Trainee Advanced Clinical Practitioner Diary- Day 10 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 10

Quinsey, Salter Harris fracture, Limping child, ear drum.

Typical ACS symptoms- Typical angina is described as pain that is sub sternal, occurs on exertion, and is relieved with rest.

Quinsey also known as a peritonsillar abscess and is a recognised complication of tonsillitis. It is a collection of pus in the peritonsillar space.

  • Severe unilateral pain in the throat;
  • Pyrexia (fever) above 39 °C (102 °F);
  • Unilateral earache;
  • Odynophagia (pain during swallowing) and difficulty swallowing saliva;
  • Change in voice (muffled voice, thickened speech, “hot potato” voice);
  • Intense salivation and dribbling, foetor oris
  • Pain in the neck;
  • Malaise, headache, stiffness.

Assessment of limp in children.

 Normal development stages

 10-12 months- cruising

12-14 months- stand and walk short distances unaided. Toddlers initially walk with broad based gait.

By 3 years of age normal gait established.

 Causes of limp

 1-3 yrs

Toddlers fracture

Developmental dysplasia (DDH)

Cerebral palsy

 4-10 yrs

Transient synovitis

Perthes disease


Slipped upper femoral epiphysis (SUFE)

Osgood Schlatters disease

 All ages



Non accidental injury

Inflammatory disease

Referred pain




Observe gait with shoes off

Gowers test

Limb length

Nuero/MSK exam

Spinal exam

Abdo exam for masses

 Red Flags

 Abnormal neuro exam




Muscle wasting

Gowers test positive

Joint swelling/tenderness/heat

Bony tenderness

Limitation of movement



 Foreign body in foot.

Inguinal lymph adenitis

Acute meningococcal disease

Influenza with myositis



Limp and fever- FBC/UE’s/ESR/CRP/cultures

Predictors of septic arthritis



ESR> 40mm hr

WCC> 12

AP/frog leg lateral X Ray if hip joint suspected.

Ultrasound useful for joint effusions.

Developmental dysplasia of the hip (DDH) is improper alignment of the head of the femur and acetabulum.

Newborn exam;

Ortolani sign

Barlow test

symmetrical thigh folds

 Observe child in standing position

Iliac crests should be level

should be able to stand on one foot without any tilting

Assess ROM supine

rotate internally and externally.


Salter Harris Fracture

Salter-Harris fractures are epiphyseal plate fractures and are common and important as they can result in premature closure and therefore limb shortening and abnormal growth. They represent approximately 35% of all skeletal injuries in children, and typically occur in the 10-15 year old child.


 Type I

  • Slipped
  • 5-7%
  • Fracture plane passes all the way through the growth plate not involving bone
  • cannot occur if the growth plate is fused
  • good prognosis

Salter harris type 1






Type II

  • Above
  • 75%- the most common
  • fracture passes across most of the growth plate and up through the metaphysis
  • good prognosis

salter Harris type 2







Type III

  • Lower
  • 7-10%
  • fracture plane passes some distance along the growth plate and down through the epiphysis
  • poorer prognosis as the proliferative and reserve zones are interupted

salter Harris type 3







Type IV

  • Through or transverse or together
  • intra articular
  • 10%
  • fracture plane passes directly through the metaphysis, growth plate and down through the epihysis
  • poorer prognosis as the proliferative and reserve zones are interupted

salter Harris type 4








Type V

  • Ruined or rammed
  • uncommon <1%
  • crushing type injury does not displace the growth plate but damages it by direct compression
  • worst prognosis

salter Harris type 5


Normal eardrum

Normal Tympanic Membrane




Some abnormal eardrums!

Trainee Advanced Clinical Practitioner Diary
Article Name
Trainee Advanced Clinical Practitioner Diary
Day 10 of the diary of the Trainee Advanced Clinical Practitioner covering quinsey, the limping child, Salter Harris fractures and the eardrum

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