By P. Tjalf. Texas A&M International University.
The calcaneus is often largely horizontal and lacks the normal upward slope from a dorsal-caudal to ventral-cranial direction quality 100mg kamagra gold erectile dysfunction caused by ptsd, which is an indication of the shortening of the Achilles tendon discount kamagra gold 100 mg visa impotence of organic origin 60784. In order to produce a meaningful results buy discount kamagra gold 100mg on line erectile dysfunction pills australia, the x-rays of the foot should be re- corded with the child standing and weight-bearing. Ad- ditional imaging investigations are not necessary in a case of flexible flatfoot. Only if a rigid rearfoot is present would there be a need for further investigation to exclude a bone coalition, which is often not visible on the plain x-ray. CT scans are usually indicated in such cases, possibly incor- porating oblique views as well ( Chapter 3. Before deciding on a treatment, the orthopaedist must carefully consider whether any treatment is even necessary. Mild forms of flexible flatfoot do not usually lead to any significant functional problems even in adulthood, nor are they painful. These patients are also usually able to participate in sports without any restrictions. In children, flatfoot is more of a cosmetic than a functional problem, and one that worries the parents b much more than the children themselves. Only severe forms of flatfeet, in which weight-bearing is greater ⊡ Fig. Lateral x-rays of both feet of a patient with severe on the medial than on the lateral side, adversely affect flexible flatfoot. Normal configuration troublesome foot symptoms can become a long-term has been restored problem. The following therapeutic options are available: bearing is greater on the medial than on the lateral side or ▬ Conservative: if the x-ray shows the corresponding signs. Only rarely is the physical therapist ▬ Surgical: successful in getting the still very small child to follow – navicular suspension with or without naviculocu- her instructions, and exercises are only useful if they are neiform arthrodesis, practiced several times a day. It is pointless therefore to – lengthening of the triceps surae muscle and/or place this unnecessary financial burden on the public Achilles tendon, healthcare system (or the insurance funds). Walking on tiptoe is an ideal way of train- – insertion of a dowel implant in the tarsal sinus, ing the foot muscles (⊡ Fig. While other types of exercise – calcaneal lengthening osteotomy according to (e. If shortening of the triceps surae muscle is already A summary of the measures for the various conditions is present, special stretching exercises for the calf muscles shown in ⊡ Table 3. In this case, physical therapy is ap- propriate since the stretching in flexible flatfoot is effec- Conservative treatment tive only if the heel is simultaneously placed in a varus Infancy position, which the child is unable to achieve on its own. If the flexible flatfoot is associated with an abduction Moreover, the mother may be unable to manage this exer- of the forefoot, it is occasionally manifest even at birth. In such cases it is worth straightening the foot with a We consider that the provision of inserts is appropri- cast during the first few months of life. Although casts as below-knee casts can easily slip down and lead the efficacy of insert treatment has not been completely to pressure sores. Moreover, the correction of the foot proven scientifically, we nevertheless manage feet with is better with a long-leg cast. We generally use Softcast fallen medial arches with inserts or shoe modifications. In this form of correction the rearfoot is ferent for treated and untreated feet [16, 17]. A study pushed in a varus direction and the forefoot is supinated conducted in our own hospital with two groups of approx. At the same time the medial longitudinal 20 children with fallen arches with and without insert arch is shaped by the cast. As a rule, we start corrective treatment only after the 2nd month of life and con- tinue the treatment until the foot shape has returned to normal, generally after 2–3 months, by which time the foot has a normal shape in the non-weight-bear- ing state. Whether a flexible flatfoot will continue to persist after the start of walking cannot be predicted with certainty since this depends to a great extent on the quality of the ligaments – and this is difficult to assess in the infant. Walking age If a flexible flatfoot persists after the start of walking, the a b possibility of inserts can be considered. The foot is par- ticularly difficult to assess at this age since the medial foot ⊡ Fig. We make more fun by competing with the child to grasp long objects with a diagnosis of flexible flatfoot at this age only if weight- the toes 414 3. Hopes that the insert or shoe modification will reduce the shoe consumption rate will be disappointed. If the heel is in a very ex- treme valgus position, a so-called inner shoe, i. The desire for cosmetic improvement can also be taken into account to a certain extent, although considerable caution is required here since the correction of the appearance should not be achieved at the expense of pain. If surgery is indicated the operation should not be performed before the age of 8, or preferably 10. Talar reduction In the severest forms, in which the weight-bearing of the foot occurs predominantly, or exclusively, on the medial side, treatment is often required even during early child- hood. Lateral transfixed, the triceps surae is lengthened and the disloca- counter supports are inserted to prevent the foot from sliding laterally tion pouch is closed on the medial side. Navicular suspension treatment showed that the end result was not influenced In this operation, which was first proposed by Lowman by the supports. However, all these studies involved in 1923, the anterior tibial tendon is looped around mild forms of flexible flatfoot or even physiological flat the navicular bone. Other studies, by contrast, have shown that relatively, thereby enhancing the tensioning effect. The the supporting of the medial arch and varization of the relocation of the attachment dorsally also causes the heel with an insert or shoe modification certainly does tendon to exert a more direct effect on the medial arch of produce an effect in more pronounced forms of flexible the foot. The underlying principle is that, by lowering derlying condition of these patients tends to involve pro- the talus and navicular bone, the tendons on the medial nounced ligament laxity and consequently the greater side of the foot (particularly that of the tibialis anterior tensioning effect soon starts to decline. Recurrences are muscle) are constantly overstretched, thus preventing frequent after this operation. Lowman himself was also them from performing their postural function at all. Our aware of this and proposed an additional arthrodesis of prescription for the insert is as follows: Derotation insert the talonavicular joint. However, since this completely with central medial arch support and a supination wedge. Even more effective is an insert with its own heel sup- A less drastic, and apparently equally effective, pro- port. The effect can be enhanced still further by incorpo- cedure is arthrodesis of the joint between the navicular rating the corrective function directly in the shoe. The combination of na- a shoe modification can control the foot more precisely vicular suspension and naviculocuneiform arthrodesis than a loose insert. On the other hand, a shoe modifica- is practiced in some places in patients with an almost tion is much more expensive than an insert since it must fully-grown foot (i. If the calf muscles are with flatfeet have a high shoe consumption rate, i.
Confirmation of the diagnosis is tion of the joint at a later date via penetration or perfora- particularly difficult in infants purchase 100 mg kamagra gold with mastercard erectile dysfunction circumcision. The circulation in the epiphyses differs before and the affected extremity spontaneously and resists attempts after the age of three cheap kamagra gold 100 mg on line erectile dysfunction caused by vasectomy. Subsequently generic kamagra gold 100 mg line erectile dysfunction doctors near me, however, the epiphysis and metaphysis are supplied by their own Diagnosis and treatment vascular systems that are largely independent of each oth-! Consequently, metaphyseal infections in children up mechanically as drug treatment on its own is three years of age can more readily enter the joint via the inadequate in a case of suppurative arthritis. The bacterial distribution roughly matches that of In all feverish patients with swelling and pain in the vicin- osteomyelitis with the same pattern of age-dependency. The aspiration serves as both a found in 43% of cases, coagulase-negative streptococci in diagnostic and therapeutic measure. In most cases an ef- 10%, streptococcus pneumoniae and salmonellae in 5%, fusion can be diagnosed clinically if it occurs in the knee, and haemophilus influenzae and group B streptococci in ankle or elbow. Although any joint can be affected in principle, the hip – the effusion will need to be diagnosed with the the major joints of the lower extremities are involved in aid of ultrasound. Only when the effusion has been diag- 90% of cases (the hip in over 50 percent of cases, knee nosed and the preparations have been made for aspiration and ankle). An x-ray is arranged to rule out any tions and the possibility of physeal damage. Only if the aspirated fluid any infection located in a joint can, in the long term, lead is clear does the surgeon await the results of bacteriology to direct or indirect, irreversible damage to the cartilage. In severe cases, avascular necrosis of the femoral head can However, if the aspirate is cloudy, or even purulent, occur. A certain remodeling of the joint may take place, the actual local treatment is initiated in the same anesthet- with reconstruction of the cartilage with hyaline and ic session, i. The aspirated pus is fibrous replacement cartilage, although this process can investigated for anaerobic and aerobic organisms. The longer perform an open arthrotomy and insert an irriga- residual mobility after the acute phase has subsided plays tion drain, since this only irrigates a track inside the joint a key role in the regeneration. During arthroscopic irrigation, the joint is irrigated liberally throughout – de-! In any joint infection that persists for longer than 4 pending on the size of the joint – with 500–1000 ml of days, the possibility of direct joint damage and fluid. Only if the arthroscopic assessment of the joint growth disorders with corresponding consequences reveals severe destruction of the cartilage, with cartilage for the physeal area must be borne in mind. However, we never delay the the discontinuation of the antibiotic treatment. On remain normal and no other symptoms are present, the the second day after the start of treatment, the patient patient may resume sports activities. Subsequent clinical initially remains fasted, the CRP is repeated and the situa- controls at 3- or 6-monthly intervals for two years serve, tion is clinically re-assessed and, if necessary, a sonogram on the one hand, to document the continuing free mobil- arranged. If joint mobility continues to be significantly ity of the joint and, on the other, to rule out any incipient restricted – and if a residual or recurrent effusion is growth disorders. If the patient is free of symptoms at confirmed clinically or by ultrasound – the arthroscopic the end of this period, the treatment can be considered lavage under anesthesia is repeated. Postinfectious deformities usually pose complex and dif- This is usually the case after 14–20 days. The widespread destruction of the inflammatory parameters – as with the treatment of a joint is often a tragedy for a child. But even if very of acute hematogenous osteomyelitis – then signifies the severe contractures are present, stiffening of a joint should conclusion of the antibiotic treatment. With aggressive, con- sistent and long-term mobilization and exercise therapy, Follow-up management, follow-up controls it is often possible to restore function in substantially Follow-up management is essentially functional, ide- destroyed joints thanks to the considerable remodeling ally with the aid of a dynamic splint. This process will require spontaneous mobility of the patient should be assisted multiple hydraulic mobilization procedures under an- passively by the physiotherapist with adequate analgesia. If avascular necrosis of the epiphysis is permitted according to the level of pain. A further CRP has occurred, insertion of a vascularized autologous bone check is arranged on an outpatient basis eight days after graft can be helpful. In clinical respects there was normal mobility (only the rotation and abduction were restricted), and the patient is now free a b of symptoms 580 4. Bennett OM, Namnyak SS (1992) Acute septic arthritis of the hip (1994) Comparison of the results of bacterial cultures from mul- joint in infancy and childhood. Clin Orthop 281: 123–32 tiple sites in chronic osteomyelitis of long bones. J Bone Joint Surg [Am] 76: 664–6 demiology of acute and subacute haematogenous osteomyelitis 24. Peters W, Irving J, Letts M (1992) Long-term effects of neonatal in children. J Bone Joint Surg Br 83: 99–102 bone and joint infection on adjacent growth plates. Carr AJ, Cole WG, Roberton DM, Chow CW (1993) Chronic multifo- Orthop 12: 806 –10 cal osteomyelitis. Ceroni D, Regusci M, Pazos J, Saunders C, Kaelin A (2003) Risks of joint involvement with adjacent osteomyelitis in pediatric pa- and complications of prolonged parenteral antibiotic treatment tients. J Pediatr Orthop 20: 40–3 in children with acute osteoarticular infections. Putz PA (1993) A pilot study of oral fleroxacin given once daily in 4 69: 400–4 patients with bone and joint infections. Reith JD, Bauer TW Schils JP (1996) Osseous manifestations of SA- F (1999) Epidemiologic, bacteriologic, and long-term follow-up PHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome. Chung WK, Slater GL, Bates EH (1993) Treatment of septic arthritis (1997) Orthopäde 26: 879–88 of the hip by arthroscopic lavage. Craigen MAC, Watters J, Hackett JS (1992) The changing epidemiol- recurrent multifocal osteomyelitis (CRMO). Stubbs AJ, Gunneson EB, Urbaniak JR (2005) Pediatric femoral akuten infektiösen Osteomyelitis. Beitr Klein Chir 10: 257–65 avascular necrosis after pyarthrosis: use of free vascularized fibu- 10. Girschick HJ, Raab P, Surbaum S, Trusen A, Kirschner S, Schneider lar grafting. Clin Orthop Relat Res 439:193-200 P, Papadopoulos T, Muller-Hermelink HK, Lipsky PE (2005) Chronic 32. Tudisco C, Farsetti P, Gatti S, Ippolito E (1991) Influence of chronic non-bacterial osteomyelitis in children. Ann Rheum Dis 64: 279-85 osteomyelitis on skeletal growth: Analysis at maturity of 26 cases 11. Gordon JE, Wolff A, Luhmann SJ, Ortman MR, Dobbs MB, Schoe- affected during childhood. J Pediatr Orthop 11: 358–63 necker PL (2005) Primary and delayed closure after open irrigation 33. Unkila-Kallio L, Kallio MJ, Peltola L (1994) The usefulness of C- and debridement of septic arthritis in children.
Organisation of neonatal care In the UK cheap 100 mg kamagra gold with mastercard impotence at 16, the British Association of Perinatal Medicine recommends three categories of neonatal care as well as the accepted level of ‘normal care’ cheap 100mg kamagra gold fast delivery erectile dysfunction doctor boca raton. These categories are: (1) Special care (2) High dependency or level 2 intensive care (3) Intensive care or level 1 intensive care The level of medical intervention and care received by the neonate increases within these clinical categories with level 1 intensive care being appropriate for those neonates who are most at risk or require frequent medical intervention discount kamagra gold 100mg otc venogenic erectile dysfunction treatment. Level 1 intensive care is therefore often provided within regional paediatric centres where specialist knowledge, experience and expertise in neonatal genetics, surgery and radiology are greater. In contrast, special care, and in many instances level 2 intensive care, are generally provided within district hospitals. Early neonatal period: birth to 7 days Late neonatal period: 7 days to 28 days Post neonatal period: from 28 days to 1 year of age Perinatal period: the period shortly before or after birth Infant: ﬁrst year of life Term: from 37 to less than 42 completed weeks gestation Pre-term: less than 37 completed weeks of gestation1 Post-term: 42 weeks or more gestation Low birthweight: less than 2500g at full gestation Very low birthweight: birthweight less than 1500g Extremely low birthweight: birthweight less than 1000g Care by the radiographer Neonatal radiography requires the radiographer to have not only a high level of technical expertise, but also an understanding of important aspects of neonatal care and the following points, related to handling, infection, warmth and noise, are intended to raise the radiographer’s awareness of non-radiographic aspects of neonatal patient care. Handling Touching and holding a new baby is important for the psychological welfare of the guardians and the child. However, episodes of bradycardia, hypoxia, apnoea and disturbance of sleep patterns are all associated with handling. These factors, combined with the increased risk of heat loss, cross-infection and the possibility of damage to the delicate skin of a pre-term baby, mean that handling by the radiographer should be kept to a minimum and the assistance of the nursing staff or guardians sought. Infection All newborn babies, particularly those born prematurely, are susceptible to infec- tion as a result of their defensive mechanisms being underdeveloped (Box 6. This immunodeﬁciency increases the risk of systemic spread of contracted infec- tions which, if left untreated, may lead to septicaemic shock and neonatal mor- tality4. Any neonate suspected of having an infection should therefore be treated with antibiotics. The radiographer can reduce the risk of neonatal infection by undertaking the following measures: Removing wrist watches and jewellery that may come into contact with the neonate prior to hand washing. Physical defences: The skin acts as a natural physical barrier to infection but its defences are reduced during the neonatal period as the skin is delicate, easily damaged and lacks the normal non-pathogenic bacteria that in themselves provide protection. Necrosis of the umbilical stump can also act as a focus for infection as can medical intervention and the introduction of catheters, endotracheal and naso- gastric tubes. Humoral immunity: Humoral immunity relates to the production of antibodies by the body to combat bacteria or viruses. Phagocyte function: The phagocytic function of leucocytes is reduced during the neonatal period. Where possible, radiographers who are suffering from viral infections (e. If this is unavoid- able, then increased attention should be given to measures designed to minimise cross-infection, in particular hand-washing2. Warmth The pre-term neonate has difﬁculty in maintaining adequate body temperature as a result of having a relatively large surface area compared to body weight, and an inability to produce heat by shivering. As a consequence, the neonate is susceptible to heat loss and its associated clinical complications (e. To address this issue, neonates are generally nursed fully clothed unless this is prohibited by medical treatment (e. Additional precautions of warming or covering all objects that may come into direct contact with the neonate (e. Neonatal in-patients who are particularly at risk from heat loss may be nursed beneath a radiant warmer and this may need to be removed during radiographic examination to facilitate the positioning of the x-ray tube. Radiographers should ensure that the length of time the heater is removed is minimised and that the heater is replaced upon completion of the examination. Neonates examined within the radiology department are still susceptible to heat loss and a convec- tor heater should be available within the imaging department to enable the examination room to be warmed. Alternatively, departments undertaking a large volume of neonatal examinations may employ a radiant warmer (Fig. Noise Sudden loud noises can precipitate sleep disturbance, crying, tachycardia, 1 hypoxaemia and raised intracranial pressure in the neonate and as a result it is recommended that noise levels within the incubator should not exceed 45 deci- bels5. Possible sources of loud noise for a neonate nursed within an incubator are objects being placed on the incubator roof and closure of the incubator doors. Respiratory and cardiovascular pathology Respiratory difﬁculty or distress frequently presents during the neonatal period and has a variety of causes. An important factor in the differential diagnosis of underlying pathology is the time at which symptoms of respiratory distress occur2 (Table 6. Transient tachypnoea Transient tachypnoea of the newborn is an ill-deﬁned but common condition thought to result from a delay in the clearing of amniotic ﬂuid from the lungs6. Symptoms typically manifest within 3 hours of birth and a clinical diagnosis is 98 Paediatric Radiography Table 6. Onset: birth–6 hours Onset: >6 hours post-delivery Onset: any time after birth Transient tachypnoea Pneumonia Upper airway obstruction Hyaline membrane disease Congenital heart disease Neurological disorders Meconium aspiration Underlying metabolic illness Pneumothorax Persistent pulmonary hypertension Congenital malformations Fig. Chest radiography under- taken within a few hours of birth may show evidence of hyperinﬂation, pleural effusion, ﬂuid within the ﬁssures, streaky opaciﬁcation and prominent vascular markings6 (Fig. However, these radiographic ﬁndings are also consistent with neonatal pneumonia and further radiographic examinations may be required to monitor the progress of the condition. Complete clinical and radio- graphic resolution of transient tachypnoea should occur within 24 hours. Surfactant diminishes alveolar surface tension thereby preventing atelectasis (collapse) of the alveoli and acini and assisting in the maintenance of normal respiratory function. The 7 incidence of HMD is directly related to gestational age at the time of birth with very pre-term babies being most at risk. Clinical symptoms of HMD include cyanosis, tachypnoea, expiratory ‘grunting’ and intercostal retraction8. Regular radiographic assessment is likely to be requested to monitor the progress of the disease. Radiographically, the lungs are under-inﬂated and appear opaque or mottled, although air bronchograms may be evident (Fig. Meconium aspiration Meconium is a dark green discharge that results from the ‘sloughing off’ of dead bowel wall cells during foetal development. It is contained within the intestines of the full-term foetus and is usually passed within 24 hours of delivery. However, if foetal distress should occur during delivery then evacuation of meconium into the amniotic ﬂuid may occur and in a small amount of cases (1%), aspiration of the meconium will result8 causing respiratory obstruction (air trap- ping) and distress. Radiographic examination of the neonatal chest will reveal hyperinﬂated lungs and patchy, bilateral opaciﬁcation2 which may become more diffuse as the condition progresses (Fig. Clinically, symptoms of respiratory distress as a result of meconium aspiration resolve within 3–5 days of delivery although radiographic resolution may take up to 1 year. Pulmonary interstitial emphysema Surfactant deﬁciency in the premature neonate may result in the rupture of small airways and dissection of air into the interstitial space where it forms small cysts within the interlobular septae (pulmonary interstitial emphysema). The neonate may present asymptomatically or display signs of gradual degeneration and pro- gressive hypoxaemia if the condition is diffuse. Radiographic evidence of the condition includes areas of translucency and atelectasis (collapse).
The principal clinical manifestations of the nail–patella syndrome are found in the nails kamagra gold 100mg without a prescription erectile dysfunction doctor boca raton, in the skeletal system generic 100 mg kamagra gold visa erectile dysfunction treatment in egypt, and in the kidney generic kamagra gold 100mg with mastercard neurogenic erectile dysfunction causes. They include longitudinal ridging or splitting and in some instances, absence of a portion or all of a nail (anonychia). Iliac “horns” are not known to occur in any other disorder in humans or in any other primates, and are therefore pathognomonic for this disorder. These iliac “horns” are posterior central iliac exostoses that are identiﬁable in 80 percent of patients with nail–patella syndrome (Figure 7. At the elbow, there is capitellar dysplasia, and the radial head is generally dislocated posteriorly with accompanying cubitus valgus. There is diminished forearm rotation, as well as extension block of the elbow. The patellae are hypoplastic or absent, and there is signiﬁcant genu valgum, which tends to be progressive resulting in patellar subluxation and dislocation (Figures 7. Other musculoskeletal abnormalities include a stiff valgus hindfoot, stiffness of the distal ﬁnger joints, clinodactyly of the ﬁfth digit, a Genetic disorders of the musculoskeletal system 158 Table 7. Renal disease ﬁndings are present in approximately 50 percent of patients. The degree of renal involvement varies both within and between families. The most frequent symptoms of renal disease are proteinuria, hematuria, and hypertension. The visit to the orthopaedist or pediatrician for an or- thopaedic »problem« may be prompted by the following reasons: ▬ The parents are worried about neglecting to do something, i. The parents fear, for example, that the intoeing gait may persist for life, that flat feet may make their child ineligible for military service in later life or that the knee pain experienced after a football training session could be an early sign of an imminent sporting disability. In many cases, the visit to the doctor is ultimately prompted by people who are not even present during the consultation: neighbors who are appalled by the »knitting needle« gait of the child, or grandparents who have com- pared the feet of the child with duck’s feet, or even shoe retailers who justify the selling of expensive Some parents seek the doctor’s support for their own rearing methods... Another important reason for the parents’ concern may be the experience from their own childhood, i. An intoeing gait, for example, would be treated by »breaking and rotating the fe- mur«, children with knock-knees or bow legs were forced to wear leg splints for years, and growing up without shoe insoles was only permitted to a few eccentrics. The parents hope that a forceful word from the orthopae- dist or pediatrician will bring the children (and the shoes) to their senses. Some parents consult the doctor to obtain a second, third or even ▬ Follow-up after a treatment or for monitoring a child’s higher opinion... While parents certainly do seek the opinion of another doctor when the first has not provided treat- One frequently asserted – but in reality non-existent ment, the reason is not the lack of treatment, but the – motivation for consulting the orthopaedist is the par- fact that they felt that the first doctor did not take them ents’ »desire for treatment«. This is due to the inappropriate con- repeatedly justify the provision of treatment for a peri- duct of the first doctor. Of course, he can very probably patellar pain syndrome, for example, by arguing that if make a diagnosis on the basis of the medical history. But 4 Chapter 1 · General he must still examine the patient with meticulous care: 1 Firstly, in order to avoid missing some other possible diagnosis, and secondly, to give patients and parents the feeling that they are being taken seriously. The next occa- sion for pushing parents into the arms of another doctor is when, after the examination, the doctor flatly states: »There’s nothing wrong with your child! The child hurts and has been experiencing pain for a long time and it’s getting worse all the time. The correct response in such situations is to explain to the patient and the parents that the pain is due to a very unpleasant problem connected with growth that cannot be influenced by treatment, but one that will not leave any permanent damage after the child has stopped growing. Patients will fully understand that the growing body is defending itself against overexertion and that a temporary reduction in sporting activity may be needed. The parents may still ask: »And can nothing be done to treat the condition? The parents may still insist on treatment, however, because, as ambitious parents, they are unwill- accurately whether you are also being honest with them. Why didn’t you say to the child: »This will hurt just for a moment, but it will The pediatric orthopaedic consultation soon be over! You should always remind yourself of this Behavior of patients need for honesty. Infants Children are quick to notice when you are talking Infants generally don’t care whether you’re a doctor, an about them with their parents but don’t want them to hear uncle or an aunt. The parents sometimes feel that the child would not unless the infant is feeling hungry or thirsty. But if the mediate reaction of some infants is to reject unknown child has a malignant tumor, who will subsequently have individuals, they just don’t take to strangers, but even with to cope with all the unpleasant treatment, if not the child these babies the odds will be in your favor if you flash itself? Even if they don’t understand or take Children in everything at the initial consultation, it is extremely important from the psychological standpoint that you » Children have no concept of time, hence their should include even small children in the discussion so protracted and detailed observations. Children are extremely diverse creatures and differ funda- Incidentally, adults find it far more difficult to cope mentally in the way they communicate with the environ- with such news than the children themselves, because ment of adults. They are not simply »adults on a small they have a much better idea of what the children will scale«. If you give an adult an injec- paedists rarely have to administer injections, children tion and then ask him whether it hurt, he will probably don’t categorize them as »bad doctors«. But pediatric say: »No, not at all«, and look at you in the expectation orthopaedists do occasionally have to cause children pain, of receiving a medal for bravery. But it wouldn’t occur for example when removing transcutaneously inserted to a child to react in this way at all, it simply yells out in Kirschner wires from bones or applying a plaster cast to pain. In most deal with the honesty of the child is that we have cases, they have previously received an injection that learned so efficiently how to lie. But children are unable to do this (yet); they pense with the identifying feature of the »medicine have a very finely-tuned sense that tells them man«, i. In my experience, however, whether someone is telling them the truth or not, children are still able to identify the doctor in the even though they may not usually be able to express sweater disguise as a person that can cause potential directly their feelings about the truthfulness of what hurt. Especially anxious children hide their face in from children in the long term without negative the mother’s lap and, when asked to walk while hold- consequences. The surest meth- jump at your command, stand straight like soldiers, od of making any further examination impossible bend down when asked and not show any opposition is to look at your watch and think about your busy to even the most adventurous contortions of the legs. Even though you may not say it out loud, In fact, most children act in this way and no great skill the child can sense the sentence forming in your head: is required to examine them, but even well-behaved »Must you behave so stupidly just at this particular children will also appreciate a joke, a smile or a little time! You must there- Adolescents 1 fore keep calm and try to distract the child with a toy » Young people yearn for the future. Perhaps you could (Jean-Paul Sartre) even play a suitable game with the child. Or you could let the mother examine the child (this only works if Adolescents deserve to be taken just as seriously as adults. Although adolescents themselves hardly ever want to at- What you should never do during the examination is tend a consultation and tend to be pressured into it by to lay the child down. In this position the child will their parents, they should nevertheless be allowed to feel helpless and even more anxious. If the par- prove successful, however, even with a crying child, ents reply to a question posed to the young patient, the is to examine it while sitting on the mother’s lap.