Failure to thrive/Child with painful limb

Question 1

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

Answer 1

Munchausen Syndrome by Proxy

Question 2

TQ

What are the two traditional types of FTT?

Answer 2

Organic FTT: underlying medical condition

Non-organic FTT (psychosocial FTT): no underlying medical dx, environmental issue

Question 3

What are the possible sequelae of FTT?

Answer 3

Intellectual or behavioral deficits

Question 4

How do you evaluate a child with FTT?

Answer 4

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)

Question 5

What are three types of undernutrition?

Answer 5

• Inadequate intake
• Malabsorption
• Increased metab demand

Question 6

Management of child with FTT

Answer 6

• Only hospitalized if refeeding syn risk
• Nutritional repletion is main tx
• space meals to drive hunger!

Question 7

Physical sign that a child is receiving inadequate nutrition for optimal growth and development

Answer 7

Failure to thrive

Question 8

TQ

• Wt drops down more than 2 percentile lines
• Wt below 3-5th percentile on wt-length curve

Answer 8

Failure to thrive

Question 9

Symmetric fall in wt and height suggests:

Answer 9

Chronic medical condition

Question 10

Short stature with sparing of weight suggests:

Answer 10

endocrine disorder

Question 11

T/F: In terms of the child with a painful limb, the temperature of the pt is truly important.

Answer 11

TRUE

Question 12

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…

Answer 12

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

Question 13

How would you reduce a Nursemaid elbow?

Answer 13

1. Apply pressure at the radial head.
2. Grasp wrist and apply slight traction.
3. Supinate wrist (palm up) while flexing elbow to 90º.

Question 14

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…

Answer 14

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.

Question 15

How would you reduce a Nursemaid elbow?

Answer 15

1. Apply pressure at the radial head.
2. Grasp wrist and apply slight traction.
3. Supinate wrist (palm up) while flexing elbow to 90º.

Question 16

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.

Answer 16

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

Question 17

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?

Answer 17

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&raquo_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)

Question 18

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?

Answer 18

Osgood-Schlatter’s Disease

Only tx: Rest and reassurance

Question 19

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?

Answer 19

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

Question 20

• 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

Answer 20

Toxic synovitis

Question 21

TQ

Explain Kocher criteria.

Answer 21

• 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%

Question 22

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?

Answer 22

Osteosarcoma

Ddx:

• Osteosarcoma
• Ewing sarcoma
• Lymphoma
• Bone cyst

Question 23

• During rapid growth spurts
• Progressive pain
• Palpable mass occasionally
• Nighttime awakenings**
• Joint effusion/tenderness/decreased ROM
• Pain not responding to conservative therapy

Answer 23

Osteosarcoma

Tx:

• Chemo
• Surgery