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Early use of MRI for suspected pyomyositis

Your short case on abdominal examination was timely and important. However, the presentation omits two clinical signs that can be useful, and even diagnostic, in children. Carnett’s sign was first described in 1926. It is based on the palpation of the abdomen. With the abdomen exposed, the examiner asks the supine patient (child or adult) to relax the abdomen and palpates the abdomen in the normal manner, noting any areas of tenderness or guarding. The examiner then asks the patient to tense his/her abdominal muscles by raising the head and legs from the couch and palpates the abdomen again. If the pain is coming from an intra-abdominal lesion, palpation with tensed muscles will be pain-free. If the pain arises from the muscles or superficial tissues in the abdominal wall, then the tenderness felt with the muscles tensed is the same as, or greater than, the pain with the relaxed muscles. Carnett’s sign is positive. This sign is highly reliable in adults. I have found that it is a common finding in children with recurrent abdominal pain who do not respond to treatment and where investigations are negative. It is also easy to demonstrate this finding to worried parents and explain that the pain is not due to an undiagnosed intra-abdominal condition, but selfreinforcing cycle of anxiety leading to muscle tension with local tenderness and pain. The second useful technique is auscultatory percussion. This is based on the fact that the sound generated by manual percussion travels well through solid tissue. Some uncooperative children will not relax to allow palpation of the lower edge of the liver. This information can be gained by placing the stethoscope over the known position of the liver, then, starting in the right iliac fossa, tap or stroke the abdominal wall, moving upwards. When the tapping or stroking reaches the lower edge of the liver, there is a sudden change in the quality of sound heard through the stethoscope. It may not be as accurate as standard palpation, but it can give information when palpation is impossible. Carnett’s sign can give evidence of intra-/extra-abdominal pathology not available by other clinical methods or by investigations. Auscultatory percussion is useful when conventional methods cannot be used. Both signs are useful in adults. I recommend them to paediatricians for consideration and formal assessment of their value in children.