Acute limping child

Question 1

define a limp

Answer 1

abnormal gait commonly due to pain, weakness or deformity.Defined as a shorter stance phase (weight-bearing) on the affected limb.

Question 2

common DDX and causes are…

Answer 2

toxic synovitis, osteomylitis, septic arthritis, infective myositis, trauma

Question 3

main site of origin in children

Answer 3

hip

Question 4

trimordial age specific causes of limps

Answer 4

0-5 = trauma, toxic synovitis, osteomyelitis, septic arthritis, DDH, JIA.
5-10 = trauma, toxic synovitis, ostemomyelitis, septic arthritis, Perthes disease.
10-15 = trauma, ostemomyelitis, septic arthritis, SUFE, chondromalacia, neoplasm.

Question 5

what do you ask in a hx for an acute limping child?

Answer 5

duration, progression, recent trauma, associated pain, accompanying weakness, time of day when it is worst, can the child bear weight/walk, interference with normal activities, systemic features,medical hx, drug hx, fhx.

Question 6

Antalgic gait…shortened stance gait…

Answer 6

reduced range of motion, tenderness, xray to test. From - trauma, overuse, toddlers fracture, infection, inflammation

Question 7

abductor lurch…

Answer 7

trendelenburg sign, pelvic radiograph to test, from- hip dysplasia, cerebral palsy

Question 8

equinus gait…toe to heel gait…

Answer 8

heel-cord contracture, neuro exam needed, from - cerebral palsy, clubfoot

Question 9

circumduction gait…

Answer 9

during swing phase, assess limb length, neuro exam needed, check range of motion, need a orthodiagram, painful foot and leg length inequality.

Question 10

On examination what do you look for?

Answer 10

sole of foot for for foreign bodies, deformity erythema, swelling, effuison, limitation of active ROM, asymmetry. Assess shoes for unusual wear on the soles, asymmetry, point of initial foot strike, and also assess the fit. In older children look for scoliosis, midline dimples, and hairy patches, which could indicate spinal pathology. Assess gait with the child barefoot. Assess thigh or calf circumference for asymmetry. Leg length assessment.
hip, ankels, knee

Question 11

what may be seen in the clinical fatures anf patient hx?

Answer 11

limp, pain, malaise, temperature, URTI, ear infections, trauma, pseudoparalysis, listen to the parent.

Question 12

Ix

Answer 12

xray, uss, bloods (wcc, crp, esr, ck, cultures)

Question 13

what is the presentation of septic arthritis?

Answer 13

Limping, Pseudoparalysis, Swollen, red joint, Refusal to move joint and cannot weight bear, Pain, Temperature, mainly effects the knee and hip. Bacteria can reach the joint via - hematogenous route, dissemination from osteomyelitis, adjacent soft tissue infection, penetrating tauma

Question 14

Ix for septic arthritis

Answer 14

fbc shows raised wcc and esr. Blood cultures, xray, US, synovial fluid shows raised wcc. Also gram stain and culture synovial fluid.

Question 15

Kocher criteria

Answer 15

pyrexia>38degrees, weight bearing, wbc>12000, esr >40. number of criteria posiitve: 4-99%, 3-93%, 2=40%
IDENTIFIES THE LIKELIHOOD OF SPETIC ARTHRITIS

Question 16

Tx

Answer 16

supportive, abx, surgical drainage and lavage.
After blood cultures and joint aspiration - iv antibiotics, (fluclox, vanc if methicillin resistant, iv fluids, arthoscopic washout (surgical drainage and lavage). arthroscopy, arthrotomy.

Question 17

what is the incidence of Osteomyelitis?

Answer 17

2-13/100000, mean age 6yo, rf = blunt trauma and recent infection

Question 18

what is it caused by?

Answer 18

staph.aureus infection

Question 19

presenting features

Answer 19

pain, localised symptoms, fever, reduced range of movement, reduced weight bearing

Question 20

what are key inflammatory markers?

Answer 20

WCC, ESR, CRP

Question 21

what are indications for surgery in osteomyelitis?

Answer 21

aspiration for culture, drainage of subperiosteal abcess, drainage of joint sepsis, debriedment of dead tissue, failure to improve, biopsy in equivocal cases

Question 22

when is it toxic/transient synovitis?

Answer 22

limping, unwell, hx of viral infection, apyrexial, low crp, normal wcc, may have joint infusion,

Question 23

Case 1…

Answer 23

8yo, kicked by friend, temp 39.8, night pain, pain on rotation of hip on examination, wcc10, crp107, esr88, hb122, apyrexial on admission. Normal pelvic audiograph, ddx - spetic arthritis, transient/toxic synovitis, osteomyelitis.
MRI - obturator internus abcess

Question 24

Case 2…

Answer 24

12 years old 2 week history of vague heel pain, Red swollen over posterior heel, Fit and well, toe weight bearing, Hb 127 CRP 34 WCC 6.4.
represented with ongoing heel pain - Mild pyrexia, Touch weight bearing, sore heel, ankle joint no effusion on examination, CRP 44, WCC 11.5, Hb 127, Blood cultures done.

Question 25

Case 3…

Answer 25

14 months old, Increasingly unwell at home pyexial, off milk, Mum noticed leg swelling, Admitted to medical ward with sepsis, USS left knee done reported as no effusion, Group A Strep grown in blood culture, MRI scan of leg done, verbal & written report of no collection, scan - effusion in knee, extensive muscle involvement

Question 26

Case 4…

Answer 26

12yo, 2 week sudden onset L buttock pain, GP dx ischial bursitis & gave injection with some improvement, Presented to RACH with pyrexia & unwell reduced hip movement but not terrible, Hb 104, WCC 12, CRP 83, ESR 95. Large collection in the Iliacus, CT guided drainage.

Question 27

what features raise concerns of neoplasm (cancer)

Answer 27

night pain, stops doing sports/going out, sweats and fatigue, abnormal bloods - low hb, atypical blood film and platelets, get an paediatrician/oncology opinion.