CLIPP case 17. 4yo refusing to walk

Question 1

4yo girl presents to clinic with refusal to walk. Recent URI. On exam, low-grade fever and decreased passive range of motion of R hip.

Answer 1

• Trauma
• Osteomyelitis
• Reactive arthritis
• Leukemia
• Transient synovitis
• Septic arthritis
• Juvenile idiopathic arthritis

Question 2

Transient synovitis

Answer 2

• Acute, self-limited inflammation of synovial lining of hip or knee, often occurring during or following an URI
• Common cause of hip pain in children
• Resolves in 3-10 days without sequelae. Treat with rest and ibuprofen

Question 3

Septic arthritis

Answer 3

• Infection of joint space, usually bacterial
• Causes severe inflammation, often erythema, warmth, or swelling.
• Patients typically appear quite ill
• Septic hip a medical emergency, as pus in the joint space can cause irreversible damage of the cartilage
• Synovial fluid aspirated from a septic hip is turbid, increased WBC (predominantly PMNs), and low glucose. Bacteria on gram stain.
• Greater increase in ESR and CRP than in transient synovitis

Question 4

Reactive arthritis

Answer 4

• Inflammatory process typically presenting 2-4 weeks following GI or GU infection
• Children are frequently afebrile at presentation. Classic association with urethritis and conjunctivitis uncommon in children.
• May be clinically indistinguishable from septic arthritis except that aspiration of an affected joint reveals inflammatory cells, but is sterile
• May last a few weeks and require anti-inflammatory treatment

Question 5

Osteomyelitis

Answer 5

-Infection of bone, usually bacterial in origin (S. aureus and before vaccines Hib)
-Usually indolent presentation, so diagnosis can be delayed
-In toddlers, usually presents as pain and refusal to bear weight (when affecting a leg bone)
-Fever, often high, is present in about half of
cases

Question 6

Leukemia

Answer 6

• BM infiltration can cause bone pain that presents as limp, refusal to walk or localized discomfort of the jaw, long bones, vertebral column, hip, scapula or ribs
• The pain of leukemic infiltration would NOT be affected by position or movement and would be more chronic in nature.
• These symptoms may precede systemic signs such as fever and weight loss

Question 7

Slipped capital femoral epiphysis

Answer 7

-The most common hip disorder in adolescents
-Posterior displacement of the capital femoral
epiphysis from the femoral neck through the cartilage growth plate, resulting in
limp and impaired internal rotation
-Patients present most commonly with months of vague hip or knee symptoms and limp
with or without an acute exacerbation
-Obesity and endocrine factors