Limp Dr Donaldson

Question 1

Sx of bone cancer

Answer 1

Bone pain - worst at night

Question 2

Hx of limping child

Answer 2

Trauma
B symptoms
FHx of arthritis or IBD (other AI conditions)
Consider non accidental injury

Question 3

What makes diagnosis of arthritis more common?

Answer 3

Multi joints affected

Question 4

Which children are most at risk of non accidental injury?

Answer 4

Non ambulatory children
Drugs and alcohol
Previous social care involvement
Mental health issues in family
Criminal records on family

Question 5

Define limp

Answer 5

Any deviation from normal gait expected for child

Question 6

Red flags of limp

Answer 6

Non weight bearing
Inability to walk acutely
Severe localised pain and fever over 38.5
Pain waking at night
Bony prominence or tenderness
B symptoms
Limp for longer than one week
Non accidental injury risk

Question 7

Most common cause of limp

Answer 7

Transient Synovitis 40%

Question 8

What is perthes

Answer 8

Avascular necrosis of head of femur

Question 9

Who is most at risk of SUFE?

Answer 9

Obese boy 8-10 years old

Question 10

Amber features of limp

Answer 10

Symptoms greater than 72 hours
Age under 2 or over 9 (less risk of transient synovitis)
No red flags
Multiple previous episodes

Question 11

Green features of limp

Answer 11

Symptoms under 72 hours
Mobile but limping
Responds to analgesia
No red or amber features

Question 12

What is pGALS?

Answer 12

Paediatric gait arms legs spine
Useful MSK assessment tool

Question 13

How to examine a limping child?

Answer 13

Fever
Abdo check for hepatosplemomegaly
MSK spine arms legs
Check skin for rashes or lymph nodes
Neuro exam - tone power sensation reflexes
Check leg length
Check joint itself

Question 14

DDx limp aged 0-4

Answer 14

Developmental dysplasia of hips
Toddlers fracture
Physeal fracture
Puncture wound
Sprain
Contusion
Osteomyelitis
Septic arthritis
Synovitis
Discitis
Neoplasm

Question 15

Developmental dysplasia of hip Sx & risk factors for developing it

Answer 15

Delayed walking
Breech presentation, FHx, twin pregnancy

Question 16

What is toddlers fracture

Answer 16

Small fracture due to twisting while learning to walk

Question 17

DDx of limp in 4-10

Answer 17

Fracture
Perthes
Transient Synovitis
Juvenile idiopathic arthritis
Osteomyelitis / septic arthritis

Question 18

DDx of limp on 10+

Answer 18

SUFE
Fracture
Perthes
Osgood Schlatter Disease

Question 19

What is Osgood Schlatter Disease

Answer 19

Necrosis at tendon insertion on bone
More in active children

Question 20

Septic arthritis Ix

Answer 20

Bloods - FBC, CRP, ESR, LFT, UEs, film, G&S, cultures
Urgent USS - to check for fluid in joint
NBM, IV access and fluids
Orthopaedic aspiration of joint

Question 21

Score for septic arthritis

Answer 21

Kocher score
- one point for fever over 38.5, inability to weight bear, ESR over 40 or CRP over 20 and high WCC
- greater the score, more likely for septic arthritis

Question 22

Define perthes

Answer 22

Avascular necrosis of capital femoral epiphysis

Question 23

Which sex is more com,on for perthes

Answer 23

Boys 4:1

Question 24

Describe perthes presentation
inc age peak / XR findings too

Answer 24

Gradual onset limp
15% bilateral
3 to 9 year old boys
XR joint shows flattening of femoral head with joint space widening

Question 25

Describe SUFE presentation

Answer 25

Obese boy 8 year olds
20% bilateral
Subtle symptoms, gradual onset
Endocrine disorder

Question 26

Ix for SUFE

Answer 26

XR hip in frog leg position

Question 27

When are no Ix needed for limp?

Answer 27

No red flags
Ambulating well
Clear diagnosis

Question 28

Ix for limp

Answer 28

XR affected area - pelvis too
USS for ?effusion
Bloods - FBC, film, ESR, CRP, UE, LFT

Question 29

2nd line Ix for limp

Answer 29

Rheumatological vasculitic bloods
LDH, ferritin, urinary catecholamines
Renal