Limp & Fracture Flashcards
What are the key clinical features to identify on hx and examination of child presenting with limp?
Unilateral vs. bilateral
Sudden or gradual onset
Degree of weight bearing - some with pain or completely NWB
Pain at rest?
ROM?
Local symptoms of joint?
Pain in buttocks, thigh and/or knee - consider abdo pain & testicular pathology
Context - Hx of trauma or injury, recent URTI or other infection
Systemic features - infection, sepsis, abdo pain, rash, neurological symptoms
Immunosuppressed?
Well or unwell child - possible sepsis? Vitals Shortened limb or altered position of limb Reduced ROM - esp. abduction and internal rotation Asymmetrical thigh/gluteal creases Swelling, redness of joint Localised tenderness Neurological findings Gait examination Ortolani and barlow tests in infant
What are important DDx to consider in all ages in child with a limp?
Septic arthritis Osteomyelitis Traumatic fracture NAI Malignancy Rheumatological - JIA Functional limp
What are DDx specifically in infants with limp/non-weight bearing?
DDH
What are DDx specifically in toddlers with limp/non-weight bearing?
DDH
Irritable hip (transient synovitis)
Toddler’s fracture
Perthes disease
What are DDx specifically in school aged child (<10) with limp/non-weight bearing??
Transient synovitis
Perthe’s disease
What are DDx specifically in adolescence (>10) with limp/non-weight bearing??
Overuse
SUFE
When should a child with limp be Ix and what Ix should be done?
If no concerning features, limp <3 days typically doesn’t require Ix
Bloods - FBE, CRP, ESR, blood cultures
XR - typically first line - chronic osteomyelitis, fracture, DDH after 6mths age, SUFE, perthe’s
U/S - effusion (transient synovitis, septic arthritis), DDH
MRI - septic arthritis
Bone scan - osteomyelitis, occult fracture
Who typically presents with transient synovitis?
Very common - most common cause of limp in pre-school age
Typically 2-8 years
How is transient synovitis diagnosed?
Diagnosis of exclusion
Absence of fever, severe symptoms, raised CRP, ESR and duration <3 days, hx of URTI highly suggestive
Joint effusion on U/S suggestive (but can’t determine if sterile or not)
What is the typical presentation of transient synovitis?
Constitutionally well child presenting with pain in hip and or partial limp
Usually unilateral but can be bilateral - if bilateral unlikely septic
Hx of recent URTI or viral illness
What are the clinical features of transient synovitis?
Mild-moderate decreased ROM (cf. with severe reduction in septic)
Afebrile, appears well
May have had previous episode - small number have repeated episodes
What are the common causes and affected joints of septic arthritis?
Most commonly lower limb
S.aureus, GAS, HIB
Gonorrhoea can cause - consider in sexually active adolescent
What is the typical presentation of septic arthritis?
Acute onset joint pain/pain with walking
Non-weight bearing or refusal to use limb
May appear unwell
Febrile
What are the clinical features of septic arthritis?
Severed reduced ROM
Pain occurring at rest
Unable to weight bear
Fever
Vitals - suggestive of sepsis
Appearance and behaviour - suggestive of sepsis
May have hx of trauma, route of infection, immunosuppression
What are features to help distinguish between septic arthritis of hip and transient synovitis?
More likely in septic arthritis
- Fever
- appears unwell
- complete NWB compared to partial
- more severe restriction of ROM
- persisting >3 days without improvement
Kocher’s criteria - elevated WCC & ESR, NWB, Fever - highly sensitive for septic arthritis if all present
CRP - independent factor
If fever and raised CRP highly suggestive of septic arthritis
U/S can show effusion but this can be present in both
Management for septic arthritis?
Ix - blood cultures, ESR, CRP, FBE
Urgent surgical referral - joint wash out
IV flucloxacillin
Immobilise and elevate limb
Management for transient synovitis?
Reassurance and education
- It is inflammation of the lining of the hip joint
- may last 2 weeks but will begin to improve after 3 days. - It is a mild, self-limiting condition that commonly occurs after an infection but it’s cause is unknown
- may have future episodes
Supportive
- rest, analgesia (paracetamol or NSAIDs)
What are risk factors and associated features of DDH?
Female Breech FHx Congenital abnormalities i.e. club foot, down syndrome First born
C-section
Oligohydramnios
Intrauterine packing disorders
Swaddling
What is the clinical presentation and features of DDH?
Detection on clinical and U/S screening after newborn or 6-week examination
- Joint instability (barlow) or joint dislocation (ortolani)
Asymmetrical thigh/gluteal creases (soft sign)
Shortened affected limb/decreased thigh length
Limb in older child
Limited hip abduction
Who should be screened for DDH?
All newborns and 6-week infants should be clinically screened
Those with high-risk factors and abnormal clinical require U/S screen
Repeat examination during first year as clinical and U/S screening has its limitations
What are the Ix choices for DDH?
<6mths = U/S >6mths = XRAY
What is the management for DDH?
Diagnosed
- before 6-weeks = observation, bracing in Pavlik harness
- Before 3-months = hip spica (cast) or surgical reduction if unable to be clinically reduced
- After walking = surgical reduction and pelvic osteotomy
What is a SUFE and what are the risk factors/associated factors?
Slipped upper femoral epiphysis
Obese, male, adolescent
Can be bilateral
What are the complications of SUFE?
Osteonecrosis
Early OA
What is the typical presentation of SUFE?
Can be acute or chronic (progressive over >3weeks) - most are chronic (85%)
Antalgic gait
Out-toeing and some shortening of affected limb
Vague pain in groin, hip, knee - most commonly presents as solely knee pain
Reliable clinical sign = external rotation of hip during flexion
Management of SUFE?
NWB
Surgical Rx
What is Perthe’s disease and what are the risk factors/associated factors?
Avascular necrosis of capital femoral epiphysis
Occurs 2 - 12 years - majority 4 - 8
Males ++
Can be bilateral
Low birth weight, delayed bone age
How does Perthe’s disease present?
Pain and limp for at least 1 week with restricted hip motion
How is Perthe’s disease Rx?
Ix - plain XR and bone scan
NWB
Surgical Rx - pinning
What are the differences in bone characteristics that make fractures different in children to adults?
Osteoid is less dense - can therefore bend before they break
- Buckle, plastic bowing and greenstick fractures
The younger the child, the quicker the healing
The closer to a joint, the quicker the healing
What are red-flags for NAI in fractures?
Delayed presentation
Injury not compatible with mechanism
Vague history
Features of FTT or prior injury
Spiral humeral shaft # in a toddler
Femoral shaft # <2y
What are the assessment principles of #?
Mechanism of injury
Tetanus status
Neurovascular assessment Tenderness and swelling Open vs. closed Visible deformity Imaging - lateral and AP views of joint + joints above and below
*consider any signs for NAI
What are the important Rx principles of #?
Referral if complicated/open #/involves joint line
Analgesia
Splinting before imaging
Reduction and immobilisation
- Often can be reduced with gas in ED, may require GA in other circumstances
- Greenstick, buckle, torus fractures usually backslab
- Surgery if open of complicated #
If manipulation or reduction need follow-up XRAY in 1/52
Need monitoring if affecting growth plate as can arrest growth
What are the important education points about fracture care and plaster care for parents?
Plasters usually remain on for ~6 weeks (can be less if backslab)
Need to avoid contact sports for ~8w after to prevent re-injury
Plaster care
- In first 24 hrs - immobilise with sling, elevate above level of heart to reduce swelling
- Represent if numbness, discolouration, swelling or pain in fingers/toes
- If lower limb <6 yrs walking frame instead of crutches
- Don’t get plaster wet, don’t stick things down it to scratch
- Avoid bumping or hitting cast
- Okay to draw on cast but don’t paint on it
What is a common # in toddlers?
Toddlers # Undisplaced # of tibia without periosteal break Due to impact or twisting injury Walking age - 3 years Back slab (not always required)
Common # in school age children?
Supracondylar #
Humeral condyles of elbow
Commonly after FOOSH
Possible injury to median and radial nerves and brachial artery
-Possible compartment syndrome - volkmann’s contracture (ischaemia of flexor tendons)
What is most commone # in early adolescence?
Forearm # in 12-14 yo
Greenstick, plastic bow or complete #
Commonly after FOOSH
Above elbow cast
