    • Children who are young (1 year or younger) or have systemic illness (ex, fever) are more likely to require hospitalization. [Luca, 2012]
    • Fortunately, overall mortality is low. [Aronson, 2013; Aronson, 2011]

 

Eczema Herpeticum: Presentation

  • Systemic symptoms
    • Fever
    • Malaise
    • Lymphadenopathy
  • Skin eruption
    • Monomorphic eruption of dome-shaped vesicles 
      • Initially starts in region of eczema
      • Can spread to involve normal skin also
    • Lesions may crust and form superficial pits and erosions
    • Head, neck, and trunk frequently affected.
      • Lesions can affect the eye and cause keratoconjunctivitis.
    • Fluid from vesicles can be sent for HSV PCR or viral culture to confirm diagnosis.
  • May have bacterial infection superinfection 
    • S. aureus is commonly cultured (~30%). [Aronson, 2011]
    • Septicemia cases can occur, but less commonly (~3%).  [Aronson, 2011]
  • Dissemination of HSV
    • Multiple organ involvement
    • DIC
    • Meningitis/encephalitis

 

Eczema Herpeticum: Treatment

  • Acyclovir is the traditional therapy
    • Depending on severity of condition, oral or IV is appropriate
    • Oral acyclovir has low bioavailability, so only use for mild cases.
  • Delayed administration of acyclovir in hospitalized patients is associated with increased length of stay. [Aronson, 2011]
    • Each day of delayed initiation of acyclovir increased LOS.
    • Challenging to recognize, but important to consider and initiate therapy early, similar to neonatal HSV.
  • Steroids
    • Topical steroids
      • Concern that topical steroids may increase spread of HSV infection.
      • Topical steroids are not definitively associated with worsening disease and prolonged LOS.  [Aronson, 2013; Aronson, 2011]
      • May be prudent to wait until acyclovir has been initiated.  [Aronson, 2011]
    • Systemic steroids do worsen eczema herpeticum and increase LOS.  [Aronson, 2013; Aronson, 2011]
  • Antibiotics
    • Empiric antibiotics for all kids have not shown to improve outcomes. [Aronson, 2013]
    • Early recognition of serious bacterial infection is important, however.

 

Moral of the Morsel

  • Most rashes in children are benign, but remain vigilant.
  • Eczema injures one of the body’s primary defenses against the outside world, so always consider bacterial as well as viral super-infections.
  • If you see blisters in child with eczema, think Eczema Herpeticum!
  • Obtain HSV PCR and viral culture of fluid from blisters and initiate acyclovir.

 

References

Blanter M1, Vickers J, Russo M, Safai B. Eczema Herpeticum: Would You Know It If You Saw It? Pediatr Emerg Care. 2015 Aug;31(8):586-8. PMID: 26241712. [PubMed] [Read by QxMD]

Aronson PL1, Shah SS, Mohamad Z, Yan AC. Topical corticosteroids and hospital length of stay in children with eczema herpeticum. Pediatr Dermatol. 2013 Mar-Apr;30(2):215-21. PMID: 23039248. [PubMed] [Read by QxMD]

Aronson PL1, Yan AC, Mohamad Z, Mittal MK, Shah SS. Empiric antibiotics and outcomes of children hospitalized with eczema herpeticum. Pediatr Dermatol. 2013 Mar-Apr;30(2):207-14. PMID: 22994962. [PubMed] [Read by QxMD]

Luca NJ1, Lara-Corrales I, Pope E. Eczema herpeticum in children: clinical features and factors predictive of hospitalization. J Pediatr. 2012 Oct;161(4):671-5. PMID: 22575249. [PubMed] [Read by QxMD]

Aronson PL1, Yan AC, Mittal MK, Mohamad Z, Shah SS. Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. Pediatrics. 2011 Dec;128(6):1161-7. PMID: 22084327. [PubMed] [Read by QxMD]

Wollenberg A1, Zoch C, Wetzel S, Plewig G, Przybilla B. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. J Am Acad Dermatol. 2003 Aug;49(2):198-205. PMID: 12894065. [PubMed] [Read by QxMD]

Appendix Testis Torsion

Testis Appendix TorsionAcute scrotal pain will always grab both patient’s and providers’ attention, appropriately.  We have already discussed the most feared cause of acute scrotal pain – Testicular Torsion. While there are many other causes of inguinal and scrotal pain (ex, varicocele, inguinal hernia), one of the common causes is Torsion of the Appendix Testis.

 

Appendix Testis: What is that?

  • There are actually 4 identified testicular appendages, but appendix epididymis and  appendix testis or the most commonly encountered.
  • Appendix testis is located in the groove between testis and the epididymal head at the upper pole of the testis.
  • The appendix testis is pedunculate and susceptible to torsion.
  • Torsion of the appendix testis is a common cause of acute scrotal pain in children. [Boettcher, 2013Sakellaris, 2008]

 

Appendix Testis: Don’t Get it Twisted

  • Etiology of torsion is unknown.
  • Usually occurs in boys 7-14 years of age.
  • More common than epididymitis in children.
  • Torsion of the appendix testis can lead to necrosis of it.
    • The necrotic tissue will lead to local inflammation and, thus, mimic epididymitis.  [Boettcher, 2013]
    • Inflammatory cells infiltrate the twisted appendix testis and are a marker of progression of the disease, not infection. [Rakha, 2006]

 

Diagnosis

  • Clinical History and Exam are helpful, but not conclusive
    • “Classic” signs:
      • Localized tenderness at the superior pole
      • Blue Dot sign
      • Preserved cremasteric reflex
    • Findings that favor Epididymitis: [Boettcher, 2013]
      • Dysuria
      • Painful epididymis
  • Ultrasound can be helpful in making the diagnosis. [Lev, 2014; Yang, 2005]
    • Findings consistent with torsion of appendix testis:
      • Size of 5 mm or greater
        • May see hyperechogenic mass between epididymal head and upper pole of the testis.
        • Often associated with enlarged epididymis and hydrocele.
      • Spherical shape
      • Increased periappendiceal blood flow
    • Findings more consistent with epididymitis:  [Boettcher, 2013]
      • Altered epididymal echogenicity
      • Increased peritesticular perfusion on the affected side
    • Often used as means to evaluate for testicular torsion.
      • Ultrasound is not perfect in ruling-out testicular torsion.
      • Recall that normal blood flow does not completely exclude the possibility of testicular torsion. [Sakellaris, 2008]

 

Treatment

  • NSAIDs
  • Restricted activity (“Sorry, no soccer or football this weekend boy.”)
  • Cool Sitz baths
  • Antibiotics are not required.
    • Obviously, this seems intuitive, but often the U/S may indicate findings consistent with epididymitis/orchitis so you may be inclined to give abx.
    • Antibiotics for epididymitis can be reserved for boys with: [Boettcher, 2013; Halachmi, 2005]
      • Recurrent infection history
      • Underlying urinary tract abnormality
      • Signs of puberty
  • Very rarely will surgical excision be required for pain control.

 

References

Lev M1, Ramon J1,2, Mor Y1,2, Jacobson JM2,3, Soudack M2,3. Sonographic appearances of torsion of the appendix testis and appendix epididymis in children. J Clin Ultrasound. 2015 Oct;43(8):485-9. PMID: 25704247. [PubMed] [Read by QxMD]

Boettcher M1, Bergholz R, Krebs TF, Wenke K, Treszl A, Aronson DC, Reinshagen K. Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children. Urology. 2013 Oct;82(4):899-904. PMID: 23735611. [PubMed] [Read by QxMD]

Sakellaris GS1, Charissis GC. Acute epididymitis in Greek children: a 3-year retrospective study. Eur J Pediatr. 2008 Jul;167(7):765-9. PMID: 17786475. [PubMed] [Read by QxMD]

Rakha E1, Puls F, Saidul I, Furness P. Torsion of the testicular appendix: importance of associated acute inflammation. J Clin Pathol. 2006 Aug;59(8):831-4. PMID: 16569689. [PubMed] [Read by QxMD]

Halachmi S1, Toubi A, Meretyk S. Inflamation of the testis and epidididymis in an otherwise healthy child: is it a true bacterial urinary tract infection? J Pediatr Urol. 2006 Aug;2(4):386-9. PMID: 18947641. [PubMed] [Read by QxMD]

Yang DM1, Lim JW, Kim JE, Kim JH, Cho H. Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis. J Ultrasound Med. 2005 Jan;24(1):87-91. PMID: 15615932. [PubMed] [Read by QxMD]

Endotracheal Tube Depth

Endotracheal Tube DepthWe all know that airway management is a critical skill for those of us who care for pediatric patients in the acute environment!  Due to conditions like severe respiratory illness (ex, asthma), acute trauma (ex, pulmonary contusion), or acute metabolic derangements (ex, DKA) children may benefit from endotracheal intubation.  We must, however, remember, that in our efforts to help the child we must first do no harm, and the act of intubation has a large potential for inducing harm.  One of the most important aspects of endotracheal intubation is proper positioning of the ETT.  Let us take a moment to review Endotracheal Tube Depth.

 

Endotracheal Tube Depth: Do No Harm

  • Unrecognized ETT misplacement (too high/too low) occurs frequently in Ped ED. [Miller, 2016]
    • Low placement (i.e., mainstrem bronchus) is the most common misplacement!
    • Younger patients and female patients are particularly at risk.
  • Unrecognized ETT misplacement leads to complications!
    • Hypoxemia
    • Inadequate / difficult ventilation
    • Pneumothorax
    • Barotrauma
    • Significant atelectasis
    • Potential for unnecessary procedures (ex, misinterpretation of their being a pneumothorax leading to chest tube)

 

Endotracheal Tube Depth: Anticipate

  • When planning to intubate, remind yourself of the proper positioning of the ETT
  • Distal tip of the ETT should be between:
    • The thoracic inlet and
    • The carina.
  • The ETT should be positioned and measured at the central incisor / alveolar ridge.
    • Do not measure at the lip.
  • Anticipate that this will be more challenging to achieve in children, particularly infants.
    • Shorter tracheal length = less room for error
    • The length from the vocal cords to the carina can vary between 5cm and 9 cm.
  • Head / neck position plays a role!
    • Neck extension will cause the ETT to move cephalad: potentially leading to extubation!
    • Neck flexion will cause ETT to move toward carina: potentially going into mainstem bronchus!

 

Endotracheal Tube Depth: Estimate

  • There are several formulas that can help estimate the depth in centimeters of the ETT.
    • Personally, I am always a little leery any time there are multiple formulas to answer a question… (see Traumatic LP CSF Evaluation)
    • Also, sadly, in the heat of the moment… doing complex calculus is not my strongest skill… 
  • Formulas can be useful to estimating initial tube placement, but their performance is variable for each individual patient.
    • Age-based or height-based formulas are based on population statistics.
    • Your individual patient may be outside the mean of that population!
    • Most formulas are less accurate for children < 3 years of age.  [Koshy, 2016]
  • PALS Estimation
    • For children > 1 year
    • [Age (in years) / 2] + 12 (for oral ETT)
    • Frequently leads to malpositioned ETT [Koshy, 2016; Lau, 2006]
  • Internal Diameter Estimation
    • 3 x ID of ETT
    • Ex: 4.0 ETT => Depth = 12 cm
    • Only used for ETT 3.0 or greater.
    • Only predicted accurate placement in ~59% of cases. [Koshy, 2016]

 

Endotracheal Tube Depth: Auscultate?

  • ETT placement confirmation has typically begun with auscultation of breath sounds.
  • Equal / symmetric bilateral breath sounds would seem to suggest aeration from above the carina.
  • The problem is that ETT’s with a Murphy eye can generate bilateral breath sounds even in the setting of a mainstem bronchial intubation.
  • Bilateral breath sounds does not exclude mainstem intubation. [Verghese, 2004]

 

Endotracheal Tube Depth: Confirm!

  • Chest Xray are traditionally used to confirm ETT position.
    • Pros: CXR has been found to be superior to over formulas or other estimations. [Koshy, 2016]
    • Cons: CXR is time consuming to obtain.
  • Palpation of the trachea has been used to help determine ETT position. [Gamble, 2014]
    • During intubation, another practitioner places 3 fingers on trachea with inferior finger at the sternal notch.
    • The ETT is slowly advanced into the airway and positioned via external palpation.
    • This was found to be superior to estimation formulas.
  • Ultrasound can help you “see” the ETT position!
    • An ultrasound probe positioned at the sternal notch can help locate the ETT. [Chowdhry, 2015; Chou, 2015; Tessaro, 2015]
    • Much more readily available than CXR!

 

Moral of the Morsel:

  • Your successful placement of the ETT through the cords is only the beginning of the airway management!
  • Don’t celebrate too early! You have now placed the patient in a precarious position!
  • Ensure that the ETT is appropriately positioned!
    • Anticipate and Estimate, but Confirm!!!
    • If there is any change in the child’s condition, Re-CONFIRM appropriate position of the ETT!
  • Bring your Ultrasound to the bedside!  Looking is better than listening!!

 

References

Miller KA1, Kimia A2, Monuteaux MC2, Nagler J2. Factors Associated with Misplaced Endotracheal Tubes During Intubation in Pediatric Patients. J Emerg Med. 2016 May 25. PMID: 27236246. [PubMed] [Read by QxMD]

Koshy T1, Misra S2, Chatterjee N2, Dharan BS3. Accuracy of a Chest X-Ray-Based Method for Predicting the Depth of Insertion of Endotracheal Tubes in Pediatric Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2016 Jan 29. PMID: 27238432. [PubMed] [Read by QxMD]

Pallin DJ1, Dwyer RC2, Walls RM3, Brown CA 3rd3; NEAR III Investigators. Techniques and Trends, Success Rates, and Adverse Events in Emergency Department Pediatric Intubations: A Report From the National Emergency Airway Registry. Ann Emerg Med. 2016 May;67(5):610-615. PMID: 26921968. [PubMed] [Read by QxMD]

Chowdhry R1, Dangman B2, Pinheiro JM1. The concordance of ultrasound technique versus X-ray to confirm endotracheal tube position in neonates. J Perinatol. 2015 Jul;35(7):481-4. PMID: 25611791. [PubMed] [Read by QxMD]

Tessaro MO1, Arroyo AC1, Haines LE1, Dickman E1. Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography. CJEM. 2015 Jan;17(1):94-8. PMID: 25781388. [PubMed] [Read by QxMD]

Chou EH1, Dickman E2, Tsou PY3, Tessaro M2, Tsai YM4, Ma MH5, Lee CC6, Marshall J2. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation. 2015 May;90:97-103. PMID: 25711517. [PubMed] [Read by QxMD]

Gamble JJ1, McKay WP, Wang AF, Yip KA, O’Brien JM, Plewes CE. Three-finger tracheal palpation to guide endotracheal tube depth in children. Paediatr Anaesth. 2014 Oct;24(10):1050-5. PMID: 24958069. [PubMed] [Read by QxMD]

Kerrey BT1, Geis GL, Quinn AM, Hornung RW, Ruddy RM. A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal tube position in a pediatric emergency department. Pediatrics. 2009 Jun;123(6):e1039-44. PMID: 19414520. [PubMed] [Read by QxMD]

Lau N1, Playfor SD, Rashid A, Dhanarass M. New formulae for predicting tracheal tube length. Paediatr Anaesth. 2006 Dec;16(12):1238-43. PMID: 17121553. [PubMed] [Read by QxMD]

Hsieh KS1, Lee CL, Lin CC, Huang TC, Weng KP, Lu WH. Secondary confirmation of endotracheal tube position by ultrasound image. Crit Care Med. 2004 Sep;32(9 Suppl):S374-7. PMID: 15508663. [PubMed] [Read by QxMD]

Verghese ST1, Hannallah RS, Slack MC, Cross RR, Patel KM. Auscultation of bilateral breath sounds does not rule out endobronchial intubation in children. Anesth Analg. 2004 Jul;99(1):56-8. PMID: 15281503. [PubMed] [Read by QxMD]

Rib Fractures

Rib FractureWe know that children are super flexible and that is a good thing!  Often kids will bend and won’t break!  Unfortunately, there are events that still lead to childhood injuries. Some of these events are unfortunate and accidental (ex, Submersions), while others are sinister and purposeful (ex, Abuse). When we think of injury in children, we often immediately consider head trauma (the leading cause of mortality), but let us not overlook thoracic trauma as it is the second leading cause of mortality in children suffering from trauma. While pulmonary contusions are the the most common intra-thoracic injury, let’s spend a moment contemplating the significance of Rib Fractures.

 

Rib Fractures: Description

  • 4 fracture types have been described. [Love, 2013]
    • Transverse
    • Oblique
    • Buckle
    • Sternal end
  • 4 locations have been described. [Love, 2013]
    • Posterior
    • Posterolateral
    • Anterolateral
    • Anterior
  • Rib fractures occur by 2 possible mechanisms:
    • Anterior-posterior compression (most common)
    • Direct trauma to rib surface

 

Rib Fractures: Age Matters

  • Children have rib fractures less often than adults due to anatomic and structural differences.
  • Rib morphology and orientation changes with age. [Weaver, 2014]
    • Rib cage increases in size and decreases in kyphosis from birth to teen years.
    • Ribs rotate inferiorly also.
    • Ribs increase in roundness and horizontal angle with increased age.
    • These changes influence risk for fracture with increasing age (particularly elderly patients).
  • The thoracic cage is more compliant (more able to deform without fracture) in children.
    • It takes a significant force to cause a rib fracture in a child.
    • The complaint chest wall does not dissipate a force as well, transmitting more of it inward to the underlying organs (see Pulmonary Contusion).

 

Rib Fractures: The Concerns

  • Abuse should always be on your radar!
    • Most rib fractures in infants are caused by child abuse. [Bulloch, 2000]
      • Other etiologies should be considered as well.
      • Ex, Birth Trauma, Rickets, Osteogenesis Imperfecta
    • Abused children have more rib fractures than accidentally injured children. [Darling, 2014]
    • Accidental injuries cause more intrathoracic injuries, likely due to the mechanisms. [Darling, 2014]
    • Lack of intrathoracic injury does not rule out abuse! [Darling, 2014]
    • Concurrent extra-thoracic fractures where more common in abuse cases. [Darling, 2014]
  • Rib fractures are associated with other injuries.
    • Children have higher rates of associated head, thoracic, and solid organ injuries with rib fractures compared to adults. [Kessel, 2014]
    • Rib fractures should be considered a sign of significant, possible multiple, trauma in kids.
  • Mortality increases in a LINEAR fashion for each fractured rib in children. [Rosenberg, 2016]
    • Adult mortality has a steep increase above 6 fractured ribs.
    • In kids, mortality odds worsen with each rib fractured.
      • Mortality increased from 1.79% without rib fracture to 5.81% with one rib fracture.
      • With each rib fracture, mortality rate increased in nearly linear fashion up to 8.23% for 7th rib fractured.

 

Moral of the Morsel

  • Highly consider abuse in children with rib fractures! May even want to consider extra thoracic injuries.
  • Consider rib fractures as a indication of significant impact and trauma! Treat it like a risk factor for other occult injuries.
  • Know that each rib fractured increases a child’s risk of mortality!

 

References

Rosenberg G1, Bryant AK, Davis KA, Schuster KM. No breakpoint for mortality in pediatric rib fractures. J Trauma Acute Care Surg. 2016 Mar;80(3):427-32. PMID: 26713973. [PubMed] [Read by QxMD]

Agnew AM1, Schafman M2, Moorhouse K3, White SE4, Kang YS5. The effect of age on the structural properties of human ribs. J Mech Behav Biomed Mater. 2015 Jan;41:302-14. PMID: 25260951. [PubMed] [Read by QxMD]

Kessel B1, Dagan J2, Swaid F3, Ashkenazi I2, Olsha O4, Peleg K5, Givon A5; Israel Trauma Group, Alfici R2. Rib fractures: comparison of associated injuries between pediatric and adult population. Am J Surg. 2014 Nov;208(5):831-4. PMID: 24832239. [PubMed] [Read by QxMD]

Weaver AA1, Schoell SL, Stitzel JD. Morphometric analysis of variation in the ribs with age and sex. J Anat. 2014 Aug;225(2):246-61. PMID: 24917069. [PubMed] [Read by QxMD]

Marine MB1, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR Am J Roentgenol. 2014 Apr;202(4):868-71. PMID: 24660718. [PubMed] [Read by QxMD]

Darling SE1, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatr Radiol. 2014 Oct;44(10):1230-6. PMID: 24771095. [PubMed] [Read by QxMD]

Love JC1, Derrick SM, Wiersema JM, Pinto DC, Greeley C, Donaruma-Kwoh M, Bista B. Novel classification system of rib fractures observed in infants. J Forensic Sci. 2013 Mar;58(2):330-5. PMID: 23406328. [PubMed] [Read by QxMD]

Hamilton NA1, Bucher BT, Keller MS. The significance of first rib fractures in children. J Pediatr Surg. 2011 Jan;46(1):169-72. PMID: 21238660. [PubMed] [Read by QxMD]

Bulloch B1, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000 Apr;105(4):E48. PMID: 10742369. [PubMed] [Read by QxMD]