Case 17: 4yo - Orthopaedic Flashcards
how to differentiate accidental v. non-accidental bruising
ACCIDENTAL = bruises over bony prominences (shins, forearms) –> esp in toddlers, young active children
NON-ACCIDENTAL = bruises over well-cushioned areas (buttocks, back, genitalia)
can you determine the age of a bruise by color
NO
not reliably
LYME dz
- cause:
- presentation:
- dx:
- complication:
- cause: Borrelia burgdorferi (bacteria) on the deer tick
- presentation: erythema migrans + fever, malaise, fatigue, HA
- dx: clinically; (blood test only to rule out if negative)
- complication: ARTHRITIS (4w after skin lesion) = esp large joints closest to rash; one-off or recurring
Developmental dysplasia of the hip
- RFs:
- presentation:
- dx:
- complication:
==> femoral head not properly aligned with acetabulum
- RFs: female, breech delivery, FFx of DDH, first born
- presentation: dysplastic, dislocatable, subluxated, dislocated
- dx: SCREENING= Ortolani, Barlow
- complication:
define ortolani
assesses for a dislocated hip by abduction of the flexed hip with gentle anterior force.
define Barlow
assesses for a dislocatable hip by adduction of the flexed hip with gentle posterior force
what does septic arthritis mimic, and how do you differentiate
septic arthritis v. transient synovitis of the hip
***1) fever >38.5
2) non-weight-bearing
3) ESR >40
4) WBC >12000
**5)elevated CRP > 20
(more factors = more predictive of septic arthritis)
septic arthritis v. transient synovitis of the hip
- cause:
- presentation:
- dx:
- tx:
== unlikely signs of severe local inflammation (erythema, warmth, swelling) b/c deeper
SEPTIC ARTHRITIS OF THE HIP
- cause: Staph aureus, Strep (neonate: group B; infant and children: Group A, pneumoniae); H. flu (unimmunized); Neisseria gonorrhea (adolescents); Kingella (kids <4yo)
- presentation:
- dx: US of hip + US-guided needle aspiration (arthrocentesis) of synovial fluid ==> turbid, increased WBC (mostly PMNs), low glucose, Gram stain + fluid culture
- tx: empiric + prolonged IV Abx (narrowed as needed), surgical I and D
TRANSIENT SYNOVITIS OF THE HIP
- cause: recent URI
- presentation: inflammation and swelling of the tissues around the hip joint; decreased ROM
- dx: no or low-grade fever; diagnosis of exclusion
- tx: rest, ibuprofen
- prognosis: pain resolves in 3-10d, with small chance of recurrence
does transient synovitis of the hip predispose kids to arthritis in the future
NO
no serious /long-lasting consequences
history taking in a child with a limp
“any bruising” ==> sickle cell disease
“prior episodes” ==> acute on chronic / recurring condition; repeated injuries ==> non-accidental traumma
“recent illness” ==> post-infectious etiology (URI)
“other sxs” ==> constitutional sxs (fever, malaise)
important parts of a MSK exam
OBSERVATION
1) naturally moving, gait
2) examine unaffected limb first
3) examine joints directly above and below affected site
4) tenderness, warmth, effusion
diffdx of acute refusal to walk
- LEUKEMIA = d/t infiltration of bone marrow by leukemic cells –> + limp, localized discomfort of jaw, long bones, vertebrae, hip, scapula, ribs + fever, weight loss
- OSTEOMYELITIS = Staph aureus, H. flu (if unimmunized) –> + pain, indolent course + fever
- REACTIVE ARTHRITIS = d/t GI/GU infection –> afebrile (+/- urethritis/conjunctivitis in adults)
- SEPTIC ARTHRITIS = + high fever
- TRANSIENT SYNOVITIS = acute onset of hip pain with NO other constitutional sxs, d/t post-URI + low-grde fever
- TRAUMA = sprain, occult fracture, non-accidental
where may osteomyelitis in the ilium present with pain?
hip
evaluation and management of painful hip
EVALUATION
1) WBC, CRP, ESR
==> infections (transient/septic arthritis); malignancies (leukemia); inflammatory conditions (JIA)
2) synovial fluid/blood culture ==> septic arthritis
3) XR of hip ==> trauma
MANAGEMENT
1) topical anaesthetic cream (lidocaine) @ site of injections / needle procedures
what is the ibuprofen dosing for infants andkids?
Pediatric dose: 10 mg/kg every 6-8 hrs PO (maximum dose = 40mg/kg/24 hr PO)
Concentration of oral suspension: 100 mg/5 mL (20 mg/1 mL)