Limp - Transient synovitis, Septic arthritis/osteomyelitis, Juvenile idiopathic arthritis, Trauma, Developmental dysplasia of hip, Perthes disease, Slipped Upper femoral epiphysis

Question 1

Management of child U3 with acute limp

Answer 1

Urgent paeds assessment
-rule out septic arthritis or traumatic injury

Septic arthritis can present in patients who are otherwise well

Always consider trauma

Question 2

Transient synovitis
-what is it
-age group affected
-presentation
-WHAT DO YOU WANT TO RULE OUT
-management

Answer 2

MOST COMMON CAUSE OF HIP PAIN
cute hip pain after a recent viral infection
3-8

Limp, refusal to weight bear
Groin, hip pain
Low grade fever
-if high => MORE LIKELY TO BE SEPTIC

RULE OUT SEPTIC ARTHRITIS 1ST
-fever => urgent specialist assessment
Monitor in primary care if
-3-9
-afebrile but limping
-symptomatic for U72hrs

Self limiting
-rest, analgesia

Question 3

Developmental dysplasia of the hip
-what is it
-risk factors
-screening
-clinical examination
-imaging
-management

Answer 3

Ball and socket hip joint does not form
-more likely in LHS

Female
Breech
FHx
1st born
Oligohydramnios, macrosomic

Routine US if
-1st degree FHx of childhood hip problems
-breech at 36wks+
-multiple pregnancy

NIP - Barlow, Ortolani test
-symmetry of leg length
-levels of knees when hips, knees are bilaterally flexed
-restricted abduction

Clinically suspected => US
If 4.5months+ => Xray

Majority stabilise by 3-6wks
Pavlik harness if U4-5months
Older => surgery

Question 4

Septic arthritis
-causative organism
-presentation
-investigations
-management

Answer 4

Staph aureus, strep pyogenes

Hip, knee, ankle most often affected
-joint pain
-limp
-fever
-systemically unwell
-swollen, red joint
-only minimal movement possible

Kocher criteria
-fever 38.5C+
-non weight bearing
-ESR 40+, WCC 12+

Joint aspiration and culture => high WCC
FBC => high CRP, ESR
Blood cultures

IV ABx + supportive

Question 5

Juvenile idiopathic arthritis
-what is it
-age of onset
-presentation

Answer 5

Autoimmune, lasting 6wks+
-6-15

Joint pain, hot, swelling - medium sized joints
Limp
ANA may be positive

NSAIDs, DMARDs, biologics
Intraarticular CS
Physio

Question 6

Perthes disease
-what is it
-risk factors
-presentation
-investigation
-management
-complications

Answer 6

Blood supply to femoral head disrupted => AVN
-new bone formation and remodelling occurs
-4-8, more common in boys

Hip pain progressing over weeks
Limp
Stiff, reduced range of hip movement

Xray
-early change => widening joint space
-late change => decreased femoral head size/flat
If Xray normal => Tc bone scan/MRI

Conservative - U6
-pain management
-activity modification, physio
-orthotics, braces

Surgical - 6+
-if persistent pain, progressive deformity, failed conservative management

Complications occur when bone reformation
-residual deformity, leg length discrepancy
-osteoarthritis
-premature fusion of growth plates
-surgical complications

Question 7

Slipped upper femoral epiphysis
-what is it
-presentation
-investigations
-management
-complications

Answer 7

Growth plate fracture => head slips out of position
-10-15, obese children

Femoral head epiphysis => postero-inferior displacement
Acute presentation following trauma or chronic persistent symptoms
-hip, groin, medial thigh, knee pain
-lost internal rotation in flexion

AP, L Xray

Internal fixation

OA
AVN
Leg length discrepancy