Limp / limb pain Flashcards
Ddx for arthritis / limb pain
ortho: SCFE, legg-calve-perthes disease
functional: growing pains, fibromyalgia, conversion rxn
inflammatory: JIA, SLE, HSP, kawasaki’s
infectious: septic arthritis, osteomyelitis, transient synovitis, reactive arthritis, rheumatic fever, lyme
Heme: sickle cell, hemophilia /w hemarthrosis
trauma: #, soft tissue, osgood-schlatter, hypermobility
malignancy: leukemia, neuroblastoma, bone tumor
non-joint: testicular torsion/appendicitis (groin)
Joint / limb pain red flags
- fever
- pain awakening from sleep
- lethargy
- redness
- non-weight bearing
- poor growth / weight loss
- trauma
- morning stiffness
septic arthritis bacteria
S aureaus, GAS, strep pneumon
chlamydia / gonorrhea if sex active
kingkingae if <4
HiB if unimmunized
GBS + gram negs in neonates
work-up for ?septic arthritis
CRP / ESR CBC (high WBCs) joint aspiration - culture + chemistries blood cultures! can US if exam unclear re effusion
management of septic arthritis
IV antibiotics if improve then PO for 3 weeks, +/- joint washout
complications of septic arthritis
joint damage (deformity, leg length discrepancy, poor ROM)
empric antibiotic choice for septic arthritis
<3mo - cloxacillin + aminoglycoside
Child - cefazolin
osteomyelitis most common sites
femur, tibia, humerus, fibula, radius
?osteo work-up
CBC (high WBCs) CRP/ESR blood cultures \+/- xray to r/o other conditions - fracture, tumor bone scan, MRI to support dx MRI = most sn/sp, but requires sedation
osteo empiric Abx choice + tx length
neonate - cloxacillin + aminoglycoside
1-3mo old - ceftriaxone + aminoglycoside
Child - cefazolin
needs 4-6wks total (can step to oral)
acute rheumatic fever timing + sx
2-4 weeks after GAS pharyngitis
arthritis carditis syndeham chorea erythema marginatum subcutaneous nodules
late: valve dx (MR, MS), joint laxity
ddx = post strep reactive arthritis - assume RF if unclear
transient synovitis presentation
follow URTI
sudden onset painful hip (or knee), well, afebrile or fever <38.5, ambulating +/- limp
ages 3-8, esp boys
septic more likely if fever, not weight bearing, ESR/CRP high, WBC high
work-up & management of transient synovitis
r/o septic A / osteo. WBC = normal CRP <20 ESR <40 joint effusion on imaging (US, xray) -- may not need if all else normal
tx = NSAIDs, rest. Improves in 7-10d
Reactive Arthritis Presentation
adolescents
inflammatory, 2-4wks after GI or GU infection
+/- urethritis and conjunctivitis
afebrile at presentation
growing pains presentation
intermittent, non-articular pain normal physical exam night time calf/shin, thigh normal function asymptomatic in day
ages 3-10
dx of exclusion
treatment: heat, massage, mild analgesia, reassurance
malignancy causing limp - presentation
leukemia - red flags = pain awakening from sleep, constitutional (FTT, lethargy, night sweat, brusing).
dx: blood smear, bone marrow bx
bone tumor
neuroblastoma
Juvenile Idiopathic Arthritis presentations
onset <16, at least 6wks
dx - exclude other causes
systemic: 1+ joint, daily fevers 2wks, 1 of evanescent (salmon macular) rash, hepatosplenomeg, pericard, serositis, lymphadenopathy
oligoarticular: <5 joints, girls 1-3yo, large joints exl hip, morning stiffness, if ANA+ve -> anterior uveitis (refer for eye screen)
polyarticular: 5+ joints, symmetric, small + large, RF -ve, if RF +ve adolescent girls, similar to adult RA
psoriatic: knees, hands, feet. Psoriasis rash. Nail changes, dactylitis.
enthesitis: heel, plantar fascia, patella. Older boys. assymmetric. Uveitis/iritis.
other
treatment of JIA
oligo: steroid injections, NSAIDs, DMARDs = 2nd line,. eye screening, physio. +/- Biologics.
Systemic: NSAIDs, then pred. If can’t wean pred then biologics.
SLE diagnostic criteria
Need 4 / 11: malar rash discoid rash serositis oral ulcers arthritis photosensitivity blood disorders renal impairment ANA +ve immunologic (anti dsDNA, Sm) neurologic sx
osgood schlatter disease
presentation + mechanism
overuse / stress injury of patellar tendon –> microavulsion of tibial tuberosity
presentation: pain + swelling at tibial tuberosity, usually athletic teens
tx: activity modification (don’t stop though), physio, ice, analgesia
legg calve perthes disease presentation + etiology
self-limited avascular necrosis of capital femoral epiphysis
painful lump + decreased ROM, esp boys 4-10
legg calve perthes disease diagnosis
MRI (more sensitive) or xray (joint wide, physis irregular, fragment, reossification, healing)
management: non-weight bearing, ortho referral, supportive, +/- abduction splints, +/- surgical osteotomy of prox femur to maintain head in acetabulum
slipped capital femoral epiphysis presentation
limb held external rotation + flexion. Pain can be poorly defined, acute or months.
passive IR limited + painful
overweight males 10-14
associated: GH def, hypoT
work-up of SCFE
xray - image both hips
TSH
management of SCFE
urgent ortho referral
no weight bearing until surgery
epiphysiodesis, fix /w screw or bone graft
toddlers fracture
oblique or spiral fracture of the tibia - limp or refuse to walk. Minor twisting trauma.
how to evaluate growth plate fractures
SALTER HARRIS
I - S - straight across/slip II - A - above (in metaphysis) III - L - beLow IV - T - through both sides V - R - crushed
Any salter #, follow up for 1 year to ensure no growth abnormalities
