Failure to thrive/Child with painful limb Flashcards
TQ
Psych illness of perpetrator and insidious form of child abuse that is assoc with:
-Pediatric condition falsification (kid’s dx)
-Factitious Disorder by proxy (perpetrator’s dx) **difficult to dx bc parents seem to have the best hx for kids – they like to be center of attention
Munchausen Syndrome by Proxy
TQ
What are the two traditional types of FTT?
Organic FTT: underlying medical condition
Non-organic FTT (psychosocial FTT): no underlying medical dx, environmental issue
What are the possible sequelae of FTT?
Intellectual or behavioral deficits
How do you evaluate a child with FTT?
History! (and physical…limbs, Turner, Downs)
- knowledge gap, financial, formula, excessive juice?
- neglect?
- Oromotor dys
- Developmental delay
- Feeding aversion
- Recurrent emesis (GERD, malrotation, incr ICP)
- Malabsorption (stool?)
- FamHx of resp/GI (CF, celiac)
- Incr metabolic demand (CHF, chronic renal dz)
What are three types of undernutrition?
- Inadequate intake
- Malabsorption
- Increased metab demand
Management of child with FTT
- Only hospitalized if refeeding syn risk
- Nutritional repletion is main tx
- space meals to drive hunger!
Physical sign that a child is receiving inadequate nutrition for optimal growth and development
Failure to thrive
TQ
- Wt drops down more than 2 percentile lines
- Wt below 3-5th percentile on wt-length curve
Failure to thrive
Symmetric fall in wt and height suggests:
Chronic medical condition
Short stature with sparing of weight suggests:
endocrine disorder
T/F: In terms of the child with a painful limb, the temperature of the pt is truly important.
TRUE
Case 1:
Sheepish-looking, somewhat apprehensive father brings child to you because Timmy won’t use his left arm. Onset was about two hours prior to office visit…Dad and Timmy were playing at the beach. Dad was swinging Timmy (like he has done many times) when Timmy let go with his right hand…
Nursemaid elbow
- child holds arm to side, will not use
- may be swelling depending on time of injury
- rarely over 5 years of age, unless recurrent
- Xrays are normal
How would you reduce a Nursemaid elbow?
- Apply pressure at the radial head.
- Grasp wrist and apply slight traction.
- Supinate wrist (palm up) while flexing elbow to 90º.
Case 1:
Sheepish-looking, somewhat apprehensive father brings child to you because Timmy won’t use his left arm. Onset was about two hours prior to office visit…Dad and Timmy were playing at the beach. Dad was swinging Timmy (like he has done many times) when Timmy let go with his right hand…
Nursemaid elbow
- child holds arm to side, will not use
- may be swelling depending on time of injury
- rarely over 5 years of age, unless recurrent
- Xrays are normal
If becomes recurrent (3x in less than one year), immobilization/splinting.
How would you reduce a Nursemaid elbow?
- Apply pressure at the radial head.
- Grasp wrist and apply slight traction.
- Supinate wrist (palm up) while flexing elbow to 90º.
Case 2:
10yo overweight boy presents to the ER. He has a 10-day hx of L knee pain and thigh pain. He plays football but has had no recent injury. No hx of fever or illness and is in otherwise good health.
On exam: afebrile, nontoxic, obese, has a painful limp
Has pain with internal rotation of the hip and decreased ROM.
Slipped Capital Femoral Epiphysis (SCFE)
- Noninflammatory
- Femoral head is displaced form femoral neck
- Overweight boys 10-14 yo
- Can be assoc with hypothyroidism or pituitary deficiencies
- Diagnosed radiographically
- B/L in 30%, so xray both hips
- Tx mostly surgical
Case 3:
- 6yo male comes to the office with mother for intermittent leg pain
- After T-ball practice he often limps for a period of time
- Is ‘fine’ the next morning. He says that his leg hurts and points to his thigh and maybe the knee.
- Not having problems or discomfort at the time of the exam…
- ROS and recent Hx not helpful
- Xrays of hip and knee normal
- Mother and child return a couple of weeks later.. this time child is carried to exam room
- Child played ball last night, slid into home plate… leg pain (now located in the “upper” leg) is more severe and this morning child would not get out of bed
Dx?
Legg-Calve-Perthes Disease
(“Avascular necrosis of femoral head”)
- Temporary interruption of blood supply to proximal femoral epiphysis
- Impaired epiphyseal growth
- Femoral head deformity
- B/L in 10-20% (not simultaneous)
- Male»_space; females
- Mean age 6-7 yo
- Painful gait, especially after strenuous activity
- Decreased internal rotation, abduction of involved hip
- Later, shortened leg length on affected side (muscular spasm + femoral head collapse)
- Classically the hyperactive, thin child who always runs/jumps (before onset of LCPD)
Case 4:
- 13 yo male reports to office with father. Just finished ‘practice’ and is here due to progressive limp according to the father.
- There was a play which caused him to fall on the affected leg; severe pain
- The patient is able to walk at present and has the knee wrapped
- Dad asking for MRI
- Pain over tibial tubercle in a growing child
- Often during growth spurt and with activity (running/jumping)
- Traction apophysis* of tibial tubercle growth plate and patellar tendon
- Local swelling is common (extreme local tenderness)
- Aggravated with activity
Dx?
Osgood-Schlatter’s Disease
Only tx: Rest and reassurance
Case 5:
- 15 mo presents with 4 day h/o fussiness and sudden refusal to move right leg
- Runny nose and cough 2 weeks ago and intermittent fever. No h/o trauma. Shots UTD.
- On exam: temp 100.4, nontoxic appearing*, holds right leg flexed and externally rotated with decreased ROM. Won’t bear weight on R leg.
Dx with Ddx?
Dx = Transient or toxic synovitis
- Benign, self-limiting disorder with no known cause
- Possibly most-infectious process
- Possibly trauma-related
- 30% of all non-traumatic limps
- Brief period of sterile inflammation resulting in joint effusion, taking 7-10 days to resolve
Ddx:
- Transient or toxic synovitis
- Septic arthritis
- Osteomyelitis
- Sudden onset of painful limp
- Afebrile or low grade fever
- Otherwise appears well
- Hip held in flexion with external rotation
- Mildly restricted ROM on exam
- C-reactive protein typically not elevated
- Doesn’t meet Kocher criteria
Toxic synovitis
TQ
Explain Kocher criteria.
- Non-weight bearing
- ESR > 40
- Fever > 38.5
- WBC > 12k
Zero criteria ›› 0.6% chance of septic hip 1 ›› 3% 2 ›› 40% 3 ›› 93% 4 ›› 99.6%
Case 6:
13 yo reports to the office with mother with complaint of leg pain. Onset was several weeks ago, but sx have worsened. Now, awakens child* and is no longer relieved with Ibuprofen (Motrin). He now limps most of the time and is very fatigued, he thinks due to his lack of sleep with the leg pain.
- CBC normal
- UA normal
- Chem normal, except for elevated ALP
- Sed rate and CRP normal
- Xray shows mass
Dx?
Osteosarcoma
Ddx:
- Osteosarcoma
- Ewing sarcoma
- Lymphoma
- Bone cyst
- During rapid growth spurts
- Progressive pain
- Palpable mass occasionally
- Nighttime awakenings**
- Joint effusion/tenderness/decreased ROM
- Pain not responding to conservative therapy
Osteosarcoma
Tx:
- Chemo
- Surgery
