Scaphoid fractures are regarded as fractures that are difficult to heal, so a classification system is needed taking different factors into account that should lead towards proper guidance to the healing time and management of these fractures. Popular classification criteria are Herbert, Russe, and Mayo classification systems. Herbert’s classification system is based on the fracture’s stability and proposes that all complete bicortical fractures (except for tubercle fractures) are unstable. Salter-Harris classification is used for categorizing epiphyseal fractures, while Delbert classification system is reserved for fractures of the proximal femur in children. Fractures of the ankles are classified using Ottawa rules, and Garland classification is used for supracondylar fractures in children.

Internal abdominal bleeding is most probably the cause of the child’s shock, especially unresponsive to fluid boluses.

Bowel sounds in the chest and curved NG tube are suggestive of a diaphragm rupture, which has caused herniation of bowel into the thoracic cavity through the defect in the diaphragm.

All of the presenting features of the child are suggestive raised intracranial pressure. Thus, urgent treatment with 20% Mannitol can improve the child’s condition. Mannitol is an osmotic diuretic that is used in the treatment of raised intracranial pressure. It should be avoided in hypovolaemia because of its diuretic effects. Other options:- Head up at 15°: Keeping the head up at 20° in the midline will aid venous drainage. – Maintain CO2 at 5 kPa: If there is an acute rise in intracranial pressure, then lowering the CO2 to 4–4.5 kPa as a temporary measure can be beneficial. However, this must be only short-lived since it causes vasoconstriction and can impair cerebral blood flow. – 10% glucose bolus: Maintaining normoglycemia in traumatic brain injury is important. – 0.9% saline infusion: Hypertonic saline infusion of 3% can reduce intracranial pressure. 0.9% saline as a bolus could be beneficial if there were hypotension.

Excessive weight loss is generally indicative of suboptimal feeding, and infants with excessive weight loss are potentially dehydrated or at risk of dehydration.Jaundice associated with suboptimal breastfeeding– this is classically associated with weight loss >10% and a vicious cycle of sleepiness that in turn leads to further poor feeding. In the absence of clinical signs of dehydration, no evidence suggests that overhydration is helpful. If the infant is dehydrated, hydration should be given as clinically indicated. However, if the infant can tolerate oral feeding, oral hydration with a breast milk substitute is likely to be superior to intravenous hydration because it reduces enterohepatic circulation of bilirubin and helps wash bilirubin out of the bowel.

Possible complications include:- Hearing loss (which may be partial or total)- problems with memory and concentration- problems with coordination and balance- learning difficulties (which may be temporary or permanent)- epilepsy (Seizures)- cerebral palsy- speech problems- vision loss (which may be partial or total)As hearing loss is the most common complication of meningitis people recovering from the condition are usually given a hearing test to assess their hearing.

The most appropriate imaging modalities to be used in this child would be CT Head, C-spine and Abdomen/Pelvis and chest X-ray (CXR).The C-spine cannot be cleared, this alongside a multi-trauma presentation means a CT C-spine is indicated rather than X-rays alone. The imaging modality for blunt trauma to the chest is CXR| if this shows significant thoracic trauma, a CT chest should be considered. Other options:- CT Head and Abdomen/Pelvis with CXR and X-ray C-spine: This child is at risk of C-Spine injury following the mechanism of trauma. He had a reduced GCS, has undergone a multi-region trauma and is now intubated. NICE head injury guidelines, therefore, recommend using CT.- CT Head, C-spine and Abdomen/Pelvis X-rays: Imaging of the chest is required following blunt trauma and for endotracheal tube position.- MRI Head: If there were concerns of abnormal neurology, then spinal MRI could be considered.- Whole-body CT: It is not recommended in children in view of the high radiation doses.

A periosteal reaction can result from a large number of causes, including injury and chronic irritation due to a medical condition such as hypertrophic osteopathy, bone healing in response to fracture, chronic stress injuries, subperiosteal hematomas, osteomyelitis, and cancer of the bone. This history is consistent with a toddler’s fracture. Here a minor, usually twisting, injury results in a spiral fracture of the tibia. An initial X-ray may appear normal as the periosteum holds the bone together preventing displacement. Ten days later a repeat X-ray will show callous formation and confirm the diagnosis.

In an acute and severe asthma attack the child cannot complete sentences in one breath because they are too breathless. The O2 saturation is less than 92% and PEF is between 33-50% best or predicted. In children that are 2-5 years old, HR is more than 140 bpm and more than 125 bpm in those older than 5 years old. The RR in children between 2-5 years old is more than 40/min, and more than 30/min in those older than 5 years old.

The Five P’s: pain, pulselessness, paraesthesia, paralysis, and pallor, are the most common symptoms of compartment syndrome. However, late signs of the condition include the absence of distal pulses.

Hirschsprung’s disease is characterized by congenital absence of the autonomic plexus (Meissner’s and Auerbach’s plexus) in the intestinal wall. Usually limited to the distal colon, it can occasionally involve the entire colon or even the small bowel. There is abnormal or absent peristalsis in the affected segment, resulting in continuous spasm of smooth muscle and partial/complete obstruction. This causes accumulation of intestinal contents and dilatation of proximal segment. Skip lesions are highly uncommon. This disease is seen early in life with 15% patients presenting in first month, 60% by 1 year of age and 85% by the age of 4 years. Symptoms include severe and complete constipation, abdominal distension and vomiting. Patients with involvement of ultra-short segments might have mild constipation with intervening diarrhoea. In older children, symptoms include failure to thrive, anorexia, and lack of an urge to defecate. On examination, an empty rectum is revealed with stool palpable high up in the colon. If not diagnosed in time, it can lead to Hirschsprung’s enterocolitis (toxic megacolon), which can be fulminant and lead to death. Diagnosis involves a barium enema or a rectal suction biopsy. Barium enema shows a transition in diameter between the dilated, normal colon proximal to the narrowed, affected distal segment. It is to be noted that barium enema should be done without prior preparation, which can dilate the abnormal segment, leading to a false-negative result. A 24-hour post-evacuation film can be obtained in the neonatal period – if the colon is still filled with barium, there is a high likelihood of Hirschsprung’s disease. Full-thickness rectal biopsy is diagnostic by showing the absence of ganglion cells. Acetylcholinesterase staining can be done to highlight the enlarged nerve trunks. Abnormal innervation can also be demonstrated by rectal manometry.

This clinical presentation is highly suggestive of choking. According to the BLS algorithm, the next step in managing a case of choking in a conscious child with an ineffective cough is five back blows.Other options:- Adrenaline intramuscularly: The history is similar to anaphylaxis, but the absence of a rash or oedema and the acute onset make choking more likely in this situation. Thus, adrenaline will not be of use in this patient.- CPR at a ratio of 15:2: Since the child is conscious, it is not advised. If the child were unconscious, you would commence basic life support.- Five abdominal thrusts: In the given scenario, the child is an infant. Abdominal thrusts are avoided in infants due to the risk of intra-abdominal injury.

Answer: Beta 2 transferrin assayBeta-2-transferrin is a protein found only in CSF and perilymph. Since 1979, beta-2-transferrin has been used extensively by otolaryngologists in the diagnosis of CSF rhinorrhoea and skull-base cerebrospinal fluid fistulas. With sensitivity of 94% – 100%, and specificity of 98% – 100%, this assay has become the gold standard in detection of CSF leakage. CSF rhinorrhoea is characterized by clear or xanthochromic watery rhinorrhoea that may not become apparent until nasal packing is removed.

Deaths by age group: 60% <1 year - due mainly to congenital, neonatal, and infection related problems.10% 1-4 years - due to accident (15%), cancer (15%), or congenital problems (14%)18% 15-19 years - accidental (42%) accidents reflect increased risk taking

The boy needs re-hydration due to his full thickness burn so IV fluids is the next most appropriate step. The greatest loss of plasma occurs in the first 12 hours after burn injury. The plasma loss then slowly decreases during the second 12 hours of the post-burn phase, although extensive leakage can continue for up to three days (Ahrns, 2004). Optimal fluid replacement during this period is essential to ensure cardiac output and renal and tissue perfusion. Usually, 36 hours post-burn, capillary permeability returns to normal and fluid is drawn back into the circulation. Burns of more than 15% of surface body area in adults and of over 10% in children warrant formal resuscitation.The Parkland formula for the total fluid requirement in 24 hours is as follows:4ml x TBSA (%) x body weight (kg)|50% given in first eight hours|50% given in next 16 hours.Children receive maintenance fluid in addition, at an hourly rate of:4ml/kg for the first 10kg of body weight plus|2ml/kg for the second 10kg of body weight plus|1ml/kg for >20kg of body weight.End pointUrine – adults: 0.5–1.0 ml/kg/hour|Urine – children: 1.0–1.5ml/kg/hour.

The Glasgow Coma Scale, being inappropriate for use in children (especially below the age of 5) as they are unable to elicit the verbal response as per the adult GCS. Therefore, GCS for the paediatric age group was modified to Adelaide coma scale (ACS), which is stated as follows:Best Eye Response (as in adult scale):Spontaneous – 4To speech – 3To pain – 2No response – 1Best Verbal Response:Oriented – 5Words – 4Vocal sounds – 3Cries – 2No response – 1Best Motor Response (as in adult scale):Obeys commands – 5Localises pain – 4Flexion to pain – 3 Extension to pain – 2No response – 1 The described child scores:Eye response – 1| Verbal response – 3| Motor response – 4Thus, bringing the total ACS score to 8.

Age (years) Respiratory rate (per minute) Heart rate (per minute) Systolic blood pressure<1 30-40 110-160 70-901-2 25-35 100-150 80-952-5 25-30 95-140 80-1005-12 20-25 80-120 90-110>12 15-20 60-100 100-120Adapted from Advanced Paediatric Life Support Manual

An epidural hematoma occurs when there is bleeding between the dura mater (a tough fibrous layer of tissue between the brain and skull) and the skull bone. These occur when arteries are torn as a result of a blow to the head, and injury in the temple area is a common cause. Although the pattern of a lucid interval followed by later neurological symptoms is characteristic, only a minority of patients display this pattern of symptoms. Reported death rates from epidural hematoma vary widely, ranging from 5% to over 40%. Middle meningeal artery is frequently involved in such incidents.

McBurney’s point is found 2/3rds of the way along an imaginary line that runs from the umbilicus to the anterior superior iliac spine on the right-hand side. On examination, features of generalised peritonitis can be observed if the appendix has perforated.Retrocecal appendicitis may have relatively fewer signs.Digital rectal examination may reveal boggy sensation if a pelvic abscess is present.Diagnosis is typically based on raised inflammatory markers coupled with compatible history, and examination findings.Ultrasound is useful in females where pelvic organ pathology can be a close differential diagnosis. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion. Ultrasound examination can also show evidence of luminal obstruction and thickening of the appendix.Management: Definitive management of appendicitis and appendicular perforation is appendicectomy which can be performed via either an open or laparoscopic approach.Simultaneous administration of metronidazole reduces wound infection rates. Patients with perforated appendicitis require copious abdominal lavage. Patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy.

The IM dose of adrenaline for anaphylaxis in:< 6 months: 150 micrograms (0.15ml 1 in 1,000)6 months - 6 years: 150 micrograms (0.15ml 1 in 1,000)6 - 12 years: 300 micrograms (0.3ml 1 in 1,000)Adult and child > 12 years: 500 micrograms (0.5ml 1 in 1,000)Anaphylaxis:Anaphylaxis is an acute, rapidly progressing, potentially life-threatening IgE mediated Type I hypersensitivity reaction.It involves the release of mediators from mast cells, basophils and inflammatory cells. It is characterised by oedematous swelling of the airway mucosa giving rise to dyspnoea and respiratory distress. The most common cause of anaphylaxis in children is a food allergy.Risk factors for death in patients with anaphylaxis include asthma, age 11+, peanut allergy, and delay in adrenaline administration.Management of anaphylaxis includes:- ABCD- Remove the allergen- IM adrenaline or Nebulised adrenaline- IV Hydrocortisone – pro re nata IV fluid support. – Followed by observation.

During lumbar puncture, the first structures encountered by the needle are skin and subcutaneous tissue. But, since they are not provided in the options, the most superficial structure after them is the supraspinous ligament.Lumbar puncture is a procedure performed to obtain cerebrospinal fluid. The procedure is best performed at the level of L3/L4 or L4/5 interspace. During the procedure, the needle pierces the following structures in order from superficial to deep: Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, the epidural space containing the internal vertebral venous plexus, dura, and arachnoid, finally entering the subarachnoid space. The supraspinous ligament connects the tips of spinous processes and the interspinous ligaments between adjacent borders of spinous processes.As the needle penetrates the ligamentum flavum, it causes a give. A second give is felt when the needle penetrates the dura mater and enters the subarachnoid space. At this point, clear CSF flows through the needle and can be collected for diagnostic purposes.

The clinical scenario provided is highly suggestive of third-degree burns (or full-thickness burns) that may have invaded the deeper levels up to dermis, evident from the insensate nature of the lesion.Degrees of Burns:- First degree burns are superficial second-degree burns.- Second-degree burns are just deeper than that of first-degree burns but vary enormously in other properties.- Third-degree burns are full-thickness burns which are leathery in consistency, and insensate. These burns do not heal on their own. The sensory neurons present in the skin at the deeper levels are destroyed completely and hence provide a paradoxical lack of pain.- Fourth-degree burns involving the subcutaneous tissues, tendons, and bones are very difficult to manage.Assessment of the extent of the burns for the treatment employs specialized charts, such as Lund and Browder charts and Wallace rule of nines.The Lund and Browder chart is, however, considered the most accurate.Wallace’s Rule of Nines can be used for children >16 years: – Head + neck = 9%- Each arm = 9%- Each anterior part of leg = 9%- Each posterior part of leg = 9%- Anterior chest = 9%- Posterior chest = 9%- Anterior abdomen = 9%- Posterior abdomen = 9%

The patient is suffering from an anaphylactic reaction to the cashew nut he consumed.Anaphylaxis:Anaphylaxis is an acute, rapidly progressing, potentially life-threatening IgE mediated Type I hypersensitivity reaction.It involves the release of mediators from mast cells, basophils and inflammatory cells. It is characterised by oedematous swelling of the airway mucosa giving rise to dyspnoea and respiratory distress.The most common cause of anaphylaxis in children is a food allergy.Risk factors for death in patients with anaphylaxis include asthma, age 11+, peanut allergy, and delay in adrenaline administration.Management of anaphylaxis includes:- Resuscitation – ABCD- Remove the allergen- IM adrenaline is given at ten microgram/kg or Nebulised adrenaline 5ml 1:1,000- IV Hydrocortisone is given at 4mg/kg- pro re nata IV fluid support. – Followed by observation.

Meckel’s diverticulum is a true diverticulum and is the most common congenital anomaly of the GI tract, occurring in about 2% of people. It is caused by incomplete obliteration of the vitelline duct and consists of a congenital sacculation of the antimesenteric border of the ileum. Symptoms are uncommon but include lower GI bleeding, bowel obstruction, and inflammation (diverticulitis). Causes of upper GI bleeding in neonates:Swallowed maternal bloodCoagulopathies including haemorrhagic disease of the new-bornStress gastritis & stress ulcersDrugs (NSAIDs, heparin, indomethacin used for patent duct closure, dexamethasone)Causes of upper GI bleeding in children 1 month to 1 year:GORDGastritis (with or without Helicobacter pylori infection)Crohn diseaseDrugs (NSAIDs)Zollinger-Ellison syndromeCauses of upper GI bleeding in children 1 -2 years:Peptic ulcer diseaseZollinger-Ellison syndromeBurns (Curling ulcer)Head trauma (Cushing ulcer)SepsisCauses of upper GI bleeding in older than 2 years:Oesophageal varices secondary to portal hypertension (most commonly portal vein thrombosis and biliary atresia)Duodenal ulcersOesophagitisGastritisMallory-Weiss tears

Being anatomically situated immediately posterior to the subclavius muscle and the medial part of the clavicle, the subclavian vein is at the highest risk of injury in the above patient.As a direct tributary of the brachiocephalic vein, it’s injury poses a high risk of massive bleeding.The brachiocephalic vein rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).Anatomy of the clavicle:The clavicle extends from the sternum to the acromion and helps prevent the shoulder falling forwards and downwards.

Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.

Based on the findings presented, the sign elicited is Rovsing’s sign.Rovsing’s sign:It is a sign suggestive of appendicitis. A positive sign is determined when palpation in the left lower quadrant of a patient’s abdomen causes pain in the right lower quadrant.Other options:- Murphy’s sign is positive in gallbladder inflammation. With the upper border of the examiner’s hand in the right upper quadrant of the abdomen under the rib cage, the patient is asked to inhale. Inhalation causes the gallbladder to descend, which catches on the fingers, causing pain.- Cullen’s sign is suggestive of ectopic pregnancy or acute pancreatitis and describes the bruising around the umbilicus.- Tinel’s sign is positive in those with carpal tunnel syndrome. The examiner’s fingers tap the median nerve over the flexor retinaculum, which causes paraesthesia over the distribution of the median nerve.- Battles’ sign describes bruising behind the ear, suggesting a basal skull fracture of the posterior cranial fossa.

Intussusception is one of the common causes of intestinal obstruction in children, resulting from the invagination or telescoping of one segment of the bowel into the other distal segment. It may induce bowel ischemia and necrosis, as well. It can occur as a complication of Meckel’s diverticulum. It usually occurs proximal to the ileocecal valve, and the most common presentation is ileocecal. Early signs and symptoms include cramping abdominal pain, nausea, vomiting, and pulling legs up to chest area. First line treatment includes resuscitation with IV fluids and nasogastric tube. It responds well to air-enema, which is also diagnostic.

NICE guidelines suggest that when a child’s single risk factor is 2 vomits, the child should be observed for 4 hours from the time of the injury, instead of having a CT.

Intussusception causes abdominal pain leading to painful lower GI bleeding. Intussusception is a condition in which part of the intestine folds into the section next to it. It most commonly involves the small bowel and rarely the large bowel. Intussusception doesn’t usually require surgical correction. 80% of cases can be both confirmed and reduced using barium, water-soluble or air-contrast enema.However, up to 10% of cases can experience recurrence within 24 hours after reduction, warranting close monitoring during this period.Most children have self-limiting and minor bleeds. However, children with massive bleeds will need emergency care and stabilisation.The various causes of lower GI bleeding in neonates include:- Anal fissures- Milk protein or soy allergy- Intussusception- Volvulus- Coagulopathies including haemorrhagic disease of the new-born- Arteriovenous malformations- Necrotising enterocolitis- Hirschsprung enterocolitis- Meckel’s diverticulitis- Drugs (NSAIDs, heparin, indomethacin used for patent duct closure, dexamethasone)The various causes of lower GI bleeding in children aged between 1 month to 2 years include:- Infection- Anal fissures- Intussusception- Malrotation with volvulus- Milk protein or soy allergy- Polyp- Meckel’s diverticulum- Duplication cyst- Foreign body- AV malformation- Colitis of immune deficiency- Tumour- HaematomaThe causes of lower GI bleeding in children older than 2 years include:- Polyp- Inflammatory bowel disease (IBD)- Infectious diarrhoea (caused by Escherichia coli and Shigella)- Intussusception- Haemangiomas- Arteriovenous malformations- Vasculitis- Tumour