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CommonskininfectionsinchildrenARTICLEinBMJ(ONLINE)AUGUST2004ImpactFactor:16.38DOI:10.1136/bmj.329.7457.95Source:PubMed

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Clinical review

Common skin infections in childrenMichael J Sladden, Graham A Johnston

Most children will have a skin infection at some time.Skin infections are a common reason for consultationin primary care and in dermatology practice.13 Wereview four common skin infections in children anddescribe their epidemiology, clinical features, andtreatment, focusing on treatments with best evidence.

Sources and selection criteriaWe searched Medline and the Cochrane Library usingthe terms molluscum, warts, impetigo, and tinea.We included randomised trials, meta-analyses, andclinical guidelines.

Molluscum contagiosumMolluscum contagiosum is a common, benign, selflimiting viral infection of the skin. It generally affectschildren and is caused by a human specific poxvirus.Infection is rare in children under 1 year of age andtypically occurs in the 2-5 year age group.4 Althoughthe prevalence of molluscum contagiosum is notknown, one of six Dutch children have visited theirdoctor for the condition.5

Infection follows autoinoculation or contact withaffected people.6 The incubation period is from twoweeks to six months. The condition is more commonin young children and in children who swim, whobathe together, and who are immunosuppressed. Littleevidence supports the view that lesions (mollusca) aremore common in children with atopic dermatitis.

Mollusca present as multiple dome shaped pearly orflesh coloured papules with a central depression(umbilication), which usually appear on the trunk andflexural areas (fig 1). They vary in size from 1 mm to 10mm, with growth occurring over several weeks.4 Inpatients who are immunocompetent, lesions may persistfor six to eight weeks. The mean duration is at least eightmonths when new lesions appear due to continuousautoinoculation.6 Resolution is often preceded byinflammation. Uncomplicated lesions heal without scar-ring.

Whether doctors should treat molluscum contagi-osum is controversial. As the condition is benign andtypically resolves spontaneously, treatment is usuallynot necessary. Advocates of treatment state thatintervention speeds resolution, reduces self inoculationand symptoms, limits spread, and prevents scarring.Often there is pressure from parents to treat their oth-erwise healthy children because of the stigma of visiblelesions.7

TreatmentMany treatments for molluscum contagiosum havebeen reported, including physical destruction ormanual extrusion of the lesions, cryotherapy, andcurettage. Treatments are painful, and there is limitedevidence that they are more effective than watchfulwaiting. One study found no difference in resolution oflesions after extrusion of the umbilicated corecompared with destruction of the lesion using phenol,although treatment with phenol produced notablymore scarring.6 Acidified nitrite cream has beenreported as effective and painless.8 Topical imiquimodcream may be useful in widespread or recalcitrant mol-lusca, but it has not been tested in controlled trials.9

A Cochrane review is under way to evaluatetreatments for molluscum contagiosum. Until there isclear evidence of safety and efficacy of active interven-tion, we recommend watchful waiting and reassuranceof patients and parents.

Viral wartsCutaneous viral warts are discrete benign epithelialproliferations caused by the human papillomavirus.Several types occur (box 1).

Viral warts are common.10 Prevalence increasesduring childhood, peaks in adolescence, and declines

Summary points

Molluscum contagiosum is a common, selflimiting condition

Topical salicylic acid should be regarded as firstline treatment for cutaneous viral warts

Mild impetigo is effectively treated with topicalmupirocin or fusidic acid for seven days

Oral antibiotics should be reserved for recalcitrant,extensive impetigo with systemic symptoms

Tinea capitis should be considered in every childwith a scaly scalp as the infection is common andthe presentation diverse

Tinea capitis should be confirmed by mycologicalanalysis before an eight week course ofgriseofulvin is started

Department ofDermatology,Leicester RoyalInfirmary,University Hospitalsof Leicester NHSTrust, LeicesterLE1 5WWMichael J Sladdenspecialist registrarGraham A Johnstonconsultant

Correspondence to:M J Sladdenm.sladden@doctors.org.uk

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thereafter.11 In healthy children, warts resolve sponta-neously; 93% of children with warts at age 11 showedresolution by age 16.12 Resolution can be preceded bythe appearance of blackened thrombosed capillaryloops. Warts may be widespread and persistent inpatients who are immunocompromised. The clinicalappearance of warts depends on their location. Thehands and feet are most commonly affected (fig 2).

TreatmentAlthough most warts resolve spontaneously within twoyears, some persist and become large and painful. Forthis reason many parents present their children for

medical treatment. Treatment in children should besimple, cheap, effective, safe, and relatively painless.

Salicylic acidTopical salicylic acid has been shown to be beneficial intreating viral warts. Data pooled from six randomisedtrials gave a cure rate of 75% in cases compared with48% in controls (odds ratio 3.91, 95% confidence inter-val 2.40 to 6.36).11 13 Preparations containing salicylicacid include creams, ointments, paints, gels, and colloids,with concentrations of the active ingredient varyingfrom 11% to 50%. Salicylic acid breaks down hyperkera-totic skin but does irritate childrens skin. Topical salicylicacid should be regarded as first line treatment.

CryotherapySystematic reviews show that cryotherapy is no betterthan topical salicylic acid.11 13 Cryotherapy is bestavoided in young children, as parents consider the sideeffects of pain, swelling, and blistering excessive for abenign self limiting condition. Aggressive cryotherapyscars childrens skin.

Other treatmentsAlthough silver nitrate pencils and glutaraldehyde andformaldehyde preparations are licensed in the UnitedKingdom for treating warts, there is currentlyinsufficient evidence of their benefit. Intralesionalbleomycin, topical immunotherapy, photodynamictherapy, and pulsed dye laser treatment are bestconfined to research centres or resistant cases.

ImpetigoCutaneous staphylococcal and streptococcal infectionsare important in children. They cause a wide spectrumof illness depending on the site of infection, the organ-ism, and the hosts immunity.14 Impetigo is a superficialskin infection characterised by golden crusts (fig 3). It iscaused by Staphylococcus aureus or Streptococcus pyogenes.

Impetigo is the third most common skin disease inchildren, after dermatitis and viral warts, with a peakincidence at 2-6 years of age.15 16 Lesions are highlycontagious and can spread rapidly by direct contact,through a family, nursery, or class.17 The condition ismore common in children with atopic dermatitis, inthose living in tropical climates, and in conditions ofovercrowding and poor hygiene. Nasal carriage oforganisms may predispose to recurrent infection in anindividual.

Impetigo can occur either as a primary infection orsecondary to another condition, such as atopic dermati-tis or scabies, which disrupts the skin barrier. It can beclassified clinically as impetigo contagiosa (non-bullousimpetigo) or bullous impetigo. Impetigo contagiosa iscaused by S aureus or S pyogenes. Bullous impetigo isinvariably caused by toxin-producing S aureus.

Impetigo contagiosaImpetigo contagiosa is the most common form ofimpetigo. Lesions begin as vesicles or pustules thatrapidly evolve into gold-crusted plaques, often 2 cm indiameter. They usually affect the face and extremitiesand heal without scarring. Constitutional symptomsare absent. Satellite lesions may occur due toautoinoculation.

Fig 1 Typical multiple dome shaped pearly or flesh coloured papulesof mollluscum contagiosum, with a central depression (umbilication)

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Box 1: Types of viral warts

Common wartsCommon warts begin as smooth flesh coloured papules that enlarge anddevelop a characteristic hyperkeratotic surface of grossly thickened keratin.They can occur at sites of injury (Koebner phenomenon)

Plantar warts (verrucae)Plantar warts occur on the soles of the feet and can be painful. Theyprotrude only slightly from the surface of the skin and often have asurrounding collar of keratin

Mosaic wartsMosaic warts occur as collections of small, discrete and densely packedindividual warts. They are often resistant to treatment

Plane wartsPlane warts are flat topped papules, typically scattered over the face, arms,and legs

Fig 2 Cutaneous viral wart showing characteristic hyperkeratoticwarty surface with capillary loops (black dots)

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Bullous impetigoBullous impetigo is characterised by flaccid, fluid filledvesicles and blisters (bullae). These are painful, spreadrapidly, and produce systemic symptoms. Lesions areoften multiple, particularly around the oronasalorifices, and grouped in body folds. To confirm thediagnosis and to target treatment, Grams stain, culture,and sensitivity testing should be carried out on theexudate from lesions.

TreatmentTreatments for impetigo include topical and systemicantibiotics and topical antiseptics.18 Good evidenceshows that topical mupirocin and fusidic acid are safeand effective treatments for mild impetigo.18 In mildcases they are probably as effective as oral antibiotics.18

To minimise the development of resistant organisms,use topical antibiotics that are available in cream formonly, which are not available as systemic preparations.

Oral antibioticsOral antibiotics may be better than topical prepara-tions for more serious or extensive disease; they areeasier to use but have more side effects than topicalagents. Flucloxacillin is considered the treatment ofchoice for impetigo.19 Macrolides, cephalosporins, andcoamoxiclav are also reported to be effective, butevidence is limited because the studies have not beenperformed.18 Selection of systemic antibiotic isdetermined by factors such as local epidemiology ofresistance, patients allergy or intolerance, and provedbacterial sensitivity after microbiological assessment.

If oral antibiotics are needed, we recommend asfirst line treatment a seven day course of flucloxacillin.In cases of allergy to penicillin, erythromycin (or simi-lar macrolide) is suitable, but in some patients thiscauses gastrointestinal disturbance, and resistance toerythromycin is increasing. For impetigo caused byerythromycin resistant organisms, cephalosporinssuch as cephalexin are effective, although 10% ofpatients who are sensitive to penicillin are also sensitiveto cephalosporins. Coamoxiclav (amoxicillin andclavulanic acid) is effective in infections caused by lactamase producing strains of S aureus. Bacteriologicalculture is important before changing to this drug.

Topical antisepticsAlthough no clear evidence supports the role oftopical antiseptics in impetigo, they do help to softencrusts and clear exudate in mild disease. In more severecases they may be a useful adjunct to antibiotics.

We suggest using topical mupirocin or fusidic acidfor seven days in clinically mild impetigo. Oralantibiotics should be reserved for recalcitrant, exten-sive, systemic disease.

Tinea capitis (scalp ringworm)Tinea capitis (scalp ringworm) is a highly contagiousinfection of the scalp and hair caused by dermatophytefungi. It occurs in all age groups, but predominatelychildren. It is endemic in some of the poorestcountries.20 The commonest cause of tinea capitisworldwide is Microsporum canis.21

The epidemiology of tinea capitis in the UnitedKingdom has recently changed dramatically,22 reflectinga similar trend in the United States 20 years ago.23 In theUnited Kingdom it is becoming a major public healthproblem, and Afro-Caribbean children are particularlyaffected.24 The predominant organism was M canis, butnow Trichophyton tonsurans causes 90% of cases in theUnited Kingdom and the United States.22 T tonsurans isan anthropophilic fungus, which spreads from person toperson. The reason for this change is unclear, buthairdressing practices such as shaving the scalp, plaiting,and using hair oils may increase spread.22

Tinea capitis causes patchy alopecia, but specificclinical patterns can be varied. Six main patterns arerecognised (box 2).25

Fig 3 Impetigo, showing classic golden coloured crustD

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Fig 4 Grey type tinea capitis, with inflammation, erythema, scaling, pustules, and crusting

Box 2: Main patterns of tinea capitis, listed according tooccurrence (commonest first) Grey typecircular patches of alopecia with marked scaling (fig 4) Moth eatenpatchy alopecia with generalised scale Kerionboggy tumour studded with pustules; lymphadenopathy usuallypresent (fig 5) Black dotpatches of alopecia with broken hairs stubs Diffuse scalewidespread scaling giving dandruff-like appearance Pustular typealopecia with scattered pustules; lymphadenopathy usuallypresent

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The differential diagnosis for tinea capitis includesseborrhoeic dermatitis, atopic dermatitis, psoriasis, alo-pecia areata, and alopecia folliculitis. Tinea capitisshould be considered in every child with a scaly scalpbecause the infection is common and the presentationdiverse. Only 7% of children receive appropriate treat-ment for tinea capitis before referral to dermatologypractice.25

TreatmentIf tinea capitis is suspected, specimens of hair and scaleshould be examined to confirm the diagnosis. The aimof treatment is to provide a quick clinical andmycological cure, with minimal adverse effects andspread of disease. This requires oral antifungal agents,although topical treatment may reduce the risk oftransmission at the start of systemic therapy.

Griseofulvin is the only treatment for tinea capitislicensed in the United Kingdom. It has been the treat-ment of choice for 40 years, with good evidence of effi-

cacy in infections caused by T tonsurans and M canis.2628

The recommended dose in children is 10 mg/kg/day,although some authors advocate up to 25 mg/kg/day.Treatment is taken until clinical and mycological cureis documented, usually about eight weeks. Side effectsinclude nausea and rashes (about 10%); griseofulvin iscontraindicated in pregnancy.

Good evidence supports the use of terbinafine fortreating tinea capitis caused by T tonsurans2628; it maybe less effective for M canis. The dose ranges between 3and 6 mg/kg/day, given for four weeks. Side effectsinclude gastrointestinal upset and rashes (about 5%).Itraconazole, fluconazole, and ketoconazole arereported to be effective in tinea capitis, but there is lesssupportive evidence.

We thank Julie Sladden for reading and reviewing themanuscript.Contributors: MJS and GAJ contributed equally to the academiccontent of this review. Both will act as guarantors for the paper.Competing interests: MJS has been coinvestigator in trials spon-sored by Merck, Sharp, and Dohme; this included speakershonorariums and travel expenses. GAJ has received speakershonorariums and travel expenses from Galderma, UCBPharma, Shire, Leo, and Steifel. He has acted as a consultant toNovartis in a peer review of drug trial protocols. He has beencoinvestigator in a trial sponsored by 3M Pharmaceuticals.

1 Hayden GF. Skin diseases encountered in a pediatric clinic. A one-yearprospective study. Am J Dis Childhood 1985;139:36-8.

2 Tunnessen WW. A survey of skin disorders seen in pediatric general anddermatology clinics. Pediatr Dermatol 1984;1:219-22.

3 Findlay GH, Vismer HF, Sophianos T. The spectrum of pediatric derma-tology. Analysis 10,000 cases. Br J Dermatol 1974;91:379-87.

4 Rogers M, Barnetson RSC. Diseases of the skin. In: Campbell AGM,McIntosh N, eds. Forfar and Arneils textbook of pediatrics. 5th ed. New York:Churchill Livingstone, 1998:1633-5.

5 Koning S, Bruijnzeels MA, van Suijlekom-Smit LWA, van der Wouden JC.Molluscum contagiosum in Dutch general practice. Br J Gen Pract1994;44:417-9.

6 Weller R, OCallaghan CJ, MacSween RM, White MI. Scarring in mollus-cum contagiosum: comparison of physical expression and phenolablation. BMJ 1999;319:1540.

7 Van der Wouden JC, Gajadin S, Berger MY, Butler CC, Koning S, MenkeJ, et al. Interventions for molluscum contagiosum in children. CochraneLibrary: 2004, Issue 2. Chichester: Wiley.

8 Ormerod AD, White MI, Shah SA, Benjamin N. Molluscum contagiosumeffectively treated with a topical acidified nitrite, nitric oxide liberatingcream. Br J Dermatol 1999;141;1051-3.

9 Bayerl C, Feller G, Goerdt S. Experience in treating molluscum contagio-sum in children with imiquimod 5% cream. Br J Dermatol2003;149(suppl):25-9.

10 Sterling JC, Kurtz JB. Viral infections. In: Champion RH, Burton JL,Burns DA, Breathnach SM, eds. Rook textbook of dermatology. 6th ed.Oxford: Blackwell, 1998.

11 Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneouswarts. Cochrane Database Syst Rev 2003;(3):CD001781.

Additional educational resources

Review articlesGibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts:systematic review. BMJ 2002,325:461Fuller LC, Child FJ, Midgley G, Higgins EM. Diagnosis and management ofscalp ringworm. BMJ 2003;326:539-41George A, Rubin G. A systematic review and meta-analysis of treatments forimpetigo. Br J Gen Pract 2003;53:480-7

Clinical referencesHarper J, Oranje A, Prose N, eds. Textbook of pediatric dermatology. Oxford:Blackwell, 2000Prime chapters on cutaneous infections of childhood

Kane K, Ryder JB, Johnson RA, Baden HP, Stratigos A. Color atlas andsynopsis of pediatric dermatology. New York: McGraw-Hill, 2002Excellentpicture book aid to paediatric dermatology

Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, eds.Fitzpatricks dermatology in general medicine. 6th ed. New York: McGraw-Hill,2004Flagship textbook with excellent chapters on cutaneous infections

Williams H, Bigby M, Diepgen T, Herxheimer A, Naldi L, Rzany B.Evidence-based dermatology. London: BMJ Publishing Group, 2003Reviewof evidence based treatment of skin disease

Useful websitesBritish Association of Dermatologists (www.bad.org.uk/doctors/guidelines/)Information and guidelines on management of common skin disease

NHS National Electronic Library for Health (www.nelh.nhs.uk/cochrane.asp)Details of evidence based medicine and research methods,with up to date information on evidence based treatment of skin disease(http://rms.nelh.nhs.uk/guidelinesfinder/) gives details of over 800 UKnational guidelines and is updated weekly

Centers for Disease Control (www.cdc.gov/ncidod/hip/Aresist/mrsa.htm)Up to date information from the United States, featuring fact sheets,frequently asked questions, and practical steps to control infection

Information for patientsBritish Association of Dermatologists (www.bad.org.uk/patients/)Containsinformation on the skin and how it works, as well as skin diseaseslp;&3qmerican Academy of Dermatology (www.aad.org/pamphlets/index.html)Contains patient information

Skin Care Campaign (www.skincarecampaign.org/)An umbrellaorganisation representing the interests of all people with skin diseases inthe United Kingdom

UKs Gateway to High Quality Internet Resources (omni.ac.uk/)Freeaccess to a searchable catalogue of internet sites covering health andmedicine

Dermatology.co.uk (www.dermatology.co.uk/index.asp)Educationalresource for skin conditions and their treatment

Fig 5 Kerion pattern of tinea capitis, showing large boggy noduleswith superficial pustules and crusting

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12 Williams HC, Pottier A, Strachan D. The descriptive epidemiology ofwarts in British schoolchildren. Br J Dermatol 1993;128:504-11.

13 Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneouswarts: systematic review. BMJ 2002;325:461.

14 Resnick S. Staphylococcal and streptococcal skin infections: pyodermasand toxin-mediated syndromes. In: Harper JO, A. Prose N, eds.Textbook ofpediatric dermatology. Oxford: Blackwell, 2000:369-77.

15 Dagan R. Impetigo in childhood: changing epidemiology and new treat-ments. Ped Annals 1993;22:235-40.

16 Bruijnzeels MA, van Suijlekom-Smit LWA, van der Velden J, van derWouden JC. The child in general practice. Dutch national survey of morbidityand interventions in general practice. Rotterdam: Erasmus UniversityRotterdam, 1993.

17 Hlady WG, Middaugh JP. An epidemic of bullous impetigo in a newbornnursery due to Staphylococcus aureus: epidemiology and control meas-ures. Alaska Med 1986;28:99-103.

18 Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris A, Butler CC,van der Wouden JC. Interventions for impetigo. Cochrane Database SystRev 2004;2:CD003261.

19 Feingold DS. Staphylococcal and streptococcal pyodermas. Semin Derma-tol 1993;12:331-5.

20 Gonzlez U, Seaton T, Bergus G, Torres JM, Jacobson J. Systemic antifun-gal therapy for tinea capitis in children. Cochrane Library, 2004: Issue 2.Chichester:Wiley.

21 Aly R. Ecology and epidemiology of dermatophyte infections. J Am AcadDermatol 1994;31:S21-5.

22 Higgins EM, Fuller LC, Smith CH. Guidelines for the management oftinea capitis. Br J Dermatol 2000;143:53-8.

23 Bronson DM, Desai DR, Barskey S. An epidemic of infection with Tricho-phyton tonsurans revealed in a twenty year survey of fungal pathogens inChicago. J Am Acad Dermatol 1983;8:322-30.

24 Fuller LC, Child FJ, Midgley G, Higgins EM. Diagnosis and managementof scalp ringworm. BMJ 2003;326:539-41.

25 Fuller LC, Child FC, Midgley G, Higgins EM. Scalp ringworm insouth-east London and an analysis of a cohort of patients from a paedi-atric dermatology department. Br J Dermatol 2003;148:985-8.

26 Caceres-Rios H, Rueda M, Ballona R, Bustamante B. Comparison of ter-binafine and griseofulvin in the treatment of tinea capitis. J Am Acad Der-matol 2000;42:80-4.

27 Fuller LC, Smith CH, Cerio R, Marsden RA, Midgley G, Beard AL, et al.A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of grise-ofulvin for the treatment of tinea capitis. Br J Dermatol 2001;144:321-7.

28 Gupta AK, Adam P, Dlova N, Lynde CW, Hofstader S, Morar N, et al.Therapeutic options for the treatment of tinea capitis caused by Tricho-phyton species: griseofulvin versus the new oral antifungal agents, terbin-afine, itraconazole, and fluconazole. Pediatr Dermatol 2001;18:433-8.

(Accepted 23 May 2004)

Lesson of the weekAvulsion fracture of the ischial tuberosity inadolescentsan easily missed diagnosisSam Gidwani, Jakub Jagiello, Martin Bircher

Avulsion fracture of the ischial tuberosity is a rareinjury in comparison with mid-substance tears of thehamstrings, and its diagnosis is often missed. Suchfracture usually occurs between puberty and lateadolescence in those who do a lot of sportit is inpuberty that the secondary ossification centre orapophysis appears and in late adolescence that it fuses.In other words, fracture occurs at a time when the apo-physis is the weakest link in the chain of muscle,tendon, and bone. The cause is usually forciblecontraction of the hamstrings, as in sports such assprinting and hurdling.

In adolescent patients with a history of proximalhamstring injury and current ischial tenderness, aradiograph of the pelvis should be performed. This isto exclude the presence of an avulsion fracture, whichmay be substantially displaced.

A prompt diagnosis of a displaced avulsion fractureof the ischial tuberosity will enable early surgery whereappropriate. This in turn will prevent the developmentof chronic pain on sitting and walking and an inabilityto return to sporting activities.

Case reportsCase 1A 14 year old boy was sprinting during a 200 m racewhen he suddenly developed a severe pain posteriorlyin the proximal part of his left thigh. He collapsed tothe ground in pain and could not complete the race.

His general practitioner advised him to rest toallow the presumed hamstring injury to settle. Despiteprolonged physiotherapy, he still had pain when hejogged. Two years after the injury, he was referred to arheumatologist in case the pain was caused by sciatica.Radiography of the pelvis showed a non-union of theleft ischial tuberosity, with marked displacement of the

apophyseal fragment (fig 1). A specialist orthopaedicopinion was urgently sought; clinical examinationshowed substantial wasting of the hamstrings accom-panied by weakness and pain on resisted knee flexion.

Three years after the injury an operation was doneusing the posterior Kocher-Langenbeck approach.The non-union was mobilised, reduced, and internallyfixed using a reconstruction plate and screws. Twomonths later, he was comfortable apart from somepain on sitting. At five months postoperatively he waswalking normally and was able to jog, and at one yearhe had returned to full sporting activities, includingsprinting. Pelvic radiography showed bony union(fig 2).

Case 2During a football game, a 15 year old boy stretched tokick the ball with his left foot. He instantly felt a severepain in his left buttock and had to be carried off thepitch. He was told he had pulled a muscle, and

Fig 1 Case 1: Anteroposterior pelvic radiograph, two years afterinjury, showing mobile non-union of left ischial tuberosity

Clinical review

Perform pelvicradiography inadolescents withhistory ofproximalhamstring injuryand currentischialtenderness

Department ofOrthopaedics andTrauma, St GeorgesHospital, LondonSW17 0QTSam Gidwanispecialist registrarJakub Jagiellosenior house officerMartin Bircherconsultant

Correspondence to:S Gidwani, 122Durham Road,London SW20 0DGsamgidwani@yahoo.com

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