Children Orthopaedics - limping child

Question 1

Define limp

Answer 1

Abnormal gait commonly due to pain, weakness, deformity.

Common presentation with many causes.

Question 2

What are common causes of limp in child?

Answer 2

Trauma, transient synovitis, osteomyelitis, septic arthritis, DDH, JIA, Perthes disease, SUFE, chondromalacia, Neoplasm

Question 3

What infection/inflammation conditions is it useful to differentiate from?

Answer 3

Septic arthritis
Osteomyelitis
Transient synovitis

Question 4

What initial investigations would you be looking to do (inflammation/infection)?

Answer 4

Temperature
X-ray
USS

Bloods – WCC, CRP, ESR, CK, cultures

Question 5

What is the usual septic arthritis presentation?

Answer 5

Limping
Pseudoparalysis
Refusal to move joint

Swollen, red joint
Pain
Temperature

Knee (37%) > Hip (33%) > ankle (13%) > shoulder > elbow >sacroiliac

Question 6

What criteria is useful for differentiating between septic arthritis and transient synovitis?

Answer 6

Kocher criteria

Question 7

What is the Kocher’s criteria?

Answer 7

CRITERIA=
Pyrexia > 38oC
WB: No
WBC count > 12,000 cells/mm3
ESR > 40mm/hr

CHANCE OF SEPTIC ARTHRITIS:
0 Positive <0.2%; 1 positive = 3%; 2 positive = 40%; 3 positive = 93.1 %; 4 positive = 99.6%

Question 8

How is septic arthritis treated?

Answer 8

Typically, S. aureus infection 
Aspiration 
Arthroscopy 
Arthrotomy 
Abx: IV empirically for 2 weeks; typically, 6-weeks total.

Question 9

When would the diagnosis be transient synovitis?

Answer 9

Diagnosis of exclusion.

Limping, often touch WB
Slightly unwell, NOT THAT UNWELL
History of viral infection (e.g. URTI/ear) 
Apyrexial 
Low CRP, normal WCC
May have joint effusion

Question 10

What organism is most common in causing osteomyelitis?

Answer 10

S. aureus.

Question 11

What symptoms are usually seen in osteomyelitis?

Answer 11

Pain
Localised sign/symptoms
Fever
Reduced ROM
Reduce WB

Question 12

What investigations are used for osteomyelitis?

Answer 12

Inflammatory markers: WCC, ESR, CRP
Blood culture
Plain radiograph
Then: MRI, bone scan, CT, bone biopsy

Question 13

What features would raise concern of neoplasm?

Answer 13

Night pain 
Often incidental trauma 
Stops doing sport/going out
Sweats and fatigue 
Abnormal blood results – low Hb, atypical blood film, atypical platelets
Get paediatrician/oncology opinion.