CASE 1 (Full Version)

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Dr.Wagner -> CASE 1 (January 9, 2006 7:14:00 AM)

16 month old child arrives in her mothers arms. The child apparently was behind the couch when loud crying was heard.
The child, according to mom, is right handed, but since the crying has refused to move the arm. The arm is held at the childs side. You see no external signs of trauma.


What would like to do (and give justification).




VagusX -> Re: CASE 1 (January 9, 2006 11:48:00 AM)

#1 See if the child will reach with the right UE for your name tag or other colorful items to see if the mother is overreacting.

#2 Move the arm to see if he starts crying again.
a)if he cries and is guarded I would start with an X-ray of the entire UE to rule out fracture.
b) I the arms feels flaccid or weak I would consider a brachial plexus injury and have a CT (A CT Scan was one was one of the first tests given to one of my patients who came out of surgery with a flaccid UE, I don't much other justification other than that.)

I would start from there.

Daniel




SJBird55 -> Re: CASE 1 (January 9, 2006 3:45:00 PM)

You know, Wags, you always have some kind of twist to what always appears to be a simple situation.

I can't picture the room the kid was in... so, I'd ask if there was an electrical outlet behind the couch with the kid. Specifically, an outlet without one of those irritating plastic protector thingies that inhibits kids from poking their finger or anything else into the hole. Maybe the kid got zapped.




Randy Dixon -> Re: CASE 1 (January 9, 2006 11:38:00 PM)

I'm not a therapist so my answers shouldn't reflect on those who are.

I would suspect the kid went over the top of the couch. There are no signs of trauma but the first thing I would suspect is nursemaid's elbow. Then maybe a fracture or shoulder dislocation that isn't visibly apparent. I think that seeing if he will move it voluntarily is a good idea, check for pulse and maybe grasp reflex. See what kind of passive motion he'll allow, then gently palpate the joints to see what I feel. What happens next depends on what you get.




Sean_Collins -> Re: CASE 1 (January 10, 2006 12:37:00 AM)

I would send them to the ER since primary diagnosis of medical conditions is not within the scope of physical therapy practice.




SJBird55 -> Re: CASE 1 (January 10, 2006 1:05:00 AM)

Sean... pretend you are truly practicing direct access and play along. Pretend that mom walked into your clinic; you accept walk-in appointments... and what are you going to do?




FLAOrthoPT -> Re: CASE 1 (January 10, 2006 2:48:00 AM)

i guess if we are going to be like major careful, what about stabilizing the neck until it is cleared




Sean_Collins -> Re: CASE 1 (January 10, 2006 2:48:00 AM)

I always respond as in a direct access scenario, but direct access does not mean examination or treatment that may be outside the scope of practice. Given the scenario provided I think this child needs a medical examination first, so I would refer them either to the ER or to a MD. Just because you accept walk in appointments does not mean you should automatically jump to examine each and every person that walks in the door.
Also - this is my response based on "direct access" without the ability to order a radiograph.




Dr.Wagner -> Re: CASE 1 (January 10, 2006 3:16:00 AM)

I will be posting again with more info (as requested)...
On initial exam there is no abrasions, lacerations, or burns.

You ask the mom again "now exactly what did you see"

"well, she went behind the couch and she just started crying. Then I noticed she was holding her arm when I picked her up"

You offer your name badge to the child, she does not reach for it.
She screams with passive motion of the arm.
Her skin is appropriately warm and dry.
Pulse is 140.
Capillary refill is normal.
When she is sitting watching Sesame Street, she is content as can be.




Jeep -> Re: CASE 1 (January 10, 2006 4:53:00 AM)

How long since the episode? (hours?/day?)

What has mom done(tx) since this happened?

How is gross inpection left to right: arm? shoulder?




Sean_Collins -> Re: CASE 1 (January 10, 2006 4:56:00 AM)

So I take it my course of action is not respected. Can I ask one question?
If so, when did direct access mean diagnosis of pathology as opposed to direct access post diagnosis for diagnosis of impairment, functional limitation and/or disability? Am I missing something?




nari -> Re: CASE 1 (January 10, 2006 8:15:00 AM)

Dr Wags
Do you know what occured in the previous hour or so before the mother found the child crying?
Any altercations between them?

Nari




karmzack -> Re: CASE 1 (January 10, 2006 8:45:00 AM)

Sounds like there is no trauma involved if the child just 'went behind the couch'. I am thinking possible spider bite with delayed redness and swelling. Did the mother immediately bring the patient to the ER or was there a delay?
Has the arm been fully visualized? The passive testing would quickly turn into active resistance with all the screaming.
I might try to move the arm while she is content watching TV.




KAK -> Re: CASE 1 (January 10, 2006 9:41:00 AM)

I think the history sounds suspicious. I’d be thinking a subluxation of the radial head as Randy suggested. Giving the mother the benefit of doubt, it possibly could have happened if she fell off the couch.




SJBird55 -> Re: CASE 1 (January 10, 2006 10:15:00 AM)

Wags, what'd the mom hear (a thud) or feel (a vibration through the floor) prior to hearing the crying?

Have the mom wait somewhere if she's all happy watching TV. Head to the freezer and grab two popsicles. Take off your lab coat. Sit down on the ground and watch Sesame Street with her about 4 feet away from her. Sit there eating your popsicle. Ask her if she wants one.... if she does, does she reach for it?




nari -> Re: CASE 1 (January 10, 2006 12:24:00 PM)

I was not talking about physical trauma, but the more common one - emotional trauma?

Nari




Jeep -> Re: CASE 1 (January 10, 2006 1:15:00 PM)

[QUOTE] When she is sitting watching Sesame Street, she is content as can be [/QUOTE]how is the arm being held/carried/positioned at this time?


DXX- Couldn't see seseme street from BEHIND the couch--- => Acute seseme street withdrawal syndrome!! LOL!




Dr.Wagner -> Re: CASE 1 (January 10, 2006 2:23:00 PM)

Because I still have no idea how to post an xray...(please someone help)...

You decide "what the heck", you get an xray and a "wet read" from the radiologist...on the sheet faxed to you it reads..."NML"

The child sits and reaches with her non dominant hand to get the popsicle. the arm has been fully visualized and there are no abrasions, lacerations, bruises etc. The child simply holds the arm in toward the body with the elbow flexed.


1. Is further radiology needed? Was it ever?
2. Supposing normal vitals (no one asked), are ANY tests needed?
3. There has been a wide range of concerns, from spider bites (hmmmmm), to burns, to common orthopedic concerns...
4. what could be an easy pay to rule out or rule in one of the above concerns (differential diagnosis)




Jeep -> Re: CASE 1 (January 10, 2006 3:03:00 PM)

What x-ray views were taken?


[QUOTE]
4. what could be an easy pay to rule out or rule in one of the above concerns [/QUOTE]Sed rate




FLAOrthoPT -> Re: CASE 1 (January 10, 2006 3:19:00 PM)

well ignoring this is a child, an ortho screen would be AROM vs PROM to see if the joint is involved or musculature involved. You could do neuro tests to rule out peripheral or chord symptoms. Motor control tests to see if CNS invloved. Functional task to see if fear avoidance etc. Palpation, sensory exam, and rule out C-spine, T-spine, rib fxs.

Now since this a kid and a bit before the real talking ages, you cannot simply ask them what happened. So you are going solely based on mom's interpretation, and you have no reason to believe mom to be deceiving you at this time. you also need to make sure no primitive reflexes are active, look for signs of trauma and or abuse, have the child attempt activities appropriate for 16 month old including walking and pushing a ball perhaps, throwing and catching you can try, climbing/crawling up a step, etc.

Now since this is hard to do in this format, let's try to figure out why heartbeat so high, check BP, check temperature, check all over for wounds including exit wound in toes perhaps from electric shock. Try to rule out a brachial plexus injury by looking for peripheral patterns of weakness. Hopefully this all takes WAY less time than it did to write!

When in doubt, I think the person was standing on the block of ice which is now a puddle of water and that's how they hung themselves...sorry reminds me of one of those conundromes.

Ben (no peds exp. whatsoever by the way)




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