Pediatric emergency medicine trisk 0774 0774
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associated neurologic signs such as leg weakness on the affected side, headache,
seizure, altered mental status, or speech difficulty.
There are several other neurologic conditions, which may lead to immobile
arm. Todd paralysis is a transient focal weakness that may occur after a seizure.
The paralysis may be partial or complete. It is typically unilateral and although
often a hemiparesis, it may be more prominent in one extremity. Complex
migraine can be associated with focal motor deficits, usually hemiplegia. The
evolution of symptoms is variable, but often includes scotomas, unilateral
dysesthesia of the hand and mouth and unilateral weakness (may involve only the
arm and face, sparing the leg). These nonheadache symptoms may precede the
headache by 30 to 60 minutes. Other features of migraine are often present and
typically involve a headache, as well as nausea and vomiting. The neurologic
symptoms typically last less than 24 hours. First episodes of hemiplegic migraine
should only be diagnosed after acute stroke has been excluded by brain imaging.
Other rare neurologic conditions one must consider when evaluating a child
with immobile arm include those causing acute flaccid paralysis (AFP), the
sudden onset of muscle weakness or paralysis and reduced muscle tone. AFP can
be due to infectious, inflammatory, and neuroimmune disorders. AFP has been
associated with infections of the spinal motor neurons due to polio, West Nile
virus, herpes zoster, as well as rabies, diphtheria, and botulism. Acute flaccid
myelitis (AFM) is a form of AFP which is thought to result from inflammation of
the gray matter in the spinal cord, leading to rapid onset of muscle weakness,
diminished reflexes, and decreased tone in one extremity, usually the arm. There
may be associated cranial nerve dysfunction or bulbar symptoms. Most cases of
AFM are associated with antecedent viral illnesses, suggesting a postviral
inflammatory etiology. Acute transverse myelitis (ATM) is a neuroimmune
demyelinating disorder affecting the spinal cord with a variable presentation that
usually affects both motor and sensory domains, most classically with a sensory
level and bowel and/or bladder dysfunction. Patients usually present with
weakness, sometimes associated with pain (see Chapter 97 Neurologic
Emergencies ).
Children with hemoglobinopathies (most commonly sickle cell disease) may
present with decreased arm use because of stroke or vaso-occlusive crisis, causing
ischemia or infarction of bone marrow with acute bone pain. Long bones are
commonly affected; however, young children frequently have involvement of the
small bones of the hands and feet (dactylitis). Precipitating events may not be
identified. The child experiences pain with localized tenderness and swelling of
the involved areas; there may be associated warmth and erythema. Acutely, there
