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 a LANGE medical book

CURRENT
Diagnosis & Treatment
Pediatrics
TWEN TY- THIRD ED ITIO N

Edited by
William W. Hay, Jr., MD
Professor, Department of Pediatrics
Section of Neonatology and
Division of Perinatal Medicine
University of Colorado School of Medicine and Children’s
Hospital Colorado
Myron J. Levin, MD
Professor, Departments of Pediatrics and Medicine
Section of Pediatric Infectious Diseases
University of Colorado School of Medicine and
Children’s Hospital Colorado
Robin R. Deterding, MD
Professor, Department of Pediatrics
Chief, Section of Pediatric Pulmonary Medicine
University of Colorado School of Medicine and
Children’s Hospital Colorado
Medical Director, Breathing Institute
Children’s Hospital Colorado
Mark J. Abzug, MD
Professor, Department of Pediatrics
Section of Pediatric Infectious Diseases
Associate Vice Chair for Academic Affairs,
Department of Pediatrics
University of Colorado School of Medicine and
Children’s Hospital Colorado

and Associate Authors

The Department of Pediatrics at the University of Colorado School of Medicine

is affiliated with Children’s Hospital Colorado.

New York Chicago San Francisco Athens London Madrid Mexico City Milan
New Delhi Singapore Sydney Toronto
CURRENT Diagnosis & Treatment: Pediatrics, Twenty-Third Edition

Copyright © 2016 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Except as permitted
under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by
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© 1999, 1997, 1995, 1991, 1987 by Appleton & Lange.

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 Contents
Authors xix Gastrointestinal Bleeding 55
Preface xxvii Gastroesophageal Reflux 55
Selected Highlighted Topics in the Infections in the Newborn Infant 56
23rd Edition of CDT-P xxix Bacterial Infections 56
Fungal Sepsis 59
1. Advancing the Quality Congenital Infections 60
& Safety of Care 1 Perinatally Acquired Infections 61
Hematologic Disorders in the Newborn Infant 63
Daniel Hyman, MD, MMM Bleeding Disorders 63
Current Context 1 Anemia 64
Strategies & Models for Quality Polycythemia 65
Improvement (Qi) 4 Renal Disorders in the Newborn Infant 65
Principles of Patient Safety Renal Failure 66
(Incident Reporting, Just Culture, Urinary Tract Anomalies 66
Disclosure, FMEA, RCA, Reliability, Renal Vein Thrombosis 66
Checklists) 7 Neurologic Problems in the Newborn Infant 67
Seizures 67
2. The Newborn Infant 10 Hypotonia 68
Intracranial Hemorrhage 68
Danielle Smith, MD Metabolic Disorders in the Newborn Infant 68
Theresa R. Grover, MD Hyperglycemia 68
The Neonatal History 10 Hypocalcemia 69
Assessment of Growth & Gestational Age 10 Inborn Errors of Metabolism 69
Examination at Birth 13 Quality Assessment & Improvement
Examination in the Nursery 14 in the Newborn Nursery And NICU 70
Care of the Well Neonate 16
Feeding the Well Neonate 17 3. Child Development & Behavior 71
Early Discharge of the Newborn Infant 17
Hearing Screening 18 Edward Goldson, MD
Common Problems in the Term Newborn 19 Ann Reynolds, MD
Neonatal Jaundice 19 Normal Development 71
Hypoglycemia 26 The First 2 Years 71
Respiratory Distress in the Term Newborn Infant 28 Ages 2–4 Years 78
Heart Murmurs 30 Early School Years: Ages 5–7 Years 78
Birth Trauma 30 Middle Childhood: Ages 7–11 Years 79
Infants of Mothers Who Abuse Drugs 31 Behavioral & Developmental Variations 79
Neonatal Intensive Care 34 Normality & Temperament 79
Perinatal Resuscitation 34 Enuresis & Encopresis 80
The Preterm Infant 39 Enuresis 80
The Late Preterm Infant 49 Encopresis 81
Cardiac Problems in the Newborn Infant 50 Common Developmental Concerns 82
Structural Heart Disease 50 Colic 82
Persistent Pulmonary Hypertension 51 Feeding Disorders in Infants & Young Children 83
Arrhythmias 51 Sleep Disorders 85
Gastrointestinal & Abdominal Surgical Temper Tantrums & Breath-Holding Spells 87
Conditions in the Newborn Infant 52 Well-Child Surveillance & Screening 89
Esophageal Atresia & Tracheoesophageal Fistula 52 Developmental Disorders 89
Intestinal Obstruction 52 Attention-Deficit/Hyperactivity Disorder 91
Abdominal Wall Defects 54 Autism Spectrum Disorders 93
Diaphragmatic Hernia 54 Intellectual Disability 96
iii
 iv
▲ Co n t en t s

Specific Forms of Intellectual Disability & 6. Eating Disorders 159

Associated Treatment Issues 98
References 99 Eric J. Sigel, MD
Etiology 159
4. Adolescence 101 Incidence 160
Predisposing Factors & Clinical Profiles 160
Molly J. Richards, MD Anorexia Nervosa 160
David W. Kaplan, MD, MPH Bulimia Nervosa 166
Amy E. Sass, MD, MPH Binge-Eating Disorder 168
Demography 101 Avoidant/Restrictive Food
Mortality Data 101 Intake Disorder 169
Morbidity Data 101 Prognosis 169
Delivery of Health Services 102 Resources for Practioners & Families 170
Guidelines for Adolescent Preventive Services 103
Relating to the Adolescent Patient 103 7. Child & Adolescent Psychiatric
The Setting 103 Disorders & Psychosocial Aspects
Confidentiality 103 of Pediatrics 171
The Structure of the Visit 103
Growth & Development 109 Kimberly Kelsay, MD
Puberty 109 Adam Burstein, DO
Physical Growth 111 Ayelet Talmi, PhD
Sexual Maturation 111 Models of Care Encompassing Mental
Psychosocial Development 112 Health in the Primary Care Setting 172
Behavior & Psychological Health 114 Prevention, Early Identification,
Psychophysiologic Symptoms & & Developmental Context 173
Conversion Reactions 114 Lifestyle Recommendations 174
Depression 116 Identification & Assessment During
Adolescent Suicide 117 Health Maintenance Visits 174
Substance Abuse 118 Other Pediatric Care Settings 182
Eating Disorders 118 Consultation-Liaison Psychiatry 182
Overweight & Obesity 118 Chronic Illness in the Pediatric Population 183
School Avoidance 120 Pediatric Terminal Illness 183
School Failure 120 Psychiatric Disorders
Breast Disorders 121 of Childhood & Adolescence 185
Breast Masses 121 Anxiety Disorders 187
Nipple Discharge & Galactorrhea 123 Attention-Deficit/Hyperactivity Disorder 197
Gynecomastia 124 Mood Disorders 200
Gynecologic Disorders in Adolescence 125 Suicide in Children & Adolescents 206
Physiology of Menstruation 125 Conduct Disorders 208
Pelvic Examination 125 High-Risk Patients and Homicide 209
Menstrual Disorders 127 Somatoform Disorders 210
Contraception 135 Adjustment Disorders 212
Pregnancy 142 Psychotic Disorders 212
Other Psychiatric Conditions 215
5. Adolescent Substance Abuse 145
8. Child Abuse & Neglect 216
Paritosh Kaul, MD
Scope of the Problem 145 Antonia Chiesa, MD
Morbidity Data 150 Andrew P. Sirotnak, MD
Predicting the Progression From Use to Abuse 151 Prevention 217
Evaluation of Substance Abuse 152 Clinical Findings 217
Treatment & Referral 155 Differential Diagnosis 223
Prevention 157 Treatment 223
References 158 Prognosis 224
 Co n t en t s
▲ v

9. Ambulatory & Office Pediatrics 225 Pertussis Vaccination

(Adolescents & Adults) 275
Meghan Treitz, MD Human Papillomavirus Vaccination 275
Maya Bunik, MD, MSPH Vaccinations for Special Situations 276
David Fox, MD Rabies Vaccination 276
Pediatric History 225 Typhoid Fever Vaccination 278
Pediatric Physical Examination 226 Japanese Encephalitis Vaccination 278
Health Supervision Visits 228 Tuberculosis Vaccination 279
Developmental & Behavioral Assessment 228 Yellow Fever Vaccination 279
Growth Parameters 231 Passive Prophylaxis 280
Blood Pressure 232
Vision & Hearing Screening 233 11. Normal Childhood Nutrition &
Anticipatory Guidance 237 Its Disorders 281
Nutrition Counseling 239
Counseling About Television & Matthew A. Haemer, MD, MPH
Other Media 239 Laura E. Primak, RD, CNSD
Immunizations 240 Nancy F. Krebs, MD, MS
Acute-Care Visits 240 Nutritional Requirements 281
Prenatal Visits 241 Nutrition & Growth 281
Sports Physicals 241 Energy 281
Chronic Disease Management 241 Protein 282
Medical Home 242 Lipids 283
Mental & Behavioral Health 242 Carbohydrates 284
Telephone Management & Major Minerals 285
Web-Based Information 243 Trace Elements 285
Advocacy & Community Pediatrics 243 Vitamins 285
Common General Pediatric Issues 244 Infant Feeding 285
Fever 244 Breast-Feeding 285
Growth Deficiency 246 Special Dietary Products for Infants 294
Nutrition for Children 2 Years & Older 296
10. Immunization 248 Pediatric Undernutrition 297
Pediatric Overweight & Obesity 298
Matthew F. Daley, MD
Nutrition Support 301
Sean T. O’Leary, MD, MPH
Enteral 301
Ann-Christine Nyquist, MD, MSPH
Parenteral Nutrition 302
Standards for Pediatric Immunization Practices 249 Nutrient Requirements & Delivery 303
Routine Childhood & Adolescent
Immunization Schedules 250 12. Emergencies & Injuries 308
Vaccine Safety 250
Vaccination in Special Circumstances 255 Kevin P. Carney, MD
Hepatitis B Vaccination 256 Kelley Roswell, MD
Rotavirus Vaccination 258 Introduction to Pediatric Emergencies & Injuries 308
Diphtheria-Tetanus-Acellular Pertussis Initial Approach to the Acutely
Vaccination 260 Ill Infant or Child 308
Haemophilus Influenzae Type B Vaccination 262 The ABCs of Resuscitation 308
Pneumococcal Vaccination 263 Management of Shock 313
Poliomyelitis Vaccination 265 Summary of Initial Approach to the
Influenza Vaccination 266 Acutely Ill Infant or Child 314
Measles, Mumps, & Emergency Pediatric Drugs 314
Rubella Vaccination 268 Approach to the Pediatric Trauma Patient 315
Varicella Vaccination 270 Mechanism of Injury 315
Hepatitis A Vaccination 272 Initial Assessment & Management 315
Meningococcal Vaccination 273 Primary Survey 315
Tetanus-Reduced Diphtheria-Acellular Secondary Survey 318
 vi
▲ Co n t en t s

Head Injury 320 Hydrocarbons (Benzene, Charcoal

Burns 322 Lighter Fluid, Gasoline, Kerosene,
Thermal Burns 322 Petroleum Distillates, Turpentine) 347
Electrical Burns 324 Ibuprofen 347
Disorders Due to Extremes of Environment 325 Insect Stings (Bee, Wasp, & Hornet) 348
Heat-Related Illnesses & Heat Stroke 325 Insecticides 348
Hypothermia 325 Iron 349
Submersion Injuries 327 Lead 350
Lacerations 328 Magnets 350
Animal & Human Bites 328 Mushrooms 350
Dog Bites 328 Nitrites, Nitrates, Aniline, Pentachlorophenol,
Cat Bites 329 & Dinitrophenol 351
Human Bites 329 Opioids & Opiates 351
Pain Management & Procedural Sedation 330 Oral Hypoglycemics (Sulfonylureas, Metformin) 352
Antipsychotics (Typical & Atypical) 353
13. Poisoning 331 Plants 353
Psychotropic Drugs 353
Richard C. Dart, MD, PhD Salicylates 355
Barry H. Rumack, MD Scorpion Stings 356
George Sam Wang, MD
Serotonin Reuptake Inhibitors 356
Pharmacologic Principles of Toxicology 331 Snakebite 356
Preventing Childhood Poisonings 332 Soaps & Detergents 357
General Treatment of Poisoning 332 Spider Bites 358
Initial Telephone Contact 332 Vitamins 358
Initial Emergency Department Contact 335 Warfarin (Coumadin) & Other Oral
Definitive Therapy of Poisoning 335 Anticoagulants 358
Management of Specific Common
Poisonings 336 14. Critical Care 360
Acetaminophen (Paracetamol) 336 Todd C. Carpenter, MD
Alcohol, Ethyl (Ethanol) 338
Amy Clevenger, MD, PhD
Amphetamines & Related Drugs
Angela S. Czaja, MD, MSc
(Methamphetamine, Mdma) 339
Eva N. Grayck, MD
Anesthetics, Local 339
Cameron F. Gunville, DO
Antihistamines & Cough & Cold Preparations 340
Leslie Ridall, DO
Arsenic 341
Carleen Zebuhr, MD
Barbiturates & Benzodiazepines 341
Belladonna Alkaloids Introduction 360
(Atropine, Jimsonweed, Potato Leaves, Respiratory Critical Care 360
Scopolamine, Stramonium) 341 Acute Respiratory Failure 360
b-Blockers & Calcium Channel Blockers 342 Conventional Mechanical Ventilation 364
Carbon Monoxide 342 Major Respiratory Diseases in the Pediatric ICU 368
Caustics 342 Acute Respiratory Distress Syndrome 368
Central a 2-Adrenergic Agonist 343 Status Asthmaticus 371
Cocaine 343 Cardiovascular Critical Care 374
Cosmetics & Related Products 344 Shock 374
Cyclic Antidepressants 344 Sepsis 377
Digitalis & Other Cardiac Glycosides 345 Neurocritical Care 381
Diphenoxylate With Atropine (Lomotil) & Traumatic Brain Injury 381
Loperamide (Imodium) 345 Hypoxic-Ischemic Encephalopathy 385
Disinfectants & Deodorizers 345 Acute Kidney Injury & Renal
Disk-Shaped “Button” Batteries 346 Replacement Therapy 385
Ethylene Glycol & Methanol 346 Fluid Management & Nutritional Support
γ-Hydroxybutyrate, γ-Butyrolactone, of the Critically Ill Child 387
Butanediol, Flunitrazepam, & Ketamine 347 Sedation & Analgesia in the Pediatric ICU 389
 Co n t en t s
▲ vii

End-of-Life Care & Death in the PICU 393 Pupils 421

Quality Improvement Initiatives in the PICU 396 Alignment & Motility Evaluation 422
Ophthalmoscopic Examination 423
15. Skin 397 Ocular Trauma 424
Ocular Foreign Bodies 424
Joseph G. Morelli, MD Corneal Abrasion 425
Lori D. Prok, MD Intraocular Foreign Bodies &
General Principles 397 Perforating Ocular Injuries 425
Diagnosis of Skin Disorders 397 Blunt Orbital Trauma 426
Treatment of Skin Disorders 397 Lacerations 427
Disorders of the Skin in Newborns 399 Burns 427
Transient Diseases in Newborns 399 Hyphema 428
Pigment Cell Birthmarks, Nevi, Abusive Head Trauma &
& Melanoma 400 Nonaccidental Trauma 429
Melanocytic NEVI 401 Prevention of Ocular Injuries 429
Vascular Birthmarks 401 Disorders of the Ocular Structures 430
Epidermal Birthmarks 402 Diseases of the Eyelids 430
Connective Tissue Birthmarks Viral Eyelid Disease 431
(Juvenile Elastoma, Collagenoma) 403 Miscellaneous Eyelid Infections 431
Hereditary Skin Disorders 403 Eyelid Ptosis 432
Common Skin Diseases in Infants, Children, Horner Syndrome 432
& Adolescents 404 Eyelid Tics 433
Acne 404 Disorders of the Nasolacrimal System 433
Bacterial Infections of the Skin 406 Nasolacrimal Duct Obstruction 433
Fungal Infections of the Skin 407 Congenital Dacryocystocele 434
Viral Infections of the Skin 408 Dacryocystitis 435
Virus-Induced Tumors 409 Diseases of the Conjunctiva 435
Insect Infestations 410 Ophthalmia Neonatorum 435
Dermatitis (Eczema) 410 Bacterial Conjunctivitis 436
Common Skin Tumors 413 Viral Conjunctivitis 437
Papulosquamous Eruptions 414 Allergic Conjunctivitis 437
Hair Loss (Alopecia) 415 Mucocutaneous Diseases 438
Reactive Erythemas 416 Disorders of the Iris 439
Miscellaneous Skin Disorders Seen Iris Coloboma 439
in Pediatric Practice 416 Aniridia 440
Albinism 440
16. Eye 418 Miscellaneous Iris Conditions 441
Glaucoma 441
Rebecca Sands Braverman, MD Uveitis 441
Common Nonspecific Signs & Symptoms 418 Anterior Uveitis/Iridocyclitis/Iritis 441
Red Eye 418 Posterior Uveitis 442
Tearing 418 Intermediate Uveitis 443
Discharge 418 Ocular Manifestations of AIDS 443
Pain & Foreign Body Sensation 418 Disorders of the Cornea 444
Photophobia 418 Cloudy Cornea 444
Leukocoria 418 Viral Keratitis 444
Refractive Errors 419 Corneal Ulcers 445
Myopia (Nearsightedness) 419 Disorders of the Lens 446
Hyperopia (Farsightedness) 420 Cataracts 446
Astigmatism 420 Dislocated Lenses/Ectopia Lentis 446
Ophthalmic Examination 420 Disorders of the Retina 447
History 420 Retinal Hemorrhages in the Newborn 447
Visual Acuity 420 Retinopathy of Prematurity 447
External Examination 421 Retinoblastoma 448
 viii
▲ Co n t en t s

Retinal Detachment 449 The Throat & Oral Cavity 489

Diabetic Retinopathy 449 Acute Stomatitis 489
Diseases of the Optic Nerve 450 Pharyngitis 489
Optic Neuropathy 450 Peritonsillar Cellulitis or Abscess (Quinsy) 492
Optic Nerve Hypoplasia 451 Retropharyngeal Abscess 493
Papilledema 451 Ludwig Angina 493
Optic Neuritis 452 Acute Cervical Adenitis 493
Optic Atrophy 452 Snoring, Mouth Breathing,
Diseases of the Orbit 453 & Upper Airway Obstruction 494
Periorbital & Orbital Cellulitis 453 Tonsillectomy & Adenoidectomy 496
Craniofacial Anomalies 453 Disorders of the Lips 497
Orbital Tumors 454 Disorders of the Tongue 498
Nystagmus 455 Halitosis 498
Amblyopia 455 Salivary Gland Disorders 498
Strabismus 456 Congenital Oral Malformations 498
Unexplained Decreased Vision in Infants &
Children 458 19. Respiratory Tract & Mediastinum 500
Learning Disabilities & Dyslexia 458
Monica J. Federico, MD
Christopher D. Baker, MD
17. Oral Medicine & Dentistry 459
Emily M. Deboer, MD
Ulrich Klein, DMD, DDS, MS Ann C. Halbower, MD
Issues in Pediatric Oral Health 459 Oren Kupfer, MD
Dental Caries 460 Stacey L. Martiniano, MD
Oral Examination of the Newborn & Infant 463 Scott D. Sagel, MD
Eruption of the Teeth 465 Paul Stillwell, MD
Periodontal Disease 466 Edith T. Zemanick, MD
Dental Emergencies 467 Michelle Caraballo, MD
Antibiotics in Pediatric Dentistry 468 Stephen Hawkins, MD, DO
Special Patient Populations 468 Respiratory Tract 500
Orthodontic Referral 469 Growth & Development 500
Diagnostic AIDS 501
18. Ear, Nose, &Throat 470 Physical Examination of the
Respiratory Tract 501
Patricia J. Yoon, MD Pulmonary Function Tests 501
Melissa A. Scholes, MD Assessment of Oxygenation & Ventilation 502
Norman R. Friedman, MD Diagnosis of Respiratory Tract Infections 504
The Ear 470 Imaging of the Respiratory Tract 505
Infections of the Ear 470 Laryngoscopy & Bronchoscopy 506
Acute Trauma to the Middle Ear 480 General Therapy for Pediatric Lung Diseases 506
Cerumen Impaction & Ear Canal Oxygen Therapy 506
Foreign Body 480 Inhalation of Medications 507
Auricular Hematoma 480 Airway Clearance Therapy 508
Congenital Ear Malformations 480 Avoidance of Environmental Hazards 508
Identification & Management of Hearing Loss 481 Disorders of the Conducting Airways 508
The Nose & Paranasal Sinuses 483 Laryngomalacia & Congenital Disorders
Acute Viral Rhinitis 483 of the Extrathoracic Airway 509
Rhinosinusitis 485 Laryngomalacia 509
Choanal Atresia 487 Other Causes of Congenital Extrathoracic
Recurrent Rhinitis 487 Obstruction 509
Epistaxis 488 Acquired Disorders of the Extrathoracic Airway 510
Nasal Infection 488 Foreign Body Aspiration in the
Nasal Trauma 488 Extrathoracic Airway 510
Foreign Bodies in the Nose 489 Croup Syndromes 511
 Co n t en t s
▲ ix

Vocal Cord Paralysis 513 Sleep-Disordered Breathing 544

Subglottic Stenosis 513 Obstructive & Central Sleep Apnea 545
Congenital Causes of Intrathoracic Apparent Life-Threatening Events 546
Airway Obstruction 514 Sudden Unexpected Infant Death
Malacia of Airways 514 and Sudden Infant Death Syndrome 548
Vascular Rings and Slings 515
Bronchogenic Cysts 515 20. Cardiovascular Diseases 550
Acquired Causes of Intrathoracic Airway
Obstruction 516 Pei-Ni Jone, MD
Foreign Body Aspiration in the Intrathoracic Jeffrey R. Darst, MD
Airway 516 Kathryn K. Collins, MD
Disorders of Mucociliary Clearance 517 Shelley D. Miyamoto, MD
Cystic Fibrosis 517 Diagnostic Evaluation 550
Primary Ciliary Dyskinesia 518 History 550
Bronchiectasis 519 Physical Examination 550
Bronchiolitis Obliterans 520 Electrocardiography 553
Congenital Malformations of the Chest Radiograph 555
Lung Parenchyma 521 Echocardiography 556
Pulmonary Agenesis & Hypoplasia 521 Magnetic Resonance Imaging 557
Pulmonary Sequestration 522 Cardiopulmonary Stress Testing 557
Congenital Lobar Emphysema 522 Arterial Blood Gases 557
Congenital Pulmonary Airway Malformation Cardiac Catheterization &
(Cystic Adenomatoid Malformation) 523 Angiocardiography 557
Acquired Abnormalities of the Lung Parenchyma 524 Perinatal & Neonatal Circulation 559
Bronchopulmonary Dysplasia 524 Heart Failure 560
Community-Acquired Bacterial Pneumonia 526 Genetic Basis of Congenital Heart Disease 562
Parapneumonic Effusion & Empyema 527 Acyanotic Congenital Heart Disease 562
Atypical Pneumonias 528 Defects in Septation 562
Viral Pneumonia 528 Patent (Persistent) Ductus Arteriosus 567
Bronchiolitis 530 Right-Sided Obstructive Lesions 568
Mycoplasma Pneumonia 531 Left-Sided Lesions 571
Aspiration Pneumonia 531 Diseases of the Aorta 575
Pneumonia in the Coronary Artery Abnormalities 576
Immunocompromised Host 532 Cyanotic Congenital Heart Disease 577
Lung Abscess 534 Tetralogy of Fallot 577
Children’s Interstitial Lung Pulmonary Atresia with Ventricular
Disease Syndrome 535 Septal Defect 578
Hypersensitivitiy Pneumonitis 536 Pulmonary Atresia with Intact Ventricular
Diseases of the Pulmonary Circulation 537 Septum 579
Pulmonary Hemorrhage 537 Tricuspid Atresia 580
Pulmonary Embolism 539 Hypoplastic Left Heart Syndrome 581
Pulmonary Edema 539 Transposition of the Great Arteries 582
Congenital Pulmonary Lymphangiectasia 540 Total Anomalous Pulmonary
Disorders of the Chest Wall 540 Venous Return 584
Scoliosis 540 Truncus Arteriosus 585
Pectus Carinatum 541 Quality Improvement in
Pectus Excavatum 541 Congenital Heart Disease 586
Neuromuscular Disorders 541 Acquired Heart Disease 587
Disorders of the Pleura & Pleural Cavity 542 Rheumatic Fever 587
Hemothorax 542 Kawasaki Disease 589
Chylothorax 542 Infective Endocarditis 590
Pneumothorax & Related Air Leak Syndromes 543 Pericarditis 591
Mediastinum 544 Cardiomyopathy 592
Mediastinal Masses 544 Myocarditis 595
 x
▲ Co n t en t s

Preventive Cardiology 596 Congenital Anorectal Anomalies 631

Hypertension 596 Clostridium Difficile Infection in Children 631
Atherosclerosis & Dyslipidemias 596 Disorders of the Peritoneal Cavity 633
Chest Pain 597 Peritonitis 633
Cardiac Transplantation 597 Chylous Ascites 633
Quality Improvement for Pediatric Gastrointestinal Tumors & Malignancies 634
Heart Transplantation 599 Juvenile Polyps 634
Pulmonary Hypertension 599 Cancers of the Esophagus, Small Bowel,
Disorders of Rate & Rhythm 600 & Colon 635
Disorders of the Sinus Node 600 Mesenteric Cysts 636
Premature Beats 601 Intestinal Hemangiomas and Vascular
Supraventricular Tachycardia 603 Malformations 636
Ventricular Tachycardia 606 Major Gastrointestinal Symptoms & Signs 636
Long QT Syndrome 607 Acute Diarrhea 636
Sudden Death 607 Chronic Diarrhea 637
Disorders of Atrioventricular Conduction 607 Gastrointestinal Bleeding 639
Syncope (Fainting) 610 Vomiting 642
Abdominal Pain 643
21. Gastrointestinal Tract 611 Acute Abdomen 645
Malabsorption Syndromes 645
Edward Hoffenberg, MD Inflammatory Bowel Disease 649
Glenn T. Furuta, MD
Gregg Kobak, MD 22. Liver & Pancreas 653
Edwin Liu, MD
Jason Soden, MD Ronald J. Sokol, MD, FAASLD
Robert Kramer, MD Michael R. Narkewicz, MD
David Brumbaugh, MD Shikha S. Sundaram, MD, MSCI
Disorders of the Esophagus 611 Cara L. Mack, MD
Gastroesophageal Reflux & GERD 611 Liver Disorders 653
Eosinophilic Esophagitis 613 Neonatal Cholestatic Jaundice 653
Caustic Burns of the Esophagus 615 Intrahepatic Cholestasis 653
Foreign Bodies in the Alimentary Tract 616 Extrahepatic Neonatal Cholestasis 661
Disorders of the Stomach & Duodenum 617 Other Neonatal Hyperbilirubinemic
Hiatal Hernia 617 Conditions (Noncholestatic
Pyloric Stenosis 618 Nonhemolytic) 663
Gastric & Duodenal Ulcer 619 Hepatitis A 666
Congenital Diaphragmatic Hernia 620 Hepatitis B 668
Congenital Duodenal Obstruction 621 Hepatitis C 670
Disorders of the Small Intestine 622 Hepatitis D (Delta Agent) 671
Intestinal Atresia & Stenosis 622 Hepatitis E 671
Intestinal Malrotation 622 Other Hepatitis Viruses 671
Short Bowel Syndrome 623 Acute Liver Failure 672
Intussusception 624 Autoimmune Hepatitis 673
Inguinal Hernia 625 Nonalcoholic Fatty Liver Disease 675
Umbilical Hernia 626 a 1-Antitrypsin Deficiency Liver Disease 676
Patent Omphalomesenteric Duct 626 Wilson Disease (Hepatolenticular
Meckel Diverticulum 626 Degeneration) 677
Acute Appendicitis 627 Drug-Induced Liver Disease 679
Duplications of the Gastrointestinal Tract 627 Cirrhosis 679
Disorders of the Colon 628 Portal Hypertension 681
Congenital Aganglionic Megacolon Biliary Tract Disease 683
(Hirschsprung Disease) 628 Pyogenic & Amebic Liver Abscess 688
Constipation 629 Liver Tumors 689
Anal Fissure 630 Liver Transplantation 690
 Co n t en t s
▲ xi

Pancreatic Disorders 691 Focal Segmental Glomerulosclerosis 719

Acute Pancreatitis 691 Membranous Nephropathy
Chronic Pancreatitis 692 (Membranous Glomerulonephritis) 719
Gastrointestinal & Hepatobiliary Diseases of the Renal Vessels 720
Manifestations of Cystic Fibrosis 693 Renal Vein Thrombosis 720
Syndromes With Pancreatic Exocrine Renal Arterial Disease 720
Insufficiency 697 Hemolytic-Uremic Syndrome 720
Isolated Exocrine Pancreatic Renal Failure 721
Enzyme Defect 697 Acute Kidney Injury 721
Pancreatic Tumors 697 Chronic Renal Failure 724
References 698 Hypertension 725
Inherited or Developmental Defects
23. Fluid, Electrolyte, & Acid-Base Disorders of the Kidneys 727
&Therapy 699 Disorders of the Renal Tubules 727
Cystinosis 729
Douglas M. Ford, MD Oculocerebrorenal Syndrome
Melisha G. Hanna, MD, MS (Lowe Syndrome) 730
Regulation of Body Fluids, Hypokalemic Alkalosis (Bartter Syndrome,
Electrolytes, & Tonicity 699 Gitelman Syndrome, & Liddle Syndrome) 730
Acid-Base Balance 700 Nephrogenic Diabetes Insipidus (NDI) 730
Fluid & Electrolyte Management 701 Nephrolithiasis 731
Dehydration 702 Urinary Tract Infections 732
Hyponatremia 704 QA/QI in Pediatric Nephrology 733
Hypernatremia 705
Potassium Disorders 706 25. Neurologic & Muscular
Acid-Base Disturbances 707 Disorders 735
Metabolic Acidosis 707
Metabolic Alkalosis 708 Sita Kedia, MD, MPH
Respiratory Acidosis 708 Kelly Knupp, MD
Respiratory Alkalosis 708 Teri L. Schreiner, MD, MPH
Michele L. Yang, MD
24. Kidney & Urinary Tract 710 Jeremy Toler, MD
Paul G. Moe, MD
Melissa A. Cadnapaphornchai, MD Neurologic Assessment & Neurodiagnostics 735
Gary M. Lum, MD History & Examination 735
Evaluation of the Kidney & Urinary Tract 710 Diagnostic Testing 735
History 710 Pediatric Neuroradiologic Procedures 737
Physical Examination 710 Disorders Affecting the Nervous System
Laboratory Evaluation of Renal Function 710 in Infants & Children 741
Laboratory Evaluation of Immunologic Altered States of Consciousness 741
Function 714 Seizure Disorders (Epilepsies) 744
Radiographic Evaluation 714 Sleep Disorders 758
Renal Biopsy 714 Headaches 759
Congenital Anomalies of the Urinary Tract 714 Pseudotumor Cerebri
Renal Parenchymal Anomalies 714 (Idiopathic Intracranial Hypertension) 762
Distal Urinary Tract Anomalies 715 Cerebrovascular Disease 764
Hematuria & Glomerular Disease 716 Congenital Malformations of the
Microhematuria 716 Nervous System 767
Glomerulonephritis 716 Abnormal Head Size 770
Tubulointerstitial Disease 718 Neurocutaneous Dysplasias 772
Acute Interstitial Nephritis 718 Central Nervous System
Proteinuria & Renal Disease 718 Degenerative Disorders of
Congenital Nephrosis 718 Infancy & Childhood 777
Idiopathic Nephrotic Syndrome of Childhood 718 Ataxias of Childhood 777
 xii
▲ Co n t en t s

Acute Ataxias of Childhood 777 Trauma 828

Congenital Causes of Chronic & Traumatic Subluxations & Dislocations 829
Episodic Ataxias 783 Fractures 830
Intermittent/Episodic Ataxias 783 Infections of the Bones & Joints 832
Progressive Ataxias 784 Vascular Lesions & Avascular
Extrapyramidal Disorders 786 Necrosis (Osteochondroses) 835
Cerebral Palsy 789 Neoplasia of the Musculoskeletal System 836
Infections & Inflammatory Disorders Miscellaneous Diseases of Bone & Joint 838
of the Central Nervous System 790 Fibrous Dysplasia 838
Bacterial Meningitis 791 Bone Cysts, Baker Cyst, & Ganglions 839
Brain Abscess 792 Quality Assurance/Improvement
Viral Infections 793 Initiatives in Orthopedics 839
Encephalopathy of Human
Immunodeficiency Virus Infection 793 27. Sports Medicine 840
Other Infections 793
Noninfectious Inflammatory Disorders Katherine S. Dahab, MD, FAAP, CAQSM
of the Central Nervous System 794 Kyle B. Nagle, MD, MPH, FAAP, CAQSM
Other Parainfectious Encephalopathies 795 Rachel A. Coel, MD, PhD, FAAP, CAQSM
Multiple Sclerosis 795 Quynh B. Hoang, MD, FAAP, CAQSM
Syndromes Presenting as Acute Armando Vidal, MD
Flaccid Weakness 796 Basic Principles 840
Disorders of Childhood Affecting Muscles 799 Fitness & Conditioning 840
Benign Acute Childhood Myositis 807 Sports Nutrition 841
Myasthenic Syndromes 807 Preparticipation Physical Evaluation 841
Peripheral Nerve Palsies 809 Rehabilitation of Sports Injuries 849
Chronic Polyneuropathy 810 Common Sports Medicine
Miscellaneous Neuromuscular Disorders 811 Issues & Injuries 855
Floppy Infant Syndrome 811 Infectious Diseases 855
Web Resources 813 Head & Neck Injuries 855
Spine Injuries 858
26. Orthopedics 815 Shoulder Injuries 859
Elbow Injuries 861
Mark A. Erickson, MD, MMM Jason Rhodes, MD, MS Hand & Wrist Injuries 863
Cameron Niswander, BA Hip Injuries 864
Disturbances of Prenatal Origin 815 Knee Injuries 867
Congenital Amputations Foot & Ankle Injuries 870
& Limb Deficiencies 815 Prevention 872
Deformities of the Extremities 816
Common Foot Problems 816 28. Rehabilitation Medicine 873
Genu Varum & Genu Valgum 818
Tibial Torsion & Femoral Anteversion 819 Pamela E. Wilson, MD Gerald H. Clayton, PhD
Developmental Dysplasia of the Hip Joint 819 Pediatric Brain Injury 873
Slipped Capital Femoral Epiphysis 821 Spinal Cord Injury 876
Common Spine Conditions 821 Brachial Plexus Lesions 878
Torticollis 821 Common Rehabilitation Problems 879
Scoliosis 822 Quality Assurance/Improvement
Kyphosis 823 Initiatives in Rehabilitation
Inflammatory Conditions 824 Medicine 881
Arthritis and Tenosynovitis 824
Syndromes with Musculoskeletal 29. Rheumatic Diseases 882
Involvement 824
Arthrogryposis Multiplex Congenita Jennifer B. Soep, MD
(Amyoplasia Congenita) 824 Juvenile Idiopathic Arthritis 882
Neurologic Disorders Involving Systemic Lupus Erythematosus 885
the Musculoskeletal System 827 Dermatomyositis 887
 Co n t en t s
▲ xiii

Vasculitis 888 Pretransfusion Testing 938

Raynaud Phenomenon 889 Transfusion Practice 938
Noninflammatory Pain Syndromes 889 References 944

30. Hematologic Disorders 891 31. Neoplastic Disease 945

Daniel R. Ambruso, MD Doug K. Graham, MD, PhD
Rachelle Nuss, MD John A. Craddock, MD
Michael Wang, MD Ralph R. Quinones, MD
Normal Hematologic Values 891 Amy K. Keating, MD
Bone Marrow Failure 891 Kelly Maloney, MD
Constitutional Aplastic Anemia Nicholas K. Foreman, MD, MRCP
(Fanconi Anemia) 891 Roger H. Giller, MD
Acquired Aplastic Anemia 892 Brian S. Greffe, MD
Anemias 893 Major Pediatric Neoplastic Diseases 945
Approach to the Child With Anemia 893 Acute Lymphoblastic Leukemia 945
Pure Red Cell Aplasia 895 Acute Myeloid Leukemia 948
Nutritional Anemias 897 Myeloproliferative Diseases 951
Anemia of Chronic Disorders 899 Brain Tumors 952
Congenital Hemolytic Anemias: Lymphomas & Lymphoproliferative
Red Cell Membrane Defects 900 Disorders 956
Congenital Hemolytic Anemias: Neuroblastoma 961
Hemoglobinopathies 901 Wilms Tumor (Nephroblastoma) 963
Congenital Hemolytic Anemias: Bone Tumors 965
Disorders of Red Cell Metabolism 908 Rhabdomyosarcoma 967
Acquired Hemolytic Anemia 910 Retinoblastoma 968
Polycythemia & Methemoglobinemia 912 Hepatic Tumors 969
Congenital Erythrocytosis Langerhans Cell Histiocytosis 970
(Familial Polycythemia) 912 Hematopoietic Stem Cell Transplant 971
Secondary Polycythemia 912 General Considerations 971
Methemoglobinemia 913 Late Effects of Pediatric Cancer Therapy 974
Disorders of Leukocytes 913 Growth Complications 974
Neutropenia 913 Endocrine Complications 974
Neutrophilia 915 Cardiopulmonary Complications 975
Disorders of Neutrophil Function 915 Renal Complications 975
Lymphocytosis 917 Neuropsychological Complications 975
Eosinophilia 918 Second Malignancies 975
Bleeding Disorders 918
Abnormalities of Platelet Number 32. Pain Management & Pediatric
or Function 919 Palliative & End-of-Life Care 977
Inherited Bleeding Disorders 924
Von Willebrand Disease 928 Brian Greffe, MD
Acquired Bleeding Disorders 929 Jeffrey L. Galinkin, MD, FAAP
Vascular Abnormalities Associated Nancy A. King, MSN, RN, CPNP
with Bleeding 931 Pain Assessment 977
Thrombotic Disorders 932 Acute Pain 977
Splenic Abnormalities 935 Chronic Pain Management 979
Splenomegaly & Hypersplenism 935 Pediatric Palliative & End-of-Life Care 981
Asplenia & Splenectomy 935 Introduction 981
Transfusion Medicine 936 Children Who May Benefit from
Donor Screening & Blood Processing: Palliative Care Interventions 982
Risk Management 936 Pain Management in Pediatric Palliative Care 982
Storage & Preservation of Blood Quality-of-Life Adjuncts & Symptom
& Blood Components 938 Management in Pediatric Palliative Care 982
 xiv
▲ Co n t en t s

Psychosocial Aspects of Disorders of Calcium &

Pediatric Palliative Care 984 Phosphorus Metabolism 1022
Children’s Concept of Death 984 Hypocalcemic Disorders 1022
Spiritual & Cultural Support 984 Pseudohypoparathyroidism
Withdrawal of Medical Life Support 984 (Resistance To Parathyroid
Advance Care Planning 986 Hormone Action) 1026
Hypercalcemic States 1026
33. Immunodeficiency 988 Familial Hypocalciuric Hypercalcemia
(Familial Benign Hypercalcemia) 1028
Jordan K. Abbott, MD Hypervitaminosis D 1028
Pia J. Hauk, MD Idiopathic Hypercalcemia of Infancy
Immunodeficiency Evaluation: (Williams Syndrome) 1028
Primary Considerations 988 Immobilization Hypercalcemia 1028
Severe Combined Hypophosphatasia 1028
Immunodeficiency Diseases 992 Gonads (Ovaries & Testes) 1029
Antibody Deficiency Syndromes 995 Development 1029
Other Combined Disorders of Sexual Development 1029
Immunodeficiency Disorders 998 Abnormalities in Female Pubertal
Phagocyte Disorders 1001 Development & Ovarian Function 1031
Complement Deficiencies 1002 Abnormalities in Male Pubertal
Other Well-Defined Development & Testicular Function 1034
Immunodeficiency Syndromes 1003 Adrenal Cortex 1036
Genetic Syndromes Adrenocortical Insufficiency
Associated with Immunodeficiency 1005 (Adrenal Crisis, Addison Disease) 1037
Congenital Adrenal Hyperplasias 1039
34. Endocrine Disorders 1007 Adrenocortical Hyperfunction
(Cushing Disease, Cushing Syndrome) 1041
Megan Moriarty Kelsey, MD, MS
Primary Hyperaldosteronism 1042
Jennifer M. Barker, MD
Uses of Glucocorticoids &
Sarah Bartz, MD
Adrenocorticotropic Hormone in
Christine M. Chan, MD
Treatment of Nonendocrine Diseases 1042
Michael S. Kappy, MD, PhD
Adrenal Medulla Pheochromocytoma 1044
Sharon H. Travers, MD
Philip S. Zeitler, MD, PhD
35. Diabetes Mellitus 1045
General Concepts 1007
Hormone Types 1007 Marian Rewers, MD, PhD
Feedback Control of H. Peter Chase, MD
Hormone Secretion 1007 General Considerations 1045
Disturbances of Growth 1008
Target Height & Skeletal Maturation 1009 36. Inborn Errors of Metabolism 1054
Short Stature 1009
Tall Stature 1015 Janet A. Thomas, MD
Disorders of the Posterior Pituitary Gland 1016 Johan L.K. Van Hove, MD, PhD, MBA
Arginine Vasopressin Diagnosis 1054
(Antidiuretic Hormone) Physiology 1016 Suspecting Inborn Errors 1054
Central Diabetes Insipidus 1016 Laboratory Studies 1055
Thyroid Gland 1017 Common Clinical Situations 1055
Fetal Development of the Thyroid 1017 Management of Metabolic Emergencies 1056
Physiology 1017 Newborn Screening 1056
Hypothyroidism (Congenital & Disorders of Carbohydrate Metabolism 1057
Acquired) 1017 Glycogen Storage Diseases 1057
Thyroiditis 1019 Galactosemia 1058
Hyperthyroidism 1020 Hereditary Fructose Intolerance 1059
Thyroid Cancer 1021 Disorders of Energy Metabolism 1059
 Co n t en t s
▲ xv

Disorders of Amino Acid Metabolism 1061 Autosomal Recessive Disorders 1101

Disorders of the Urea Cycle 1061 X-Linked Disorders 1103
Phenylketonuria & the Nonmendelian Disorders 1104
Hyperphenylalaninemias 1062 Disorders of Imprinting 1104
Hereditary Tyrosinemia 1063 Disorders Associated with Anticipation 1104
Maple Syrup Urine Disease Mitochondrial Disorders 1105
(Branched-Chain Ketoaciduria) 1064 Disorders of Multifactorial Inheritance 1106
Homocystinuria 1065 Cleft Lip & Cleft Palate 1106
Nonketotic Hyperglycinemia 1065 Neural Tube Defects 1107
Organic Acidemias 1066 Common Recognizable Disorders
Propionic & Methylmalonic Acidemia with Variable or Unknown Cause 1108
(Ketotic Hyperglycinemias) 1066 Genetic Evaluation of the Child with
Carboxylase Deficiency 1068 Developmental Disabilities 1110
Glutaric Acidemia Type I 1068 Perinatal Genetics 1111
Disorders of Fatty Acid Oxidation & Carnitine 1069 Teratogens 1111
Fatty Acid Oxidation Disorders 1069 Assisted Reproduction 1112
Carnitine 1070 Prenatal Diagnosis 1112
Purine Metabolism Disorders 1070
Lysosomal Diseases 1071 38. Allergic Disorders 1114
Peroxisomal Diseases 1075
Congenital Disorders of Glycosylation 1076 Ronina A. Covar, MD
Smith-Lemli-Opitz Syndrome & David M. Fleischer, MD
Disorders of Cholesterol Synthesis 1076 Christine Cho, MD
Disorders of Neurotransmitter Metabolism 1077 Mark Boguniewicz, MD
Creatine Synthesis Disorders 1078 Asthma 1114
Quality Initiatives in the Field of Allergic Rhinoconjunctivitis 1131
Metabolic Disease 1078 Atopic Dermatitis 1135
Urticaria & Angioedema 1139
37. Genetics & Dysmorphology 1080 Anaphylaxis 1141
Adverse Reactions to Drugs & Biologicals 1143
Margarita Sifuentes Saenz, MD Food Allergy 1147
Naomi J.L. Meeks, MD Insect Allergy 1148
Anne Chun-Hui Tsai, MD, MSc
Ellen R. Elias, MD 39. Antimicrobial Therapy 1150
Foundations of Genetic Diagnosis 1080
Cytogenetics 1080 Sarah K. Parker, MD
Molecular Genetics 1085 John W. Ogle, MD
Principles of Inherited Human Disorders 1086 Principles of Antimicrobial Therapy 1150
Mendelian Inheritance 1086 Antimicrobial Stewardship 1151
Multifactorial Inheritance 1090 Antimicrobial Susceptibility Testing 1158
Nonmendelian Inheritance 1090 Alteration of Dose & Measurement
Family History & Pedigree 1092 of Blood Levels 1159
Dysmorphology & Human Embryology 1092 The Use of New Antimicrobial Agents 1159
Mechanisms 1092 Prophylactic Antimicrobial Agents 1160
Clinical Dysmorphology 1093 Initial Empiric Antimicrobial Choices
Chromosomal Disorders: Abnormal Number 1095 for Selected Conditions 1161
Trisomies 1095 Specific Antimicrobial Agents 1163
Sex Chromosome Abnormalities 1096 Penicillins 1163
Chromosomal Abnormalities: Glycopeptide Agents 1164
Abnormal Structure 1097 Oxazolidinones 1165
Chromosome Deletion Disorders 1097 Cephalosporins 1165
Contiguous Gene Disorders 1098 Aztreonam 1166
Mendelian Disorders 1099 Carbapenems 1166
Autosomal Dominant Disorders 1099 Macrolides & Azalides 1166
 xvi
▲ Co n t en t s

Clindamycin 1167 41. Human Immunodeficiency

Sulfonamides 1167 Virus Infection 1214
Tetracyclines 1167
Aminoglycosides 1168 Elizabeth J. McFarland, MD
Fluoroquinolones 1168 Perinatally HIV-Exposed Infant 1216
Metronidazole 1169 Acute Retroviral Syndrome 1217
Daptomycin 1169 Progressive HIV Disease 1218
References 1169 Prevention 1223
Quality Assurance and Outcome Metrics 1225
40. Infections: Viral & Rickettsial 1170
42. Infections: Bacterial & Spirochetal 1226
Myron J. Levin, MD
Edwin J. Asturias, MD John W. Ogle, MD
Adriana Weinberg, MD Marsha S. Anderson, MD
Viral Infections 1170 Bacterial Infections 1226
Respiratory Infections 1170 Group A Streptococcal Infections 1226
Viruses Causing the Common Cold 1170 Group B Streptococcal Infections 1230
Infections Due to Adenoviruses 1175 Streptococcal Infections with
Influenza 1176 Organisms other than
Parainfluenza (Croup) 1178 Group A or B 1233
Respiratory Syncytial Virus Disease 1178 Pneumococcal Infections 1234
Human Metapneumovirus Infection 1180 Staphylococcal Infections 1237
Infections Due to Enteroviruses and Meningococcal Infections 1242
Parechoviruses 1181 Gonococcal Infections 1244
Acute Febrile Illness 1181 Botulism 1247
Respiratory Tract Illnesses 1181 Tetanus 1249
Rashes (Including Hand-Foot-and-Mouth Gas Gangrene 1251
Disease) 1182 Diphtheria 1252
Central Nervous System Illnesses 1183 Infections Due to Enterobacteriaceae 1253
Infections Due to Herpesviruses 1185 Pseudomonas Infections 1256
Herpes Simplex Infections 1185 Salmonella Gastroenteritis 1257
Varicella & Herpes Zoster 1189 Typhoid Fever & Paratyphoid Fever 1259
Roseola Infantum (Exanthem Subitum) 1191 Shigellosis (Bacillary Dysentery) 1261
Cytomegalovirus Infections 1192 Cholera 1262
Infectious Mononucleosis Campylobacter Infection 1263
(Epstein-Barr Virus) 1195 Tularemia 1264
Viral Infections Spread by Insect Vectors 1197 Plague 1266
Encephalitis 1197 Haemophilus Influenzae Type B
Dengue 1201 Infections 1267
Colorado Tick Fever 1202 Pertussis (Whooping Cough) 1270
Other Major Viral Childhood Exanthems 1202 Listeriosis 1272
Erythema Infectiosum 1202 Tuberculosis 1273
Measles (Rubeola) 1204 Infections With Nontuberculous
Rubella 1205 Mycobacteria 1276
Infections Due to Other Viruses 1207 Legionella Infection 1278
Hantavirus Cardiopulmonary Chlamydophila Infections
Syndrome 1207 (Psittacosis [Ornithosis],
Mumps 1208 C Pneumoniae, & C Trachomatis) 1279
Rabies 1209 Cat-Scratch Disease 1281
Rickettsial Infections 1210 Spirochetal Infections 1282
Human Ehrlichiosis 1210 Syphilis 1282
Rocky Mountain Spotted Fever 1211 Relapsing Fever 1286
Endemic Typhus (Murine Typhus) 1212 Leptospirosis 1287
Q Fever 1213 Lyme Disease 1288
 Co n t en t s
▲ xvii

43. Infections: Parasitic & Mycotic 1291 Proctitis, Proctocolitis, & Enteritis 1342
Vaginal Discharge 1343
Kevin Messacar, MD Genital Ulcerations 1344
Samuel R. Dominguez, MD, PhD Genital Warts & Human Papillomavirus 1348
Myron J. Levin, MD Other Viral Infections 1349
Parasitic Infections 1291 Ectoparasitic Infections 1351
Protozoal Infections 1294
Systemic Infections 1294 45. Travel Medicine 1352
Gastrointestinal Infections 1300
Trichomoniasis 1305 Suchitra Rao, MBBS
Metazoal Infections 1306 Sarah K. Parker, MD
Nematode Infections 1306 Introduction 1352
Cestode Infections (Flukes) 1312 Preparing Children and Infants
Trematode Infections 1314 for Travel 1352
Pneumocystis and Other Opportunistic Vaccinations—Routine Childhood
Fungal Infections 1326 Vaccines Modified for Travel 1354
Pneumocystis Jiroveci Infection 1328 Vaccinations—Travel-Specific 1356
Mycotic Infections 1316 Traveler’s Diarrhea 1358
Malaria Prophylaxis & Prevention 1359
44. Sexually Transmitted Infections 1330 Visits To Friends & Relatives (VFR)
in High-Risk Areas 1360
Daniel H. Reirden, MD HIV & Sexually Transmitted Diseases 1360
Ann-Christine Nyquist, MD, MSPH Fever in the Returned Traveler 1363
Adolescent Sexuality 1330 References 1366
Risk Factors 1331
Prevention of Sexually 46. Chemistry & Hematology Reference
Transmitted Infections 1331 Intervals 1367
Screening for Sexually
Transmitted Infections 1331 Frank J. Accurso, MD
Signs & Symptoms 1332 Georgette Siparsky, PhD
The Most Common Antibiotic-Responsive Challenges in Determining &
Sexually Transmitted Infections 1332 Interpreting Pediatric Reference Intervals 1367
Chlamydia Trachomatis Infection 1332 Guidelines for Use of Data in a
Neisseria Gonorrhoeae Infection 1333 Reference Range Study 1367
The Spectrum of Signs & Symptoms Statistical Computation of
of Sexually Transmitted Infections 1339 Reference Intervals 1368
Cervicitis 1339 Why Reference Intervals Vary 1369
Pelvic Inflammatory Disease 1340 Sensitivity & Specificity 1369
Urethritis 1341 Pediatric Reference Intervals 1370
Epididymitis 1342
Index 1383
 Authors
Jordan K. Abbott, MD
Assistant Professor, Department of Pediatrics, University
of Colorado School of Medicine and Children’s Hospital
Colorado; Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 33: Immunodeficiency
Frank J. Accurso, MD
Professor, Department of Pediatrics, Section of Pediatric
Pulmonary Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 46: Chemistry & Hematology Reference Intervals
Daniel R. Ambruso, MD
Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant,
University of Colorado School of Medicine and Children’s
Hospital Colorado; Associate Medical Director, Belle Bonfils
Blood Center
Chapter 30: Hematologic Disorders
Marsha S. Anderson, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Infectious Diseases, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 42: Infections: Bacterial & Spirochetal
Edwin J. Asturias, MD
Associate Professor, Departments of Pediatrics and
Epidemiology and Infectious Diseases, University of
Colorado School of Medicine; Associate Director, Center for
Global Health, Colorado School of Public Health
Chapter 40: Infections: Viral & Rickettsial
Christopher D. Baker, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Jennifer M. Barker, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Sarah Bartz, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
xix
Mark Boguniewicz, MD
Professor, Department of Pediatrics, University of Colorado
School of Medicine and Children’s Hospital Colorado;
Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 38: Allergic Disorders
Rebecca Sands Braverman, MD
Assistant Professor, Department of Ophthalmology, University
of Colorado School of Medicine
Chapter 16: Eye
David Brumbaugh, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Maya Bunik, MD, MSPH
Assistant Professor, Department of Pediatrics, Section of
General Academic Pediatrics, Director of the Child Health
Clinic, University of Colorado Denver School of Medicine
and Children’s Hospital Colorado
Chapter 9: Ambulatory & Office Pediatrics
Adam Burstein, DO
Senior Clinical Instructor, Department of Child & Adolescent
Psychiatry, Psychiatry Resident Training Programs,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 7: Child & Adolescent Psychiatric Disorders &
Psychosocial Aspects of Pediatrics
Melissa A. Cadnapaphornchai, MD
Associate Professor, Departments of Pediatrics and Medicine,
University of Colorado School of Medicine, Section of
Pediatric Nephrology, Director, Pediatric Continuous
Renal Replacement Therapy, Hemodialysis, and Peritoneal
Dialysis, The Kidney Center, Children’s Hospital Colorado
Chapter 24: Kidney & Urinary Tract
Michelle Caraballo, MD
Former Fellow, Department of Pediatrics, Section of Pediatric
Pulmonary Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Assistant Professor, Department of Pediatrics, Division of
Respiratory Medicine, University of Texas Southwestern
Medical Center
Chapter 19: Respiratory Tract & Mediastinum
Another random document with
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 Fig. 341

Subcoracoid. Subclavicula Subspinous. Subglenoid.

r.
Dislocations of the head of the humerus. (Erichsen.)
 Fig. 342

Relation of circumflex nerve to the head of the humerus, explaining mechanism of

deltoid paralysis. (Marion.)

For convenience of description, and in the order of their frequency,

shoulder dislocations are referred to as anterior, downward,
posterior, and possibly upward, when combined with acromial
fracture. Anterior displacements vary in degree, so that they are
described as subcoracoid or subclavicular. Complete displacement
in this direction can only occur through a rent in the anterior portion
of the capsule, while the subclavicular muscle is pushed away or
torn. The nearer the head of the bone rests to the sternum the
greater the amount of laceration of the capsule, while its posterior
portion is either stretched tightly or torn. In aggravated cases the
tendon of the biceps is also torn out of its groove (Figs. 341, 343 and
344).
 Fig. 343

Subclavicular dislocation. (Lejars.)

Fig. 344

Subcoracoid dislocation. (Lejars.)

In the downward or subglenoid luxations the capsule is lacerated

lower down. These displacements occur when the shoulder has
been dislocated with the arm in the extended and elevated position.
Here the head of the humerus is found in the axilla, resting against
the border of the scapula, and the axillary structures, especially the
circumflex nerve, usually sutler, while the external rotators are either
ruptured or their insertions detached (Fig. 345).

Fig. 345

Subglenoid dislocation. (Lejars.)

The posterior or subspinous dislocation is the least common of all.

In its production the arm is apparently adducted and the elbow
raised. Here the humeral head is found beneath the posterior
surface of the acromion or beneath the spine of the scapula (Fig.
341).
Symptoms.—The indications of shoulder dislocation are pain;
flattening of the shoulder; undue prominence of the
acromion; depression opposite the glenoid cavity, with loss of the
rounded contour due to the presence therein of the head of the
humerus; appearance of a more or less globular mass in the position
now abnormally occupied by the head of the humerus; change in the
axis of this latter bone; inability to bring the elbow to the side; more
or less complete loss of function, and more or less spasm of the
muscles about the joint. Owing to the fact that the thorax presents a
curved or warped surface, to which a straight line can be tangent
only at one point, it results that the hand of the injured side cannot
be made to wrap itself over the opposite shoulder while its elbow still
touches the chest or side (Dugas’ test).
Diagnosis.—As between fracture and dislocation the surgeon
may be greatly helped by deciding that the head of the
humerus is still in its proper position; that the deltoid is not flattened
as in dislocation; that the arm is shortened rather than lengthened;
that motility is increased rather than diminished; that bony crepitus is
usually obtainable, and that replacement, which may be
comparatively easily secured, is maintained only so long as the parts
are held in position by the operator’s hands. An additional sign of
value is the fact that a straight edge cannot ordinarily be made to
touch the tip of the acromion and the external condyle of the
humerus at the same time, because of the protrusion caused by the
presence of the head of the humerus in its socket. When the straight
edge can be so applied it must be either because the head of the
bone is out of the socket or the upper end of the bone broken. A still
more crucial test which should, however, only be applied when
others prove unsatisfactory, may be furnished by passing a sterilized
hat-pin through the sterilized skin over what seems to be the
displaced head of the bone and into the globular mass. Rotation of
the humerus will then cause its end or head to make an excursion
which will be quite distinctive.
 Fig. 346

Exhibits a subcoracoid dislocation and the position of the patient in his endeavor to
find relief from pain. (Mudd.)

Treatment.—Prompt reduction is the only treatment for shoulder

or other dislocations. This may be first attempted
without anesthesia. Should muscle spasm prevent easy reduction it
should be relaxed by an anesthetic, for which purpose nitrous oxide
will often suffice. In the forward or forward and downward
dislocations it will sometimes be sufficient to simply make firm
traction in a direction obliquely outward and upward, with rotation.
When this is insufficient it may be assumed that there is more or less
laceration of the capsule and entanglement of the head of the bone,
as well as that it is caught around the border of the glenoid cavity,
against which it is firmly held.
The above simple maneuver failing, the luxation is to be reduced
by a more scientific manipulation, in which traction figures largely,
the method now generally in vogue being that suggested by Kocher,
by which rotation and leverage are added to traction, and a minimum
of power made to do a maximum of good. Kocher’s method is
especially applicable to the anterior displacements. It consists of a
triple manipulation whose three stages are portrayed in Figs. 347 to
349. The first procedure is to flex the forearm to a right angle with
the arm, apply the former firmly to the side, and then, while keeping
the elbow at the side, forcibly rotate the limb outward until the
forearm points away from the body (Fig. 348). This having been
done the arm is abducted and the elbow moved upward until the limb
is in the horizontal plane of the shoulder, the scapula being held
firmly during these movements, as shown in Fig. 348. After the arm
has been brought to the level of the shoulder it is rotated inward and
brought downward by a process of circumduction, the elbow being
made to describe some part of the arc of a circle as it comes down.
The displaced head should slip into place during this movement, and
will do so unless the capsular tear is too small. In that case the
movements should be repeated, perhaps with more force, until the
opening is sufficiently enlarged to permit the button-hole in the
capsule to slip over the head of the bone.
 Fig. 347

First position in Kocher’s rotation method.

 Fig. 348

Arm is being carried forward and upward toward second position.

 Fig. 349

Completion of third movement in Kocher’s method.

 This method of manipulation, with such modification as
circumstances may require, or such addition as pressure with the
hand or fingers of the assistant, has superseded all the older more
crude and forceful methods, and proves sufficiently applicable for all
cases. It is assumed that the operator has sufficient judgment to
modify any method to fit the exigencies of a given case, else he
should not proceed with it. For instance, in the axillary dislocations
upward traction affords valuable assistance. In the subspinous form
the arm is raised to a level while extension is made upward and
forward. In other words, all these methods depend upon the
combination of traction, rotation, and leverage. The old method of
Astley Cooper, with the foot in the axilla, the shoe having been
removed, coupled with traction upon the arm and swaying
movements, combined with rotation, abduction, and adduction, may
be made effective, but is not nearly as elegant as the simpler
manipulation above described. On the other hand, old, unreduced
dislocations, complicated with adhesions, are often exceedingly
difficult.
In rare instances dislocations several months old have been
reduced after adhesions have been broken up by more or less
violent manipulations. When forcible efforts of this kind prove futile
fair restoration of function may be obtained by maintaining regular
motion, at first passive, later active, to prevent reformation of
adhesions, the head of the bone gradually forming a new and false
socket for itself. Finally, the method of excision can be employed
should occasion demand. The experience of a number of surgeons
has shown that in old cases, or those impossible of reduction by
justifiable force, an open division of the joint, with severance of those
tissues which prevent reduction, may be profitably, safely, and
satisfactorily practised. Porter and McBurney, among the American
surgeons, have devised a corkscrew instrument which may be driven
into the head of the bone, by which manipulation after arthrotomy is
materially facilitated.
The simultaneous occurrence of fracture and dislocation has been
treated of in the previous chapter. When difficulty presents the best
result will be obtained by open incision, replacement of the head of
the humerus, and fixation of fragments by sutures, wire or otherwise.
If seen late the upper fragment should be removed. The possibilities
of aseptic surgery have led to the abandonment of the old method of
first permitting the fracture to unite and then attempting to reduce
dislocation.
Physiological rest is the essential feature of the after-treatment of
all these cases, a sling and a retentive bandage being sufficient for
the purpose. Function should be restored by an increasing degree of
motion.
One of the most serious complications of shoulder dislocations is
deltoid paralysis from injury to the circumflex nerve. The momentary
pressure of the head of the bone upon the nerve is sufficient to more
or less permanently impair its function. In its medicolegal aspect it
should always be maintained that the surgeon is never to blame for
the accident, and is only to some degree blamable in case he has
failed to diagnose the dislocation so soon as opportunity was
afforded and has thus permitted prolonged pressure to possibly
intensify the effect which has already been produced by the injury.[42]
[42] The shoulder is liable to numerous injuries that produce disability.
Pain in some of these conditions may be almost constant and spread
upward to the neck and be aggravated by even passive motion. Loss of
power varies from moderate paresis to complete paralysis. When the
circumflex nerve is especially involved it is the deltoid which shows the
effects. More severe injuries may involve the muscles of the arm and the
forearm. Muscle atrophy may be greater than can ordinarily be accounted
for by mere disease. In rheumatic patients a dry synovitis may be added to
the other complications. Most of these features are due to traumatic
neuritis. When aggravated they may result from rupture of nerves or
cicatricial formations around them. The best treatment consists of
immobilization for three or four weeks to favor nerve repair, counterirritation,
especially with the flying cautery, over the roots of the branchial plexus, with
massage, electricity, and even deep injections of strychnine to stimulate the
paralyzed muscles. When paralysis is persistent and scar tissue seems to
press upon nerves, exposure of the plexus and freeing its branches from all
source of pressure will be necessary.

DISLOCATIONS OF THE ELBOW.

The irregularities of the elbow-joint have permitted a complicated
dovetailing of its component parts which would seem to make
dislocations almost impossible without fracture. Nevertheless, and
especially in the tender years of childhood, both bones may be
dislocated in either direction, or either bone of the forearm alone in
any direction save toward the other. Diagnosis will be greatly aided
by observance of the anatomical facts stated in the section on
fractures of the elbow-joint and by an estimate of the relative
positions occupied by these bony landmarks. When, however,
intense swelling prevents this then we should either wait for its
subsidence or depend upon a skiagram.
The most common dislocation is that of both bones backward, one
of the possible consequences of a fall upon the extended arm and
palm of the hand. The coronoid process may rest beneath the joint
end of the humerus, making the dislocation incomplete, or back of it,
making it complete. If the coronoid process has been broken off the
dislocation can be made and reduced as often as desired. The fan-
shaped lateral ligaments are always more or less lacerated. The arm
will be partially bent and there will be prominent deformity upon the
posterior aspect of the joint while the axes respectively of the arm
and the forearm will be somewhat disturbed. Usually the lower end
of the humerus can be felt in front of the normal situation of the
elbow-joint (Figs. 350, 351 and 352).
Reduction is more or less easily accomplished by traction with an
easy movement, by which the upper end of the forearm shall be
directed toward its proper position.
Lateral displacements result also from falls in extreme positions.
Lateral dislocations are rare and the result of violence, and may
compel amputation. In these cases the lateral diameter of the joint is
markedly increased, while the normal relation of the condyles to the
olecranon is greatly altered. In these cases movement is painful and
limited.
 Fig. 350

Backward dislocation of both bones. (Lejars.)

Fig. 351

Outward displacement of both bones. (Lejars.)

The ulna alone may be dislocated backward, in which case the

orbicular ligament must be lacerated and the upper ends of the
adjoining bones forcibly separated. The olecranon will present back
of its proper position, while the head of the radius will rotate where it
belongs.

Fig. 352

Dislocation forward and outward of head of radius. (Lejars.)

Anterior dislocation of both bones is exceedingly rare unless

complicated by fractures of the olecranon. When thus injured the
forearm is lengthened and fixed. The posterior surface of the
humerus here has only a skin covering, the condyles are bulging, the
olecranon fossa empty, and the upper ends of the forearm bones felt
in front of the elbow.
The head of the radius alone may be displaced in any direction
save toward the ulna. The forward dislocation is the most common,
which may be produced by a fall upon the overextended and
pronated hand. The orbicular ligament here is lacerated or the head
of the radius is slipped out of it. In the latter case it may be difficult to
replace it. When dislocated backward the capsule is torn posteriorly
as well as the orbicular ligament (Fig. 353).
 Fig. 353

Position of the bones in an old unreduced dislocation forward of the radius.

(Erichsen.)

Treatment.—The treatment of elbow dislocations is based upon

general and but slightly differing principles. It consists
of a combination of traction with sufficient force, made with one
hand, while with the other pressure should be made upon one or
both bones in the desired direction; at the same time by a
combination of swaying and rotary movements more or less
massage may be given to the parts, by which complete reduction
may be more easily effected. Anesthesia is nearly always necessary,
not alone for the relief of pain, but to produce muscular relaxation, by
which manipulation is materially assisted.
A peculiar form of dislocation of the head of the radius in young
children has received considerable attention. It is produced by a firm
pull upon the wrist or forearm, as in lifting or jerking a child by the
forearm or hand. Pronation of the hand is usually a feature of the
injury. It is probable that the head of the bone is pulled out of the
orbicular ligament and displaced forward. The forearm is slightly
flexed, movements of the elbow are very free, except that supination
of the forearm meets with resistance. The displacement is rectified
by a forced supination with traction. An epiphyseal separation of the
head may simulate this injury. Such cases necessitate a few days’
rest in a splint, with the arm flexed and supinated, although recovery
often occurs without particular restraint.

DISLOCATIONS OF THE WRIST AND HAND.

 Wrist dislocations are rare, the posterior being more frequent than
the anterior. It simulates the deformity of a Colles fracture, and is
produced in a similar way. The deformity is more marked, the
outlines of the various bones more distinct, except in front, where
they may be masked by the flexor tendons. There is no alteration in
the relations of the styloid processes. The forward dislocation may
possibly simulate Smith’s fracture, the symptoms being the reverse
of those above mentioned.
Firm traction, with pressure in the proper direction upon the
carpus, will suffice for reduction of these cases. The subsequent
dressing may be practically that of a Colles fracture.
The lower ends of the ulna and radius are sometimes dislocated
from their proper relations. Reduction is easy, but rest and restraint
are required for some time until the ligaments have recovered their
tonus.
Of the carpus the os magnum is the only one likely to be
displaced, it being occasionally forced backward so that it forms a
projection on the dorsum of the hand. It requires extreme force to
displace the carpal bones, enough frequently to produce other
injuries at the same time, some of which may be compound. A carpal
bone which cannot be reduced to position by pressure may be safely
removed through an incision.
Of the carpometacarpal dislocations, the thumb is the most
frequently displaced, usually in a backward direction. Traction and
pressure suffice for its reduction. When the bone is forced forward it
is usually as the result of direct violence. Wherever the base of the
bone may rest it is easily detected, while pressure with traction
suffices for its replacement.
Of the dislocations of the phalanges upon the metacarpus those of
the thumb are the more frequent. This may occur as the result of a
fall, by which the thumb is forced backward into a position of
hyperextension. Nearly all of these dislocations are accompanied by
a rupture of capsule. Those of the thumb are difficult of reduction;
this appears to be due to the tendons of the short flexor, which
surround the head of the metacarpal bone. The sesamoid bones
also furnish a source of difficulty, while the long tendons, when
contracted by their respective muscles, increase it (Fig. 354).
 Fig. 354

Metacarpophalangeal dislocation.

Treatment, especially of the thumb dislocations, is facilitated by

first exaggerating the abnormal position, then making traction and
pressure in the proper direction at the same time. Special forceps
have been devised for seizing and holding the digits, or a clove-hitch
can be thrown over the thumb or finger. Extension should not be first
made in the axis of the metacarpal bone, but rather at an abrupt
angle to it in order to relieve the expanded phalangeal end. The
majority of writers concede that in some cases reduction is
practically impossible. When effort has proved futile the parts should
be sterilized and incised, the incision being utilized for open
reduction or for excision, as deemed best.
Dislocations of the other phalanges are usually easily recognized
and treated by traction and pressure.

DISLOCATIONS OF THE HIP.

 Hip dislocations constitute about 5 per cent. of the total. As they
are produced by violence they are much more frequent in men, and
occur mostly between the ages of twenty and fifty years. Before the
twentieth year epiphyseal separations often take place, while after
the fiftieth year violence will usually break the neck of the femur.
Nevertheless dislocations may occur at any age. The hip is a ball-
and-socket joint, with a deep socket still further extended by
cartilage, in which the head of the bone is not only retained by the
ligamentum teres, but by atmospheric pressure, which in the natural
state furnishes a factor of perhaps one hundred pounds. The
strongest muscles and tendons of the body envelop the joint. When
dislocation occurs the capsule is usually torn along its inferior
aspect. The limb is usually in an extreme position, or it would require
more violence to tear the head from the socket. The anterior
dislocations occur during abduction without outward rotation;
posterior dislocations occur during flexion. Thus when a person is
stooping over in work and a heavy weight falls upon the back the
head of the bone is more easily pushed backward, especially if the
feet be close together.
While hip dislocations are classified for convenience, and because
of their final form, the head of the bone may rest upon almost any
segment of the margin of the acetabulum, though within a short time
it will assume a position justifying a designation as anterior or
posterior, meaning thereby in front of or behind Nélaton’s line. This
is, moreover, a convenient distinction, as the symptoms vary
between the two groups. Another classification is into the forward,
the backward or backward and upward, and the downward, which
are again referred to as iliac, ischiatic, dorsal, and supracotyloid
among the posterior, and perineal, obdurator, suprapubic, etc.,
among the anterior (Fig. 355).
Allis, however, has simplified the subject by showing that all forms
of dislocation escape primarily from the lower segment, shifting their
position later either upward or downward. He classifies them as
follows:
1. Lower - All present the general characteristics of adduction and
thyroid. rotation outward.
 2. Middle
thyroid.
3. High
thyroid.

1. Low
dorsal.
2. Middle All present the general characteristics of abduction and
-
dorsal. rotation inward.
3. High
dorsal.

The relation of the so-called Y-ligaments to the successful

reduction of these dislocations, as well as to their formation, is of
considerable importance.