within the bicipital groove Pressure may produce exquisite tenderness in this area, so palpation should be gentle; if uncertainty about a finding of tenderness exists, a comparison with the examination of the uninjured side is helpful Finally, the proximal humeral shaft and the scapula are palpated During the neurologic evaluation, it is important to test sensation over the deltoid muscle (to assess axillary nerve damage after shoulder dislocation) and over the lateral proximal forearm (to assess musculocutaneous nerve damage) Next, examine the patient’s active and passive range of motion (see Fig 43.7 ) Internal and external rotation can be observed easily in a child by asking the patient to touch behind the neck (external rotation) and lower back to the inferior tip of the opposite scapula (internal rotation) FIGURE 43.7 Range of motion of the shoulder joint Once the pain has been localized, appropriate radiographs should be obtained When indicated, additional specific tests may be performed: The apprehension test for shoulder subluxation and laxity ( Fig 43.4 ), painful arc ( Fig 43.3 ) test for rotator cuff injury If the patient has nonspecific pain with numbness, paresthesias, weakness, or diffuse swelling, Roos test can be performed to distinguish between possible thoracic outlet syndrome and brachial plexus injury Patients with normal radiographs and negative maneuvers are most likely to have sprains or contusions, but occasionally, they may be experiencing referred pain Suggested Readings and Key References Dashe J, Roocroft JH, Bastrom TP, et al Spectrum of shoulder injuries in skeletally immature patients Orthop Clin North Am 2013;44:541–551 Flynn JM, Skaggs DL, Waters PM, eds Rockwood and Wilkins’ Fractures in Children 8th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2014 Hermans J, Luime JJ, Meuffels DE, et al Does this patient with shoulder pain have rotator cuff disease? The rational clinical examination systemic review JAMA 2013;310(8):837–847 Micheli LJ, Purcell L, eds The Adolescent Athlete: A Practical Approach New York: Springer; 2007 Sarwark JF, ed Essentials of Musculoskeletal Care 4th ed Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010 CHAPTER 44 ■ JAUNDICE: CONJUGATED HYPERBILIRUBINEMIA ERIN B HENKEL, SANJIV HARPAVAT INTRODUCTION The pediatric emergency provider is typically confronted with the finding of hyperbilirubinemia in one of two situations: (1) a jaundiced child, or (2) an incidental finding during a laboratory evaluation When conjugated hyperbilirubinemia is found, the challenge lies in determining if it is a sign of a life-threatening condition NORMAL BILIRUBIN PHYSIOLOGY Senescent red blood cells release heme which is eventually converted to unconjugated bilirubin Unconjugated bilirubin then binds to albumin and is transported to the liver In the liver sinusoids, unconjugated bilirubin detaches from albumin and gains entry into the hepatocyte, where it is conjugated with glucuronide by the action of uridine diphosphate glucuronyl transferase The soluble conjugated diglucuronide then is secreted out of the hepatocyte, across its canalicular membrane into the bile Conjugated bilirubin, along with bile salts, phospholipids, cholesterol, and metabolites are the major constituents of bile Bile flows through the intrahepatic biliary tree, into the extrahepatic bile ducts (including the common bile duct), and finally into the intestine at the ampulla of Vater In the intestine, bacterial flora converts bilirubin to urobilinogen Some urobilinogen is reabsorbed and taken up by the liver cells, only to be reexcreted into the bile A small percentage of urobilinogen escapes into the systemic circulation and is excreted in the urine The unabsorbed urobilinogen is excreted in the stool as fecal urobilinogen (see Chapter 45 Jaundice: Unconjugated Hyperbilirubinemia ) DEFINITION The definition of conjugated hyperbilirubinemia has evolved in recent years Most recently it has been redefined as a conjugated bilirubin level >1 mg/dL (or >17 mmol/dL) after weeks of life (2017 NASPGHAN Guidelines) From the perspective of an emergency physician, following this definition will decrease the risk of missing diagnoses Cholestatic jaundice is always considered pathologic and warrants further evaluation for hepatobiliary dysfunction ... ■ JAUNDICE: CONJUGATED HYPERBILIRUBINEMIA ERIN B HENKEL, SANJIV HARPAVAT INTRODUCTION The pediatric emergency provider is typically confronted with the finding of hyperbilirubinemia in one of... mg/dL (or >17 mmol/dL) after weeks of life (2017 NASPGHAN Guidelines) From the perspective of an emergency physician, following this definition will decrease the risk of missing diagnoses Cholestatic