Approach To Rhe Child With A Red Limb Flashcards
What is the general cause of a red, hot, tender limb in a child?
• A septic condition where any tissue in the limb may be infected
• Other conditions:
• Vascular malformations (chronic cases)
• Deep vein thrombosis
• Trauma
What should be included in the clinical approach to a child with a red limb?
• Full history, including events leading to presentation, constitutional symptoms (fever), and history related to symptoms
• General and systemic examination
• Specific examination of the affected limb:
• Signs of severe sepsis (e.g., tachycardia)
• Check for tenderness, fluctuance, mass, range of movement
What are the signs of severe sepsis in a child with a red limb?
• Subtle signs, often just marked tachycardia
• Must rule out:
• Staphylococcal sepsis (can be rapidly fatal)
• Necrotizing fasciitis (similar outcome)
What investigations should be considered for a red, hot, tender limb?
• Ultrasound: Assess abscess, joint fluid, or sub-periosteal collection
• X-ray: May show osteitis (note that bone x-rays may be normal in early osteomyelitis)
• Nuclear medicine scintigraphy scan: To exclude osteitis if clinical suspicion persists
What are the danger signs in a child with a red, hot, tender limb?
• Red overlying skin with skin oedema and tenderness
• Rapidly spreading cellulitis
• Impaired range of movement of the joint (septic arthritis or osteomyelitis)
• Pyrexia (fever >39°C), consider underlying septic arthritis, osteomyelitis, or deep soft tissue abscess
• Systemic signs of sepsis (e.g., tachycardia in neonates)
• Tenderness of underlying bone or joint
• Poor response to antibiotics in presumed “cellulitis,” consider underlying bone or joint infection
What should be considered if a neonate presents with a swollen red limb?
• Septic arthritis or osteomyelitis should be considered until proven otherwise
• Life-threatening conditions, requiring urgent referral
• Start high-dose anti-staphylococcal antibiotics
• Perform baseline septic markers and blood culture before starting antibiotics
What is the differential diagnosis for cellulitis in a red, hot, tender limb?
• Staphylococcus or streptococcus
• Erysipelas (raised edges) suggests streptococcal infection
What antibiotics are used for cellulitis with poor response?
• High-dose penicillin/gentamycin added to cephalosporin/cloxacillin
What are types of suppurative soft tissue infections?
• Subcutaneous/deep-seated abscess
• Pyomyositis
• Necrotizing fasciitis
How can necrotizing fasciitis be identified?
• Overlying skin oedema, tachycardia, pyrexia
• “Dish-water pus” and easy passage of a wound swab
• Rapidly spreading oedema in an ill child
What is required for diagnosing necrotizing fasciitis?
• Urgent surgical exploration and tissue biopsy
• Fascial debridement to healthy tissue
What bone and joint conditions should be considered?
• Septic arthritis
• Osteomyelitis (including long-bone fractures and non-accidental injury)
What causes oedema with pain but no redness?
• Deep vein thrombosis
What are other causes of focal tenderness?
• Ruptured Baker’s cyst or bursitis
What should be considered in longstanding oedema without redness?
Vascular malformation
What are other possible causes of oedema without redness?
• Deep vein thrombosis (DVT)
• Ruptured Baker’s cyst or bursitis (focal tenderness)
• Vascular malformation:
• Longstanding history
What are the possible bone and joint conditions causing a red, hot, tender limb?
• Septic arthritis
• Osteomyelitis:
• Consider long-bone fractures and late presentations
• Always consider non-accidental injury
