Pediatric orthopedics in primary care

Pediatric orthopedics in primary care

740 hand contact, genital-genital contact, penile penetration, etc. There are too few photographs, and some of them are confusing. The photographs ar...

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hand contact, genital-genital contact, penile penetration, etc. There are too few photographs, and some of them are confusing. The photographs are black and white; color may have helped make them clearer. One photograph illustrates interruptions of the hymeneal edge due to digital penetration, but it is difficult to differentiate these findings from normal notches; in another, a laceration is out of focus and is very hard to see. In view of the many clinicians who are unsure of their ability to recognize hymeneal injuries in the prepubertal child, a greater number of clearer photographs in this section would have been a worthwhile addition to the book. The third section of Chapter Four describes the physical examination itself. It effectively describes how to set the stage for a successful examination and how to prevent revictimization of the patient, The section is well illustrated with examples of patient positioning and techniques needed to visualize the external prepubertal genitalia, however, there is insufficient information presented on the subject of hymeneal measurements. The text states “[t]he transverse diameter [of the hymen] alone is rarely sufficient to determine whether a child has or has not been sexually abused and should not be used as a sole criterion for such a determination.” However, because normal and abnormal values for this measurement are not included in the text, the reader may be unable to assessif a child’s introitus is larger than usual. I agree with the authors that the transverse diameter is not very helpful; however, it is important to recognize an introitus that is larger than normal becauseit suggeststhe possible presence of hymeneal trauma. The last section of Chapter Four, titled “laboratory evaluation,” is short and describes the techniques to be followed for forensic evidence collection within 72 h of an assault. Specimen collection for sexually transmitted diseases (STDs) is covered in a later chapter. Emergency departments that lack a pediatric rape protocol of their own will find useful material here. Chapter Five has short descriptions of diagnoses that may be confused with sexual abuse. The organization of the chapter is logical and functional. Diagnoses that may be confused with sexual abuse are divided into the subheadings: 1) anogenital erythema, excoriation, pruritis; 2) anogenital bruising; 3) anogenital bleeding or bloody vaginal discharge; 4) nonbloody vaginal discharge; and 5) unusual anatomic appearance. Diagnoses discussed include lichen sclerosis, perianal streptococcal infection, straddle injuries, and vaginal foreign bodies. This

The Journal of Emergency Medicine

chapter contains 10 clear and useful black and white photographs, in addition to the text. Chapter Six covers sexually transmitted diseases. A separate section is devoted to each STD and addressesthe presentation of the STD in a prepubertal child, the correct culture materials to use, appropriate and inappropriate testing methods for this age group, treatment options, and the likelihood of sexual abuse if such an infection is diagnosed. This chapter provides abundant information relevant to STDs in prepubertal children in a very concise, readable form. Chapter Seven discussesmental health evaluation. Most of the information here will not be directly useful to the emergency physician, but it is interesting reading. The final chapter covers documentation and courtroom testimony. There is also a very useful table to assist in deciding which cases need to be reported to the legally mandated agencies. All states require a physician who suspects abuse to make a report. It can be difficult, at times, determining whether the level of suspicion warrants a report. This table will be helpful in that situation. Despite the noted identified limitations, A Practical Guide to the Evaluation of Sexual Abuse in the Prepubertaf Child is an excellent primer for the emergency physician. Robert A. Shapiro, MD Associate Professor of Pediatrics Children’s Hospital Medical Center Cincinnati, Ohio

Cl PEDIATRIC ORTHOPEDICS IN PRIMARY CARE. By VT Tolo, B Wood, 365 pp. Baltimore, Williams &Wilkins, 1993, $59.00. This text, one of several available on the subject of pediatric orthopedics, is designed as an introduction to the evaluation and management of congenital and acquired musculoskeletal disorders. The text is written by the Chairman of Orthopedic Surgery at Children’s Hospital in Los Angeles, with the assistanceof the Chairman of Radiology at the same institution. The Preface identifies this text as one that is written for the primary care physician, covering orthopedic conditions seen in everyday practice, with emphasis on treatment appropriately provided in the primary care setting.

Reviews: Books and other Media

The book begins with a brief overview on differences between the immature and adult skeletal system. This is followed by an update on advances in clinical imaging of the musculoskeletal system, with emphasis on use of computed tomography (CT) and magnetic resonance (MR). Indeed, there is considerable discussion of the use of CT and MR for identifying occult abnormalities that are not visualized by other imaging techniques. The remainder of the text is organized in chapters by anatomic location, from neck to foot. Each chapter begins with a review of pertinent anatomy and suggestions for examination. This is followed by a thorough discussion of appropriate imaging studies and normal radiographic findings. Specific disorders covered in each chapter are divided into congenital and traumatic. Additional chapters address spinal deformity, septic arthritis and osteomyelitis, torsional and angular conditions of the lower extremity, the limping child, childhood arthritis, musculoskeletal tumors, the young athlete, and orthopedic aspects of child abuse, neuromuscular, chromosomal, genetic, and metabolic disease. A sufficient number of suggestedreadings are provided at the end of each chapter. Illustrations by Robert Amaral of Children’s Hospital Los Angeles are clear, accurate, and plentiful. The plain radiographs unfortunately are frequently of poor quality or do not reproduce well. There are numerous CT and MR scans throughout the text, most of which are of good to excellent quality, and help distinguish this text from other textbooks of pediatric orthopedics. The table of contents and index are well organized. In terms of usefulness to the emergency physician, this text will be most helpful for medical students and residents in the emergency department due to the succinct but excellent reviews of anatomy and techniques of examination found at the start of each chapter. While it excels in describing and demonstrating newer radiographic imaging techniques such as MR, many emergency physicians do not have the benefit of, or time for, some of these modalities. In addition, congenital abnormalities are overemphasized at the expense of the traumatic disorders more commonly seen by emergency physicians. Although the text is purported to emphasize treatment appropriately provided in the primary care setting, it frequently falls short of this goal, and could use more discussion of common treatments, such as techniques for reduction and immobilization of fractures and dislocations. While this book may have a place in the ED library, I believe most practicing emergency physicians will find it a less helpful reference than


some of the other textbooks currently available on pediatric orthopedics. E. M. Singletary, MD, FACEP Department of Emergency Medicine Eastern Virginia Medical School Norfolk, Virginia

•I EWEBY FEtXA :A TO AMBULATORY CARE (4th ed). Edited by RM Bwkin, P Rosen, 74 pp. St. Louis, Mosby-Year Book, Inc. 1994, $51 .oo. The field of Emergency Medicine is undergoing rapid evolution in the care of the pediatric population. In addition, health professionals working in the emergency department are faced with the challenge of incorporating a wide variety of differential diagnoses in the care of children requiring “immediate” attention. Drs. Barkin and Rosen approach these challenges in this text by addressing medical, toxicological, traumatic and orthopedic emergencies, surveying a myriad of basic pediatrics problems, and also reviewing advanced neonatal and cardiac life support. The authors place emphasis on parental education and on common medications used in the ED. Overall, their “guide” is practical, complete, and fun to read. The format of each chapter is unique to a textbook of Pediatric Emergency Medicine. Rather than focusing on algorithms, the authors utilize a table format of diagnoses with signs, symptoms, and clinical tips of data collection, and a well outlined management for each condition. This approach provides an excellent reference to the clinician in need of quick help in the management of seriously ill children. The initial part of the text covers basic ED policies and IV fluids, and reviews the latest in neonatal and cardiac life support. The section on advanced life support provides a well outlined review of basic resuscitation, shock, and dysrhythmias including recognition, management tips, and pharmacological approaches. The neonatal portion also includes a brief review of a variety of neonatal problems by organ system. Next, the text covers emergent and urgent complaints that present to the pediatric emergency department. Several tables outline an exhaustive list of considerations for each complaint and are helpful in