Childhood limp: Flashcards
List some common causes of limp/limb pain in a child:
Infectious - osteomyelitis, septic arthritis
Inflammatory - STILLs (systemic JIA), SLE
Reactive/post infectious - GUT/GU
Haematological - HSP, sickle cell, haemophillia (haemarthrosis)
Endocrine - Rickets
Malignancy - Ewings, osteosarcoma
Give 3 causes of limp in following ages of children - 1-3yrs, 3-10yrs, 10-16yrs:
1-3years:
- Septic arthritis (painful)
- Transient synovitis (painful)
- Developmental dysplasia of hip (painless)
3-10years:
- Tranient synovitis (painful)
- JIA
- Perthes’ disease (acute=painful, chronic= painless)
10-16:
- Slipped upper/capital femoral epiphysis (SUFE/SCFE, acute = painful, chronic= painless)
- JIA
- Malignancy
What is the commonest cause of acute limp in a child?
Transient synovitis
What is transient synovitis thought to be precipitated by?
Viral infection
What is the aetiology of those with transient synovitis?
2-12years, usually males
What are the symptoms of transient synovitis?
- Unilateral sudden onset painful limp
- Pain may be referred to medial thigh/knee
- Pain not present at rest
- No fever
What are the signs of transient synovitis?
- Mildly decreased ROM
- No fever
- CRP, Xray, FBC, blood culture all normal
- US shows joint effusion
What is the treatment of Transient synovitis?
- NSAIDs
- Resolves within a few days
What are the symptoms of septic arthritis?
- Acute painful hip with pain at rest
- Fever
- Reduced ROM with reluctance to move hip
What investigations can be performed in someone with suspected septic arthritis and what would the results be?
How is the diagnosis confirmed?
Ix:
- Xray
- Aspirate - MC+S
- USS
- MRI
Diagnosis is confirmed by joint aspirate culture
Ix results:
- Neutrophil and CRP raised
- Joint aspirate culture (+ve)
What is the Rx for septic arthritis?
- Antibiotics
- Surgical drainage
What can develop if there is not prompt treatment of septic arthritis?
Joint destruction
What is Juvenile Idiopathic arthritis defined as?
Arthritis for more than 6 weeks before age of 16.
What serology is typically present in those with JIA?
Rheumatoid factor negative
ANA negative
In what form of JIA is ANA positive and what else is typically present with this?
Pauciarticular/oligoarthritis (ANA positive).
Eye involvement
(most common form of JIA)
In what form of JIA may there be RF positive?
Polyarticular disease in some older girls. similar to rheumatoid (RF positive)
List the classifications of JIA:
- Pauci-articular/oligoarthritis - 4 or fewer joints in the first 6 months (60%)
- Polyarticular - 5 or more joints (20%)
- Systemic: Stills disease (10%)
Who does systemic JIA usually affect?
<5y/o
List 3 symptoms of Systemic JIA:
- High swinging fever
- Salmon coloured macular rash
- Myalgia (may precede arthritis)
List 3 features which may also be present in those with systemic JIA:
- Lymphadenopthy and hepatoplenomegaly
- Pleurisy
- Pericarditis
What features is not present in those with systemic JIA?
Eye involvement
What is seen on investigation in those with JIA?
- Raised ESR and CRP
- Anaemia
What is the prognosis of systemic JIA?
Majority recover. 1/3 progress to severe arthritis.
Who does Pauci-articular/oligoarthritis JIA typically affect?
Age 2-6 y/o - girls.
What joints does pauci-articular/oligoarthritis typically affect?
Medium sized joints (not hip): knees, ankles, wrists.
Asymmetrical
What additional features are sometimes present in pauci-articular JIA?
1/3 develop anterior uveitis (iritis) - often ANA positive.
Think Anterior Uveitis (AU) and pAUci-articular JIA.
What joints does polyarticular JIA often affect?
Symmetrical involving any joint, typically hands, wrists knees. Neck and temporal-mandibular joints may be affected.
MCP joints spared.
What group of children goes polyarticular JIA typically affect?
Girls >8years or Rh factor (+ve).
How is JIA managed?
- Multidisciplinary - physio, OT, educational input
- Simple analgesia
- Steroid injections (often in Pauci-articular disease)
- DMARDs - methotrexate, biologicals (anti-TNFs)
What may children who have Pauci-articular JIA require?
Regular eye check ups.
What is Perthes’ disease?
Idiopathic ischaemia of femoral epiphysis. This leads to avascular necrosis.
What is the epiphysis?
The end part of a long bone
What is a growth plate known as?
Epiphyseal plate
Who does perthes disease typically affect?
Males, 5-10y/o.
How does Perthes disease present?
- Gradual onset on limp
- Initially painful
- Decreased ROM (reduced abduction and internal rotation)
What are the xray findings in someone with perthes disease?
Initially - increased density of femorla head
Later - irregular edge of femoral head
What is the prognosis of someone with Perthes like?
Good prognosis if <1/2 of epiphysis involved and <6years old.
What is the management for those with Perthes disease?
Conservative - re-vascularisation and re-ossification follows (over 1.5-3 years).
If severe, surgery maybe needed - cast, brace, traction.
What is a SUFE/SCFE?
Slipped upper/capital femoral epiphysis. It is displacement of the femoral head - usually posteriorly and medially.
What are the symptoms of a SUFE?
- Pain may be referred to knee
- Acute painful limp often after minor trauma
- Reduced ROM (abduction and internal rotation)
Who is SUFE usually seen in?
- Age 10-15yrs
- M>F
- Obesity
What investigation would you perform in to confirm a SCFE?
Frog-leg lateral X-ray.
Tretoans sign
What is the Rx for SCFE?
Screw fixation to stabilise the hip. Open reduction may be needed in severe cases.
