Objective The objective of this study was to evaluate the presenting features of bone and joint infections with a view to identify distinguishing trends that will be useful for pediatric emergency departments. Methods We performed a retrospective review of patient records over a 12-year period in the pediatric emergency department of a large regional pediatric teaching center serving a diverse population. Results There were 88 cases of osteoarticular infections during the study period. Pain, fever, and impaired function were commonly reported, but overall, there was inconsistency in the presenting features. Inflammatory makers were sensitive tools, particularly in combination. When C-reactive protein, total white cell count, and erythrocyte sedimentation rate were all abnormal, 98% of bone and joint infections were identified. Causative organisms were identified in only 38% of cases, mostly from cultures of synovial fluid and bone. Streptococcal organisms were significantly more likely to be isolated in children under 5 years than in children over 5 years (P = <0.014). Staphylococcal organisms were significantly more likely to be isolated in children over 5 years than in children under 5 years (P = <0.001). Identification of virulent organisms such as Panton-Valentine leukocidin Staphylococcus aureus and methicillin-resistant S. aureus in our study should prompt review of diagnostic techniques and antibiotic choices. Conclusions Overall, children under 5 years were significantly more likely to be diagnosed with septic arthritis than osteomyelitis (P = 0. 006). Children over 12 years were significantly more likely to be diagnosed with osteomyelitis than septic arthritis (P = 0. 019). These trends are useful to consider at presentation and in cases of diagnostic uncertainty.

patients were admitted to our hospital for management of propeller related injuries. These injuries ranged in severity from superficial lacerations that did not require closure to severe, devastating injuries with limb loss (Table 1). No patients died of propeller injuries after reaching the hospital during the period of this study. Five of the injuries occurred at very low speed (estimated less than 5 mph) including one patient with two amputations. Five occurred at speeds that were estimated to be greater than 10 mph. Three records did not provide enough information to estimate boat speeds. Eleven injuries occurred in fresh water, one in salt water, and one occurred while on land. Fall from a boat prior to propeller strike occurred in seven patients. Four were in the water from skiing or other activities when struck. The sequence of injury could not be determined for one patient (#9), and one propeller injury occurred while on land. Motorboat Propeller IntroductionOutboard motorboat propeller strikes can cause devastating injury, infection, and death. Approximately 10%-15% of propeller injuries are fatal [1,2]. Motorboat propeller injuries present management problems that may be unfamiliar to trauma surgeons because of the mechanism of injury and bacterial contamination from underwater impact. Severity of injury and complex contamination may not be apparent on initial inspection. It has been noted that these injuries are underreported even though laws are in place requiring all boaters to report boating accidents and injuries to local and national authorities [3]. This paper provides a review of all propeller injuries admitted to Orlando Regional Medical Center during a 6 year period. The mechanical aspects of propeller injuries are presented along with a literature review and recommendations for initial evaluation and management. Methods and MaterialsWith approval from our Institutional Review Board and assistance from the health information management office and coding department at Orlando Health Systems all hospitalized patients with ICD-9 and e-codes pertaining to boating injuries were identified between October 2003 and August 2009. A total of 267 patient encounters were identified in this time period. Further review of those 267 charts identified 13 patients with propeller related injuries. Demographic information, injury and treatment data, complications and outcomes were analyzed. AbstractBackground: Motorboat propeller strikes can cause devastating injury due to injury mechanics and complex contamination. The frequency of these injuries has been under-reported. This paper provides a review of propeller injuries admitted to our hospital over a six-year period. Discussion includes injury mechanics, initial management, literature review, accident statistics, and possible prevention measures.

AIMTo determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.METHODSFollowing an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.RESULTSDuring the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.CONCLUSIONKetamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

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Background Clinical prediction rules (CPRs) are developed to aid the identification of serious infections (SI), but their value in young febrile infants remains unclear. Aim To systematically review existing CPRs and subsequently validate these CPRs in two external cohorts of young febrile infants at risk for SI in the Netherlands 1 (N = 925; ≤1 year) and Spain 2 (N = 2148; ≤3 months). Methods We included seven multivariable developed CPRs for febrile children to predict SI, including clinical predictors and/or diagnostic tests results. CPR performance was assessed by sensitivity, specificity, calibration analyses and area under the receiver operating characteristic curve (AUC). Results All CPRs (including 19 different predictors) originally performed moderate-good (AUC0.60-0.93). The original cohorts, with SI prevalence variation of 0.8-27%, varied between 381 and 5279 febrile children. Almost all CPRs were derived in emergency care populations including wide age ranges of 0-16 years.Validation of CPRs missing ≥2/3 of the required variables was not performed, resulting in limited evaluation of two CPRs including eg capillary refill time and vital signs (heart/respiratory rate) in the Spanish cohort.Four out of 7 CPRs showed acceptable ROC-areas (0.76-0.89) in both cohorts. Sensitivities of CPRs predicting high/low risks ranged from 0.60-0.93 and specificities from 0.71-0.97. Three CPRs were non-informative (AUC 0.49-0.53). Calibration slopes were mostly <1, which could indicate overestimation of predictor effects in young febrile infants. Discussion and Conclusion Four (out of 7) CPRs showed comparable performance in the identification of SI in infants ≤1 year, although with more emphasise on their rule-in value (specificity).However, predictor effects were generally overestimated.